Wednesday, February 29, 2012

The Mayo Model

The Mayo model consists of a large group of patient-centered, salaried physicians, specialists and primary care doctors alike, making similar incomes, gathered in one place, with hospitals and doctors under one roof, practicing conservatively , concentrating on outpatient care, working in teams, communicating electronically, keeping hospital care at a minimum, keeping hospital-based care at a minimum, and delivering care at 20% less than the outside world.

R. Reece, Obama, Doctors, and Health Reform (IUniverse, 2009)

February 29, 2012 – What I wrote in 2009 was not completely accurate. Mayo did not practice in “one place” but in three major locations – Rochester, Minnesota, Jacksonville, Florida, and Scottscale, Arizona – and in 135 counties in 70 communities serving 1 million patients in Minnesota, Iowa, and Wisconsin. And I could not corroborate my statement that Mayo does this at 20% less than the “outside world.”

Nevertheless. let there be no doubt. In 2009 and today, Mayo is an efficient financial operation. So efficient, it plans to invest $700 million in new facilities – including a protein beam center for treating cancer, its ER at St. Mary’s Hospital in Rochester, its Wellness Center in Rochester, and its clinics in Austin, Minnesota and Barron, Wisconsin.

The Mayo Clinic shows the power and potential of a well-organized, centralized physician-led organized multispecialty group.

Still, the Mayo Clinic does not typify the physician culture elsewhere.

As I said in my 2009 book in a chapter entitled “Please Pass the Mayo,”for most independent doctors, the Mayo Clinic is not an apropos setting for them.. These doctors prefer to remain autonomous. They prefer not to work for a fixed salary for a large employer.”

This does not mean we doctors do not admire the Mayo Clinic or hesitate to refer patients to its 3 centers. We admire the Mayo Clinic and refer patients to it without hesitation.

It simply means that multispecialty physician practices with a clear mission for serving the public, are financially efficient, successful and have prominent roles to play in health reform.

Tweet: The Mayo Clinic in Rochester has announced plans to invest $700 million in the next 5 years in a proton beam center and other facilities.

Tuesday, February 28, 2012

Origins of Innovators

There’s a better way to do it – find it.

Thomas Edison (1847-1931)

February 28, 2012 - As one who tries to direct traffic at the intersection of culture, politics, technology, and health reform, the origins, attitudes, and discoveries of innovators in our society fascinate me.

Innovators may be individual entrepreneurs, members of the academic establishment, or participants in corporate teams. All are full of ideas, in pursuit of ideas, risk takers, and society makers and shakers.

In my experience, most ideas originate with individuals with a dream of what could and should be. These individuals tend to be well-educated but do not necessary have degrees. The titans of the information age – Bill Gates of Microsoft, Steve Jobs of Apple, and Mark Zuckerberg of Facebook -are college dropouts. Edison do not even go to college. Entrepreneurs are not always to the manor born. Andy Grove, the CEO of Intel who made Intel one of heavily capitalized companies in the word, is a Hungarian refugee who came to this country at age 20 without a college education and rose to the heights of the corporate pinnacle and helped make Silicon Valley what it is today – the Venture Capital center of the world.

Nitin Nohira, Dean of the Harvard Business School, just sent out an 11 page pamphlet to Harvard Business school graduates and graduates of its affiliated programs. I was on his mailing list because I happen to be graduate of an 8 week program on Health Systems Management at Harvard. The Dean writes those with advanced degrees ought to focus on how to advance society through Innovation, Intellectual Ambition, Internationalization, Inclusion, and Integration, Towards those ends, he has assembled teams of student innovators to develop and refine products, generate and analyze data for target markets, sell to those markets, and generate revenue.

Jon Gerber, author of The Idea Factory: Bell Labs and the Great Age of American Innovation, writes in the February 26 week end section of the New York Times , that corporate commitment to innovation often makes the difference in advancing society. As evidence, he cites 30 Bell Lab discoveries over the last 87 years, including the first fax service, the first digital computer, the first transistor, the first laser, and the first communication satellites.

Tweet: Innovation occurs because of a combination of individual imagination, educational preparation, and corporate enterprise – not one or the other.

Monday, February 27, 2012

Physicians, Get Real

Life is real! Life is earnest!

Henry Wadsworth Longfellow (1897-1882)
Psalm of Life

Humankind cannot bear too much reality.

T.S. Eliot, (1888-1965), Burnt Norton

February 27, 2012

About reality, two poets can’t be wrong
For all of us, “get real” is their song.

The lyrics apply to we physicians,
Do these poetic admonitions.

These realities are unpleasant,
At least for the present.

One, There will be no permanent SGR fix,
Not with the present political mix.

Two, Medicare fees will fall in next decade,
Much of them bundled and prepaid.

Three, Market-based incentives will not occur,
Those on the left concur.

Four, Don’t count on national tort reform,
Barring a perfect political storm.

Five, Swing states could swing the right way,
As of now, polls show that sway.

Six, let's hope the public will remember
These things,come November.

Source: Susan Page, “Health Law Hurting Obama in Swing States", USA Today, February 27, 2012

Tweet: For doctors, present political realities are: no SGR fix, no fee increases, no market incentives, no tort reform.

Sustainable Physician Practice Models

The concept of sustainable development is now known – even among those who haven’t accepted it – and it’s recognized, debated, and followed by increasing numbers of businesses.

Maurice Strong (1929- ), Canadian entrepreneur

February 27, 2012 – In response of reform and economic pressures, American physicians are in the process of developing new practice business models. The nature of these practice models varies with specialty, regions of the country, hospital relationships, and physician leadership.

In my 2009 book, Obama, Doctors, and Health Reform, I listed a dozen of these models with examples of each

1. Medical homes

2. Hospital-based systems with owned primary care doctors, and employed specialists

3. Doctor-owned, clinic-based organizations, with salaried physicians

4. Geographically distribute practices under one practice umbrella

5. Specialty hospitals and surgicenters

6. Worksite clinics or groups serving worksites

7. Academic-based centers with outlying community hospitals and other clinical feeders

8. Hospitals with bundled-billing arrangement between hospitals and medical staff

9. Social networking physician organizations

10. Innovative delivery practices with and without third party connections

11. Practices that rely on patients with HSA accounts and high deductible plans for payment

12. Urgent care clinics or centers, in or near retail centers, in deserted malls with empty real estate, or in place competing with retail clinics staffed and backed by doctors.


Physician success depends on how physician practices are organized. Physicians are reappraising how large their organizations must be, how they can consolidate to offer a full range of services, how they can practice alone using tools like the Internet and electronic records, how they can innovate to provide 24 hour service and accessibility, how they can offer convenience and lower prices, and in general how they can leverage their skills to maintain sustainable practices. The name of the sustainable practice game is how to do this in a financially attainable way in manner that is explainable to colleagues and patients.

Tweet: A number and variety of new physician practice models are cropping up around the country in response to reform and economic pressures

Sunday, February 26, 2012

"SGR" - Title for Health Reform Book

To dream – the impossible dream

To fight – the impossible foe

To bear – with impossible sorrow

To run – where the brave dare not go

To right- the uprightable wrong

To love- pure and chaste from afar

To try – when your arms are too weary

To reach – the unreachable star

Lyrics from “The Impossible Dream" – Man of La Mancha, 1972 Musical

February 26, 2012 - Last night I awoke with a start. The lyrics of “The Impossible Dream” were resonating in my head.

My impossible dream was what to name a dream book. The book would consist of my blogs. It would cover the period from March 2010, when the health reform law passed, to June 2012, when the Supreme Court pronounced its decision on the law’s constitutionality.

It would be concern what’s happening at the intersection where politics, technology, and health reform collide. It would be 1000 pages long - too long for a paper book and too expensive to produce. The return of investment would be too meager. It would be, in short, an impossible dream, a publisher’s nightmare.

So SGR would have to be an E-book. E-books lend themselves to enormous, eclectic, e-technologic subject matter. This book would qualify on all e-counts.

In my dream, the book at first lacked a title. But that hesitancy was short-lived. In short order, I came up with the title of SGR.

One word book titles are in vogue.. Two books on my personal library shelves came to mind Next by Michael Lewis and Blink by Malcolm Gladwell. In today’s New York Times book section, I count 25 books with one word titles – Moneyball, Outliers, Blackout, Wonderstruck, Inheritance, Fablehaven, Pure, Crime, Blood, Visuals, Switched, Matched, Fallen, Lethal, Raylan, Quiet, Unbroken. Auschwitz, Taken, Bonnie, Ameritopia, Liebesod, Girlchild, Iago, and Bossypants. My favorite is Bossypants, perhaps because my book was done by the Seatofmypants, not a bad title by the way.

My SGR title beats them all in my dream. Why? Because it would be an acronym and algorithm wrapped into one. It would be a book that captured the essence of the 2700 page health reform law in one fell stroke.

Acronyms, after all, litter the law - PPACA, GAO, CHIP, ACA, ACO, PCORI, IRS, CMS, and IPAB – to mention a spacious few.

Reform’s most famous algorithm is SGR – Medicare's Sustainable Growth Rate formula.

Congress concocted the SGR in 1997 to make sure Medicare physician expenditures didn’t exceed GDP. CMS updates and calculates SGR annually and passes it on to Congress for approval.

• Each year the SGR produces unrealistic numbers calling for draconian cuts in physician pay.

• Each year since 2002, Congress chucks aside the SGR. Its cuts would surely cause physicians to abandon Medicare patients. This would be unacceptable to voting seniors.

• Each year a Congress proposes “doc fix.”

• Each year the “fix” proves to be an impossible dream. It costs the government too much, drains too much money from other government programs, and alienates senior voters.

In my book, SGR would stand for “So Goes Reform“ The book would be about sustaining the unsustainable. It would be about how Congress changes positions faster than the speed of light. The actions of the Congressional elite led me to compose this limerick. “There was a Congress who thought itself bright, whose speed it deemed was faster than light, it set out one day, in a relative way, and returned the previous night.” In the case of Congress, the previous night is the 1997 SGR.

I thought of other titles as well.

AC- DC. This acronym stood for - "After Conception – Darkness and Confusion", which refers to the passage of the health reform law and ensuing controversies in D.C. I rejected this title as too cute and too cynical.

Will Obamacare Survive? Sequel to The Health Reform Maze,my previous book.This title was too pejorative and too self-serving.

Everything You Ever Wanted to Know about Health Reform but Were Afraid to Ask. This moniker has already been used in books about sex by Dr. David Reuben in 1969 and by Woody Allen in a movie in 1972 and by countless others on countless other subjects. Too overused. Anyway, I did not want my title to imply the 2700 page PPACA law violated somebody’s bodies, individual rights, and religious rights.

Period. End of dream. SGR would be my title.

Tweet: SGR, for “So Goes Reform,“ for the Congressional formula for Medicare paying doctors, might be a good title for a book on health reform.

Saturday, February 25, 2012

Going Home and Staying Home, Away from Nursing Homes

Home is where the heart is and where care ought to be.


February 25, 2012 – A movement away from nursing homes back to the home is gathering steam. Anticipated cuts of $56 billion now underway and over the next 10 years from the Obama administration are driving this trend.

So are desires of the old and the frail to be home again. So are technological trends that allow home monitoring. So are emergence of teams of skilled health care professionals – doctors, nurses, social workers, nutritionists , occupational therapists - who are ready and willing to deliver care in personal homes. And so is the emergence of a new health care model, PACE (Program for All-Inclusive Care of the Elderly), which features care at adult day care centers, In the home, and occasionally at doctors’ offices.

I have personal experiences with home care. When my mother was dying from lung cancer, she desperately wanted to die at home. But Medicare policies at the time allowed pay only for hospital care. Mom died unhappy, alone, and desolate in the hospital. My twin sister had Mad-Cow disease, Jacob Creutzfeld disease. Her mental state was deteriorating quickly. Her family chose to have her cared for at home by hospice nurses. It was the right decision. She died peacefully at home, surrounded by the ones she loved.

An article in the February 23 New York Times “ A Shift from Nursing Homes to Managed Care at Home” describes the elements of the trend away from nursing homes and back to personal homes.

Nursing homes are closing facilities because of lowered reimbursements and higher costs. As an alternative, nursing homes are embracing a new model of care – care at home and at adult day care centers administered by teams of health professionals. The model is less expensive than nursing homes. It is more compassionate and satisfying for the frail elderly.

Because of economic pressures, the number of nursing homes and nursing home beds is going down in America. Over the last 6 years, 350 homes have closed. More closings will come. The Archdiocese of New York is shuttering 2 of 7 homes it owns. The diocese is opening a PACE center (Program for the Inclusive-Care of the Elderly).

At PACE, patients may spend the day at an adult day care center. But they go to sleep in their own bed at night – often with a health aide or nurse nearby. They are given preventive care to keep them out of nursing homes. They live out their days at home.

When necessary, a nurse may visit them at home to change pill boxes or inject drugs. Patients may go to PACE centers 2 or 3 times a week, but they know they’ll be going home after each PACE visit. In New York, PACE receives $4000 a month from Medicare and $3300 a month from Medicaid, in either case less than the $9000 a month required by nursing homes. The aim of the New York model and 29 programs in other states is to keep people out of nursing homes.

Towards the goal of keeping people out of nursing homes, new and innovative technologies are springing up. An example of these devices are audiovisual units sitting on tables next to patients’ bedsides. Ordinary telephone lines connect patients to caregivers. When patients need help or sense a complication, they initiate calls to doctors and nurses, who can visually observe the patients, listen to hearts and lungs, take blood pressures and pulses, record weights, even measure blood oxygens.

It is Skype and more. It is telemedicine in action. It is care delivered away from nursing homes. It is decentralized care – the wave of the future.

Tweet: Nursing homes across U.S. are downsizing and switching to a new care model, delivering care in day care centers and in patients’ homes.

Friday, February 24, 2012

Electronic Health Records Program Advances to ‘Stage 2′

This is an operative statement. The others are inoperative.

Ron Ziegler (1939-2003), Press Secretary to President Nixon

February 24, 2012

Preface: Kaiser Health News encourages reader to re-circulate their News Capsules to wider audiences. Here I’m reprinting their capsule of today. Because of bureaucratic data-gathering requirements and current lack of interoperability of various and sundry systems, this process is going to take a long time. But when $30 billion of federal funds are available for distribution, people will find ways to get it done.

By Christian Torres, Kaiser Health News,

"It’s time to take electronic health records to the next level. Federal officials on Thursday released their second-stage guidelines for “meaningful use” of electronic records, which advocates say have the potential to reduce medical errors and streamline care. The proposed rules require doctors and hospitals to significantly step up their usage, as well as better engage patients and improve the transferability of records."

"2009 federal stimulus provided $30 billion as an incentive for health care providers nationwide to implement electronic records for their Medicare and Medicaid patients. Officials established the “meaningful use” program, which provides financial rewards in three stages if certain standards are met. The first stage requires providers to begin setting up an electronic system and to record basic information including diagnoses and prescriptions for a portion of patients."

"The rules proposed Thursday start off by extending Stage 1; providers who began compliance in 2011 would now have until 2014 to move on to Stage 2."

"Many of the objectives of the second stage will be the same — ordering prescriptions electronically and so forth — but the minimums for “meaningful usage” will go higher. For example, at least 60 percent of patients must have their medications and lab tests ordered electronically during Stage 2, instead of the 30 percent required during Stage 1."

"In the second stage, the government is also putting an emphasis on making sure that electronic systems are able to talk to one another – or are “interoperable.” It’s “a real push ahead,” said Farzad Mostashari, the national coordinator for health information technology. Mostashari talked generally about the guidelines as he gave the keynote speech at the HIMSS annual conference in Las Vegas on Thursday."

"The rules require systems be able to transfer patient information across platforms. A “summary of care” — which includes past diagnoses, procedures and test results – must be able to follow patients across referrals and changes in health care provider. The information should also be available to some patients, who under Stage 2 requirements should be able to view their records online, as well as download and transfer information."

"Additionally, some patients must be able to communicate with their doctors through a secure, online system."

"A few new initiatives, although not absolute requirements for providers, were also added in the Stage 2 rules. For example, it’s asked that systems be able to transmit data to public health agencies and connect to registries, like those used for cancer research. Providers are also encouraged to record family health history and be able to transmit imaging results — x-rays and the like — to help avoid the need for duplicate scans.
The Stage 2 rules also advance other government health initiatives."

"Records will be used to help measure the quality of care being provided and would be aligned with reporting requirements for accountable care organizations and other quality efforts coming out of the 2010 federal health law."

"The proposed rules are open for 60 days of public comment once they are published in the Federal Register on March."

Tweet: Federal officials will release a final set of rules for "meaningful u"use" of EHRs in the March Federal Register.

The Reform Game

Come, Watson, come! The game is afoot.

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

February 24, 2012 - March is nearly here, and the political health reform game is afoot. Both sides are in spring training, the unified Democrats in Chicago and Washington, and the divided Republicans in play-offs across the fruited plain. Much of the of the game is concentrated in the “Swing States”, where the outcome – the number of Electoral College votes –hangs in the balance and where the winner will emerge.

This year is different for these reasons.

The umpires, not the players, may determine the winner. In March, the umpires – the nine Supreme Court judges- begin hearing arguments on whether Obamacare is constitutional and whether government has the power to run Medicaid programs in the states. Conventional wisdom has it that the judges will declare the health reform law unconstitutional by 5 to 4 because of the Court’s political makeup. But, the world’s largest prediction market, disagrees. Bettors there predict only a 37.8% chance the Court will rule the individual mandate unconstitutional.

The public – Voters look unfavorably upon the health reform law by 49.8 %to 37.3 % , 12.5 %, margin - the average consensus of national polls as compiled by Real Clear Politics. Those favoring repeal outnumber those opposing repeal by 50.7 % to 39.7 %, a 11.0 % margin. In the polling world, these margins are landslides, and could be factors in November.

The political players - Democrats naturally favor the health reform law and its mandates, but given the public polls, Democratic enthusiasm is mooted. Democrats rarely mention health reform as a leading campaign issue. Republicans are uniformly for repeal of Obamacare, but they have a problem. When Mitt Romney was governor, Massachusetts passed Romneycare, said to be the prototype for Obamacare. Romney says his first act as President would be to repeal Obamacare, but first he must explain Romneycare and why it differs from Obamacare.

The imponderables – These include concerns over the national debt, government intrusion into individual and religious liberties, government health care rationing , the fragile economy with unemployment, rise of gas prices and energy costs, handling of red hot issues of immigration and Iran’s nuclear threat.

Tweet: The ides and vibes of March are nearly upon us, and the march towards health reform solutions in June and November has begun.

Thursday, February 23, 2012

Good News and Bad News on Colonoscopies

The Good News is the Bad News is Wrong.

Title of book, by Ben Wattenberg, Simon and Schuster, 1984

Tidings do I bring, and lucky joys
And golden times, and happy news on price.

Shakespeare(1564-1616) Henry IV

February 23, 2012 - The good news, as reported in today’s New England Journal of Medicine, is that colonoscopic removal of adenomatous polys cuts colon cancer deaths by 53% (”Colonoscopic Polypectomy and Long-Term Prevention of Colonrectal Cancer Deaths”) The bad news is that pricing for colonoscopies is chaotic and varies according to your insurance or lack of it, and may cut your access to colonoscopies.

A WSJ Op-Ed today, “Health Care's Coming Price Revolution.”says the private sector is moving to give people the information they need to get treatments that are worth the money, but ObamaCare blocks the way.

The author, a member of the WSJ editorial board, cites the case of 4 identical patients, each undergoing a colonoscopy but having different insurance coverage.

Patient #1 has Medicare. Medicare pays a set price for all colonoscopies regardless of quality or outcome of past colonoscopies performed by the doctor. Medicare pays twice as much if the colonoscopy is performed in the hospital rather than in a doctor’s office.

Patients #2 and #3 have private coverage, one provided “in network” and one outside the health plan’s network. Those out of network pay more. But whether in or out of network, the cost averages about 40% more than Medicare.

Patient #4 has not insurance coverage and must pay out-of-pocket. The “chargemaster” of the hospital bills for a market-up sticker price no one wit6h coverage would ever pay.

To sum up, one doctor, four patients, four different prices, for prices disconnected to value or outcome.

The WSJ writer says this situation is changing because private insurers are out of money. So the big insurers- UnitedHealth, Aetna, Digna, and Wellpoint - are turning to data based on quality and outcome to price colonoscopies. They will use this data as leverage in contract negotiations to force hospitals and physicians show their colonscopies are better than those of competitors.

But the WSJ sadly concludes:

The impulse here is to restore the price signals that will drive U.S. health care to deliver care that is worth the money. But these gains—in transparency and efficient pricing, for instance—will need to be consolidated and expanded to constitute a true revolution. The Affordable Care Act stands in the way.”

“ObamaCare's core philosophies are standardization and centralization, which in practice will mean higher costs for everyone caused by suffocating price competition. The share of insurance industry revenue that comes from government now stands at 42%, up from 36% just three years ago, and that's before the new entitlement kicks in. And a wave of ObamaCare-promoted provider consolidation is creating hospital monopolies that can demand higher-than-competitive prices.”

Which philosophy prevails – government standardization or market-driven pricing based on quality and outcomes – may depend on the Supreme Court decision in June and the election in November.

Tweet: Colonoscopies with polypectomies cuts colon cancer death in ½, but costs for colonoscopies can be prohibitive in non-Medicare patients.

EHR Breakthroughs

The mass of men live lives of quiet desperation. Resignation is confirmed desperation.

Henry David Thoreau (1817-1862)

Success doesn’t necessarily come from breakthrough innovation but from flawless execution. The win comes from basic blocking and tackling.

Jain Naveen (1969--) business executive and entrepreneur

February 23, 2012 - I’ve been writing periodically about EHRs in my blog, my books, and in MIT’s Technology Review. In these venues, I have developed the sense that physicians are resigned to the inevitability of EHRs and have been desperately seeking solutions.

Statistics on the “hits” on my medinnovation blog bear this out. Three times more readers view my EHR blogs than read the #2 and #3 most popular subjects, the primary care shortage and accountable care organizations.

Of EHRs, it strikes me, physicians are saying: EHRs here to stay, let’s get on with them. Just show me a way to get around obstacles – cost, training my staff, integrating software with my current practice management system, and making EHRs user-friendly, clinically useful, and acceptable to the government so I can qualify for CMS “meaningful use” financial incentives – a total of $44,000 per doctor for Medicare, and $68,750 for Medicaid.

Meanwhile, in the background, 100 or so EHRs companies have sprung up to get a piece of the $27 billion for EHRs and HIT use embedded in the 2009 $787 billion stimulus bill. The leading companies, with number of physician users, in May 2010 were:

Epic 45,000

AllScripts 40,000

eClinicalWorks 40,000

GE Centricity 35,000

NextGen 35,000

SOAPWare 30,000

Practice Fusion 18,500

Eclipsys 11,000

Sage Health 10,000

Greenway Medical 6,000

This list doesn't include EHRs designed for specialists, who have their own special needs, or new entries into the market.

No doubt, these numbers have changed, as have the vendors, as they would in any dynamic market. Practice Fusion, for example, reports it now has 130,000 physician users. The other major vendors are not standing still. Kathleen Sibelius ,the Health and Human Secretary, reports a sudden uptick to 41,000 physicians qualifying for “meaningful use” incentives to meet a February 29 deadline.

The technologists of these companies have done a lot of systemic “blocking and tackling,” working out the kinks in their EHRs, and their marketers have been hard at work too – asking what physician clients need and want. At the same time, computer transistor capacity has been doubling ever 2 years, as Gordon Moore, co-founder of Intel predicted back in 1965, and new mobile applications have been proliferating.

To explain what has been going on, its successes and its failures, Harvard Business School Professor Clayton Christensen in The Innovator’s Dilemma (1997) advanced the Technology Mudslide Hypothesis:

“Coping with the relentless onslaught of technological change is akin to trying to climb a mudslide surging down a hill. You have to scramble with everything you’ve got to stay on top of it, and if you ever once stop to catch your breath you get buried.

Enter the concept of disruptive innovations, which allows vendors and physicians to ride the mudslide. Disruptive innovations are products that typically are cheaper, simpler, smaller, and, frequently, more convenient to use than traditional products.

There are many examples of disruptive healthcare innovations – desk top office computers rather than the phone or FAX; mobile devices(IPhone, IPad, IPod) rather than office-based computers; arthroscopic and endoscopic surgery rather than invasive surgery; angioplasty, rather than open-heart procedures; portable ultrasound rather than stationary MRIs or CTs; decentralized outpatient facilities rather than hospitals.

In the EHR field, disruptive technologies include a new business model, whereby: one, advertisers seeking to reach physician audiences and some health care plans, pay for installation and use of EHRs, and two, computing that takes place in “cloud,” on distant Internet browsers, rather than on EHR systems situated in physician offices.

These two disruptive innovations – “Free” EHRs paid for by someone else, and cloud computing, carried on outside the office, are a revelation and a revolution to small physician practices, primary care and specialty practices alike, who to date have not had the time, the skills, or the resources to install or use EHRs.

These disruptive innovations could be a breakthrough: As Bill Frist, MD, physician businessman, U.S, senator, and Senate Majority Leader from 2003- to 2007, has observed, “America has the best doctors, the best nurses, the best medical technology, the best medical breakthroughs. There is absolutely no reason we should not have in this country the best health care in the world. “

Tweet: EHR use is breaking through in the U.S., thanks to hard work by vendors and two disruptive innovations – “free” EHRs and “cloud computing.”

Wednesday, February 22, 2012

Book Review: Andy Grove, The Life and Times of an American, by Richard S. Tedlow, Professor , Harvard Business School, and Business Historian, 2006, 581 pages

You are always in danger. You are in danger of competitors, you are in danger of new ways of doing things, but more importantly, you have a danger that the way you have conducted your business is going to lose relevance.

Andrew S. Grove (1936 - ), Only the Paranoid Survive (1996)

February 22, 2012 - Why review a six year old book written by the former CEO of Intel, a Silicon Valley based microprocessor company? Why would physicians be interested in such a book?

For the simple reason that some physicians are paranoid. The fear losing their relevance in the age of personal computers where everybody seems connected to everybody else and everybody has access to medical information.

What is it about Silicon Valley that attracts entrepreneurs and investors that seek to make money and revolutionize society.

Here is how Tedlow explains it.

“What is Silicon Valley? It is a geographic location, but also a state of mind. It is a place where the intensity of the desire to make money can hardly be overstated. However, neither can one overstate the intensity of the desire to make ‘a dent in the world.’”

What is Grove’s company, Intel? It is an anchor tenant in Silicon Valley. It is a quintessential American Company that rose to greatness under the management of Andy Grove, a Hungarian who left his native land at age 20 and became an American and an information revolutionary in a world transformed by the internet and social technologies. Andy Grove’s story is a story of the success of American entrepreneurialism, freedoms, opportunities, and why one’s state of mind can trump all obstacles thrown into one’s path.

As I read Grove’s biography , I thought of Rudyard Kipling’s famous verse: “I keep six honest serving men (They taught me all I know); There Names are What and Why and When, And How and Where and Who.”

To read this book is to understand.

· What historical events occurred from the invention of the transistor, to integrated circuits , to the dawn of the semiconductor industry, to the impact of the silicon chip, to the introduction of the Internet, to Intel providing microprocessors to IBM and Microsoft.

· Why pioneers like Andy Grove, Bill Gates, and Steve Jobs turned the world upside own by making access to information ubiquitous and practical.

· When these events occurred from 1958 to the present, the founding of Intel in 1968, the establishment on Microsoft in 1975. IBM’s introduction of the PC in 1980 . the rise and fall and resurrection of Apple from 1983 to 1997.

· How Moore’s Law, that the number of transistors in a chip, would double every 2 years, accurately predicted the phenomenal growth of the consumer electronic industry with personal computer in 70% of American households. Gordon Moore was a co-founder of Intel, and Gorve was Intel’s third employee.,

· Where has become everywhere. The Internet is an international groundswell in an interconnected world where distance has become irrelevant in many business and most transactions.

· Who has become almost everyone. One paragraph in a chapter “The PC Is It,” reads: “Business in the late twentieth century turns out to be about information. Information processing became the essential infrastructure of the era. The computer was to the United States what the railroad was to the United States in 1990. It was the backbone of business.”

The computer is fast becoming the backbone of medicine. Practices are installing websites. Websites, like Health Grades, are grading doctors. Eighty percent of individual visit search engines are looking for medical information. Young doctors are weaned on the computer. Government is paying, even demanding, doctors install electronic records, and it is establishing a computerized data-based Outcome Institute to judge doctor performance. Doctors are marketing their services via the social media.

Andy Grove, now 76, is busy trying to translate chip-technologies into cost-effective health care. In a 2009 NYT interview, he asks, “Why doesn’t technology give us medical treatments that are better, faster, and cheaper? A system that works, heaven forbid, like the chip world.” He may be right - Moore’s Law is at work.

Tweet: The biography of Andy Grove, former CEO of Intel, is a good read on the impact of information technologies on medicine.

Tuesday, February 21, 2012

Doubling Down on the Sick, the Old, and Doctors Who Care for Them

Doubling down – To engage in risky behavior when one is already in a dangerous situation.

Urban Dictionary definition

February 21, 2012 - The news for the day comes out of Colorado. A survey of 100 Colorado primary care doctors indicates two-thirds refuse to accept or will limit care to new Medicare patients (Colorado Public News, February 21, 2012).

Here is how the reporter explained the methodology of the survey:

A survey of Colorado primary care doctors found most are reluctant to take a new patient on basic Medicare, the government health insurance for people 65 and over.

Colorado Public News
called family, general practice and internal medicine physicians across the state, using the nation’s official website that lists thousands of doctors the site claims treats patients on Medicare. Of 100 contacted, only 34 said they would readily accept a new patient."

"Of the remainder, 40 said they would not add a new patient on traditional Medicare. Another 26 limit new clients, making decisions on a case-by-case basis, or placing patients on waiting lists of up to six months. That adds up to 66 – or two-thirds – refusing or limiting new patients."

"The questions focused on traditional Medicare, which is used by most recipients.
Several doctors said they hesitate to take Medicare patients because Medicare doesn’t pay enough, pays late, and can require a nightmare of paperwork and repeated telephone calls.”

A survey of 100 doctors is not big enough to be statistically significant, but it is a danger sign for Obamacare. The health reform law cuts $575 billion out of Medicare over the next 10 years, just as 78 million baby boomers are entering Medicare at the rate of 12, 000 a day over the next 18 years and as 32 million are scheduled to enter Medicaid in 2014.

This is at a time, when the Association of American Medical Colleges estimates by 2020, there will be 45,000 too few primary care physicians and 46.000 too few surgeons and other specialists.

In my 1988 book, my title asked “And Who Shall Care for the Sick?”

I was referring then to the deleterious effect of managed care on the physician supply. Now the same question applies to Medicare, which has adopted similar techniques of business management to control physician economic and clinical behavior.

These techniques include: pre-treatment certification, utilization review, standardization of care, treatment of medicine as strictly a business rather than a profession, quality and outcome management, capitation, bundling, and codification of fees with funneling of payment to doctors who follow government mandates.

These management techniques come at a price – physician shortages because of the decreasing attractiveness of medicine as a profession. Doctors do not look favorably at third party intervention into clinical affairs, whether by government or corporation. Bright students may respond by not becoming doctors. Doctors may abandon the profession, refuse to accept Medicare or other 3rd party patients, enter into cash-only, direct pay, or concierge practices devoid of third party payers.

The magnitude of the physician shortage, and who shall for care for the sick, is not apparent yet. But it may when the Physicians Foundation completes its e-mail survey of 650,000 physicians this year. The survey will ask how doctors react to reform and what they plan to do in the near future.

The survey results will come after the Supreme Court decision on the constitutionality of the individual mandate and other aspects of Obamacare and before the November presidential election.

Meanwhile and after, the sick and the old still be with us, and they will demand and seek doctors to care for them.

If government continues to double down on doctors, the doctor shortage will accelerate. Declining access to doctor care will become a political time bomb.

Tweet: In a survey, two-thirds of Colorado primary doctors say they will not accept or will limit care to Medicare recipients.

Monday, February 20, 2012

Grading President Obama’s Performance – 2009-2012

To be toasted and roasted at the same time is a lost art.


February 20, 2012 – It’s President’s Day. I take this occasion to grade President Obama’s performance over the last three years based on a toast I gave to him in my 2009 book Obama, Doctors, and Health Reform (IUniverse, 2009). The grades are A (exceptional or superior ), B (good or satisfactory), C(adequate or average). D ( inferior or subpar), F (failure), and I (Incomplete). This is a subjective exercise and represents the views of one doctor.

A Toast for President Obama (2009): Retrospective Evaluation

To the fulfillment of your dream - A

To the content of your character-B+

To hope - C-

To change – C-

To vision – B

To audacity – C

To equality – B

To selflessness – C-

To unity – F

To fairness – C

To idealism – B

To realism – D

To coverage for all –I

To access for all – I

To more doctors with more access – D-

To healers of every specialty – C-

To the sick in need of care – B+

To affordable care – D-

To health care savings accounts – F

To clinical information systems – B+

To more prevention – B

To more personal responsibility – C-

To the right foods – B

To more exercise – B

To no smoking – D

To less obesity and diabetes – B

To less chronic disease – B

To better outcomes – B

To comprehensive care – B

To coordinated care – B

To top-down dispensation – A

To bottom-up innovation – D+

To doctor accountability – B

To financial transparency – D

To multicultural fluency – A-

To freedom to choose – D+

To freedom to pay – D+

To free exercise of judgment – C-

To revamped Medicare doctor pay – D-

To reasonable Medicare reimbursement – D-

To malpractice reform – F

To clinical collaboration - B-

To respect for markets – F

To less intrusive government – F

To feasible individualism – C

To reasonable collectivism – C-

To less regulations and hassles – F

To a sustainable health system – D+

To the end of free entitlements – F

To economic recovery - C-

To you and your family – A

To your health – A

To the health of the nation – C

To fiscal sanity – D-

To the preservation of capitalism – D-

Overall grade, based on average of above - C

Tweet: Based on health reform performance from 2009-2012, President Obama deserves an overall grade of C, with less favorable for Rx of physicians.

Sunday, February 19, 2012

EHR Story: Mastodons in Kitchen and Elephants in Refrigerator Come in from out of the Cold

The elephant in the room of what we’re trying to do is in the small physician practice. That’s the hardest part, and it will bring this effort to its knees if we fail.

David Brailer, MD, National Coordinator for Health Information Technology for Bush Administration, in 2005 New York Times Interview on prospects for universal national interoperative electronic record system

February 19, 2012 - Doctor Brailer’s 2005 comment came to mind as I was listening to Alan Simpson on a February 16 C-Span call-in show. The colorful, plain spoken 80 year old senator from Wyoming from 1979 to 1997 and co-chair of the Bowles-Simpson National Commission on Fiscal Responsibility and Reform, was talking about the U.S. budget deficit and failures to address it.

To one call-in viewer, Simpson referred to critics of the Bowles-Simpson plan as “mastodons in the kitchen” and “elephants in the refrigerator.” For the U.S. economy, Simpson was predicting, the Ice Age Cometh if we do not get our debt under control.

In health reform, the mastodons are the hospitals and the elephants are the doctors. Some critics consider hospitals and doctors as Ice-Age relics of modern information technology. When you strip away the rhetoric, the high-minded talk about ACOs, EHRs, Medical Homes, and demonstration projects, health reform success comes down to how fast hospitals and doctors adopt information technologies.

On April 27, 2004, President George Bush called for America to have a national interoprrative electronic health information system by 2014. Well, after nearly eight years of being out in the HIT cold, hospitals and doctors are finally warming up to HIT adoption.

Kathleen Sebelius, Secretary of Health and Human Services, has announced, as of February 2012, hospitals and doctors have received $3.12 billion in incentive payments for adopting “meaningful use” of EHRs. This is a fraction of the $27 billion the 2009 $787 billion stimulus bill set aside for HIT (Health Information Technologies). Never mind, it’s a start.

Sebelius says more than 2000 hospitals of the nation’s 5500 hospitals and 41,000 of its estimated 550,000 practicing doctors (estimates of the actual number of practicing doctors varies from 500,000 to 950,000) have adopted EHRs. For hospitals, HIT use more than doubled from 16% to 35% from 2009 to 2011. In January 2012,CMS paid $519 million to hospitals and doctors for HIT – a term used synonymously with EHR adoption. That leaves 3500 hospitals and roughly 509,000 doctors to go before EHR adoption becomes universal.

Hospitals and doctors are rushing to meet the February 29, 2012 deadline for the first year of incentive payments. Those who qualify will be eligible for the 2nd year of incentive payments. Sebelius estimates 65% of hospitals will take advantage of incentives by 2015. She has not projected 2015 figures for doctors.

But it is safe to say more mastadons and elephants will gather at the EHR payment trough by 2015. The government’s financial temptations -totaling $44,000 for each physician for Medicare incentives, $63.750 for each physicians for Medicaid incentives, and $2 million for each hospital in incentives incentives – will simply be too great to resist).

Of the HIT future, Secretary Sibelius says,

“Health IT is the foundation for a truly 21st century system where we pay for the right care, not just more care. Health care professionals and hospitals are taking advantage of this unprecedented opportunity to begin using smarter, new technology that improves care and creates the jobs we need for an economy built to last.”

How long our economy and our international creditors will tolerate expenditures of this magnitude will depend on the size of our national debt. Until then, on the other side of the ledger, the maxim “Pay them, and they will come” will hold true.

Tweet: CMS has paid hospitals and doctors $3.12 billion to adopt electronic health records, and the adoption pace is accelerating.

Saturday, February 18, 2012


I recently sent out a press release from the Publisher of my new E-book, The Health Reform Maze; A Blueprint for Physician Practices, in which I incorrectly identified the Health Reform Law (Obamacare) as the "Accountable Care Act" rather than by its correct name the "Affordable Care Act. " I apologize for th error.

Richard L. Reece, MD

Health Reform in Historical Context

He mastered Arabic so he could talk to people unfiltered by others. No other reporter covered the region with as much depth of knowledge, cultural awareness, and historical context as Anthony Shadid.

Rick Gladstone, “Ex-Globe Reporter Dies in Syria”, Boston Globe, February 17, 2012

February 18, 2012 – When one writes about a long-drawn-out conflict, whether it is fighting in the Middle East or controversy over health reform in the United States, historical context is important. So are depth of knowledge, grasp of culture, and mastery of language. In health reform that language mixes bureaucratic , managed care, and medical jargon.

Shadid in Syria

When history, health care, and technology intersect, historical context becomes even more important. Anthony Shadid, a 43 year old year old, Oklahoma City born and bred American of Lebanese descent, two –time Pulitzer Prize winner, died at that intersection from a bout of asthma while reporting from inside Syria on a historic conflict sparked, in part, by the social media. His legacy will be a body of work, including his dispatches from the Middle East and three books, that put the Middle East in historical context. Shadid’s approach was to accumulate masses of revealing past and present detail to drive a narrative about ordinary people trapped in conflict.

J.D.Kleinke in the U.S.

On the health reform front, J.D. Kleinke is Anthony Shadid’s counterpart. Kleinke is a resident fellow at the American Enterprise Institute. He is a health care information entrepreneur, medical economist, business strategist, and reporter. He helped create four health care information organizations; served as a Wall Street Journal columnist, advised Democrats and Republicans on pragmatic approaches to health policy and legislation; and long advocated a data-driven, post-partisan health care system. Kleinke’s books include: Bleeding Edge: The Business of Health Care in the New Century Oxymorons: The Myth of a U.S. Health Care System, Catching Babies.

Kleinke’s latest WSJ article “The Myth of Runaway Health Spending,” dated February 17,2012, puts to rest the claim that government intervention is required to put the brakes on out-of-control spending.

Using CMS data, Kleinke shows health cost increase rates have been steadily moderating from 9.4% in 2002 to 3.9% in 2012, thanks to more effective generic drugs; positive changes in consumer behavior engendered by electronic information, pressure from various market disciplines, and transfer of health care responsibilities from government and corporate bureaucrats to consumers and their families.

Kleinke Position on Health Reform

Kleinke advocates a continuing transition to a market-driven system. He closes his article with these words.

“The decade-long trendline shows the way toward good policy for the future. If we really want to tame the health-care cost beast and make insurance "affordable," we would double down on all of the positive developments. “

“We would liberate people with their own money from layer upon layer of arcane, localized insurance rules. We would fix the tax code to uncouple health insurance from employment and let people purchase their own mix of services and coverage. And we would let them do so in a competitive, national market just like with auto insurance—instead of holding them hostage in fragmented, local markets while shaking down their employers to subsidize a system that wants desperately to change itself.”

Tweet: Historical context, cultural knowledge, and long-term trends are important when evaluating health reform and other conflicts.

Friday, February 17, 2012

Government Committee Mandate

A committee is organic rather than mechanical in nature, it is not a structure but a plant. It takes root and grows and flowers, wilts, and dies, scattering the seed from which other committees will bloom in their turn.

C. Northcote Parkinson (1909-1993), Parkinson’s Law(1957)

February 17, 2012 - Scott Gottlieb, MD, a physician and resident fellow at the American Enterprise Institute, former deputy commissioner of the FDA, and senior advisor to CMS, wrote a 2/16/12 WSJ Op-Ed, “Meet the Obamacare Mandate Committee.” It was Gottlieb’s version of the maxim,” A committee is a camel designed as a horse.”

Gottlieb’s thesis was: “Under Obamacare, a single committee – The United States Preventative Services Task Force – is empowered to evaluate preventive health services which will be covered by health insurance services.” Gottlieb implies this Committee, like the camel, he implies suffers from poor design.

The committee will rate services from “A” to “D”, or as ”I” if there is insufficient evidence to earn a rating. Those services rated as “A’ or “B”, e.g. colon cancer screening for adults aged 50-65 or mammography in women over 50, will be covered “free” without co-pays, Those rated as “C” or “D” –e.g. routine screening for prostate cancer for men over 65 or women at any age for ovarian cancer – may not be covered at all.

In November 2009, the Committee ruled woman, aged 40-49, should not get routine mammograms. Women and doctor organizations were outraged Recently, the Committee ruled routine PSA and cervical cancer screening was a bad idea.

As far as I know, the Committee has not committed itself on the ticklish issue of whether health plans should offer oral contraceptives and other birth control measures for free, but that too may come. It will probably follow President Obama’s lead.

The Committee’s grade require a randomized prospective screening. Consumers and physicians often react with outrage because the Committee’s findings are often out of sync with their expectations or traditional practices.

No matter. The Committee is exempted from government’s traditional advisory and regulatory services rules, just as the Independent Payment Advisory Board will be. The Committee’s meeting are private. It has no obligation to release its minutes. Its decisions are not open to public hearings and cannot be appealed.

Gottlieb says, at a minimum, the Committee should be subject to the Federal Advisory Committee Act. This would make its deliberations public and subject to the rules of the Administrative Procedure Act that binds other regulatory bodies. All of them are required to consider public comment and provide avenues for appeal.

The Committee can now make unilateral edicts, like forcing insurers to pay for pregnancy prevention or termination. This, he adds politely, is an “initial exploit of an elaborate new system, ” signaling more “exploits “ will follow.

This Committees’ actions, in turn, raises questions:

--Should a government committee have the power to dictate to private employers and health plans to provide something for “free’?

--Is this the American way of democracy? Should private companies be forced to pay for, even it violates their moral sensibilities and religious consciences?

--Should the public and the profession have a voice in these matters?

--Does one-size-fit-all in a pluralistic society?

Federal government has a Committee, the Preventative Services Task Force, that decides what health plans must offer for “free.”

ICD-10 Delay( WARNING: This is Complicated Stuff)

I attempted to rise, but was not able to stir: for as I happened to lie on my back, I found my arms and legs were strongly fastened on each side to the ground; and my hair, which was long and thick, tied down I the same manner. I likewise felt several slender ligatures across my body, from my armpits to my thighs. I could only look upwards, the sun began to grow hot, and the light offended mine eyes. I heard a confused noise about me, but in the posture I lay, could see nothing except the sky.

Jonathon Swift (1667-1745), Gulliver's Travels

February 17, 2012 - Before yesterday, government’s bureaucratic Lilliputians have been planning to tie down physicians with another mandate, the ICD-10 code.

Thank goodness, Kathleen Sebelius, HHS secretary, has announced physicians won’t have to comply for the time being with ICD-10, short for International Classification of Diseases 10th edition”.

ICD-10 was to replace ICD-9, the coding system by which physicians are now paid.

The new ICD-10 code would require physicians to completely revamp their practice management systems. It would distract from patient care. It would come at great cost and confusion. It would take overhauling and reprogramming existing computer programs. It would drive physicians out of private practice into the arms of large organizations with technological and administrative resources.

According to HFMA (Health Management Finance Association), carrying out the transition to ICD-10 would take the following steps.

--Establishing a project management team

--Creating an implementation plan

--Producing and projecting a timeline

--Preparing a gap analysis for each department or system

--Calculating and preparing for impact on the revenue cycle


As I forewarned in my blog title, this is complicated. Unfunded government mandates cost money, time, energy and distract from patient care.

These mandates, I submit, require a tremendous expenditure of time, money, and energy to adjust to bureaucratic demands. About 70% of medical practices have 10 or less members. These practices do not usually have the money, time, or resources to prepare for or to carry out these actions.

Other Complicated or Anticipated Mandates

The delay allays tremendous anxiety among physician and physician practice managers’already struggling to rise above other Lilliputian mandates.

• Electronic health records, to be rewarded or punished on basis of “meaningful use

• Transition to 5010 HIPPA Standards

• The uncertain legal status of the Accountable Care Act, presumably to be resolved by the Supreme Court in June.

• The concentrated push for Accountable Care Organizations

• Constant calls for bundled billings and doing away with fee-for-service.

• Incessant chatter about the matter of new modes of physician practice.

Doctors have enough on their bureaucratic plate to tie them down and to distract them from patient care.

Tweet: CMS has delayed its unfunded ICD-10 coding mandate which would require revamping of physician management systems at great cost and confusion.

Thursday, February 16, 2012

Doc Fix – Robbing Peter to Pay Paul

To rob Peter to pay Paul.

John Heywood (1497-1580)

He robbeth Peter to Pay Paul.

John Florio (1553-1625)

Give not Saint Peter so much to leave Saint Paul nothing.

George Herbert (1593-1633)

February 16, 2012 - No matter how you slice it, who you quote, and who you steal it from, the tentative doc fix is about robbing Peter to pay Paul. It is a zero sum game.

The fix proposal would cut The Prevention Fund by $5 billion, and make up the rest, which amounts to $50 billion over the next decade, by cutting Medicare payments to most hospitals and other providers as well as Medicaid payments to hospitals serving the poor.

In addition, the fix would gut $2.5 billion in Medicaid fees to Louisiana, the amount originally designated for the “Louisiana Purchase” because it was said to buy Senator Mary Landrieu’s vote to pass the Accountable Care Act.

Of the $50 billion, about $20 billion would go doc fix and Medicare extenders package. It would take $9.6 billion in cuts from clinical laboratory services and Medicare “bad debt” and from nursing homes whose patients can’t pay. It would reduce Medicaid “disproportionate share” payments to hospitals by $4 billion.

It would slash additional payments for mental health services and bone density scans. It would phase out payments to rural hospitals for high labor costs and payments for technical services provided by pathologists.

What a deal, It would steal from hospitals, nursing homes, mentally ill, and other doctors to pay doctors for the rest of the year.

A billion here and a billion there, from here and there, and pretty soon, like next week when Congrees goes on vacation for President’s day, you can seal the deal.

Tweet: The “doc fix”deal is imminent. It will cost $50 billion over 10 years and will take money from other health care providers to pay doctors.

Wednesday, February 15, 2012

Obama Budget Would Cut $360 Billion from Medicaid and Medicare over Next 10 Years

Balanced budget requirements seem to more likely to produce accounting ingenuity than genuinely balanced budgets.

Thomas Sowell (1930- ), Hoover Institute

February 15, 2012 – In its 1252 word summary of the president’s 2013 budget, gleaned from 300 news organizations, Kaiser Health News concludes: “Cuts, which would be made over 10 years, would come primarily from reduced payments to drug companies and health care providers.”

Reduced payments would be comprised of:

• $236 billion from drug companies, including $156 billion in discounts for seniors and other rebates.

• $36 billion from hospitals, including $19 billion in cuts for residency funding.$664 million from CDC.

• Unknown $ billions from doctors because of uncertainties of “doc fix,” though ACA stipulates doctor fees for Medicare would be below those for Medicaid by 2019, and cuts are already occuring for high tech specialities like radiology, orthopedics, and cardiology.

Starting in 2017, billions of more dollars would be “saved” by raising premiums for new baby boomer retirees and well-to-do seniors (means testing), charging co-pays for seniors and penalizing Medigap policy-holders with higher copays and higher deductibles for part B (doctor services part D(prescription services).

It remains is doubt, wWhether this budget:

-- is a real budget plan or merely a campaign document;

-- has the political will exists to make “deep cuts” in Medicaid and Medicare;

-- the Senate has the guts to implement a budget;

--the Supreme Court renders impotent Obamacare;

--Democrats will retain the balance of power after November 2012.

Only one thing is certain: balanced budgeting can always be counterbalanced by fudgeting it.

Tweet: President Obama’s $3.3 trillion 2013 budget would cut $360 billion over next 10 years, mostly from drug companies and health providers.

Tuesday, February 14, 2012

Balancing Obama Budget: Tip-A-Canoe Thoughts

Every man paddles his own canoe.

Frederic Marrymat (1792-1848), early pioneer of sea stories

February 14, 2012 - Jerry Brown, current and past governor of California, a state with a budget deficit of over $20 billion, once wrote:

“Politics is like paddling a canoe. You paddle a little on the left, and you paddle a little on the right, and you try to stay in the middle.”

In my canoe, each morning I do my paddling by reading the lead editorial in the New York Times , then reading the lead editorial in the Wall Street Journal, and balancing the two without tipping over the canoe, although sometimes I find myself righting it.

New York Time’s Lead

Today of President Obama’s $3.3 trillion budget, the Time’s lead editorial “ A Responsible Budget” leads off:

President Obama’s 2013 budget was greeted with Republican catcalls that this is a simply a campaign document, but budgets are supposed to explain priorities. This one offers a clear and welcome contrast to the slashing austerity - and protect the wealthy priorities –favored by Republican leaders and the party’s presidential candidates.

Wall Street Journal’s Lead

Its lead paragraph in “The Amazing Obama Budget “reads:

Federal budgets are by definition political documents, but even by that standard yesterday’s White House proposal for the fiscal year 2013 2013 is a brilliant piece of misdirection. With the abracadabra of a tax increase on the wealthy and defense cuts that will never materialize, the White House asserts in President Obama’s second term, revenues will soar, outlays will fall, and $1.43 trillion deficits will be cut in halflike the lady in the box on the stage.

NYT and WSJ Conclusions

The NYT concludes of the budget,

As it is, the budget will go nowhere, largely because of the Republican refusal to raise taxes on the wealthy and to spend money on vital programs. Senate Democrats, who don’t want to make political choices, share the blame. They have already said they do not intend to pass the president’s or their own budget.

The WSJ retorts:

His plan would raise tax rates across the board on anyone or any business owner making over $200,000 for individuals and $250,000 for couples. These are the 3% of taxpayers that Mr. Obama says aren’t paying their fair share though that 3% pays more in income tax than the other 97%.

Where does this leave us? Up a creek without a paddle.

NYT says the Obama budget is “responsible.” WSJ says it is “misdirection.” Either way,defense,healthcare,”wealthy” take hits.

It's Valentine's Day

February 14, 2012

It’s time to show, my Dear Lady Fair,
There’s more to life than health care.

It’s time for romance,
To ask, may I have this dance?

It’s time for red and pink,
To show these colors are in sync.

It’s time to ask, Will you be mine?
My sweet, everlasting Valentine.

It’s time for hearts and flowers,
To show love’s greater powers.

It’s time for chocolate candy,
To show that candy is dandy,

It’s time for the Valentine’s curse
Bad but well-intended verse.

It’s time for Valentine’s day,
To put our love on display.

It’s time for a love tweet,
My Sweet.

Monday, February 13, 2012

Will Big Doctoring Be Big Enough Quickly Enough in Time to Help Health Reform?

Big Doctoring is about a way of medical life, an approach to health care and healing, a skill set, and a mindset that is called primary care.

Fitzhugh Mullan, MD, Big Doctoring in America, Profiles in Primary Care , University of California Press, 2002

February 13, 2012 – In my last blog, I used the term ”big doctoring” to describe primary care. With the primary care doctor as the entry point of patients into the system and as the point of referral to specialists and hospitals, policy experts believe more primary care physicians will be central to effective health reform and to bringing down costs.

If you don’t believe me, I invite you to read two pieces that appeared today in the media, one out of the U.K. , the other out of Washington, D.C.

• Richard Hoey, editor of Pulse, a weekly magazine for U.K primary care physicians, wrote the first “Minders of the Gap.” Hoey uses the word “gap” to refer to the management of care by NHS bureaucrats versus general practitioners. David Cameron, the British Prime Minister, and his government colleagues believe GPs can handle health reform more efficiently than government bureaucrats. In the U.K,GPs are they lynchpin of the health system. GPs all use EHRs,they often have incomes greater than specialists, they are highly trained in management, and they are valued for their ability to handle as many patients as possible without referral to specialists or hospitals. The UK has handed over much NHS management from bureaucrats to GPs. The thought seems to be GPs can keep referral rates to a minimum. The average is now 4%. The Prime Minister and his team envision a health service run by doctors, not bureaucrats. The British health secretary, Andrew Lansky, believes GPs will make or break the NHS.

• The second media piece appeared in today’s Washington Post under the title “Success of Health Reform Hinges on Hiring 30.000 Primary Care Docs by 2015.” The author never clearly explains why 2015 and where the 30,000 will come from. Enough nit picking, now to the problems. The writer notes that 1/3 of medical students have educational debts over $200.000, that primary doctors earn $29.58 an hour while specialists earn $74.75, and that hospitals tend to hire specialty residents rather than primary care residents because specialty residents bring in about twice as much money per hour. Government seeks to remedy the primary care shortage through various means, including paying them more and a program called Primary Care Residency Expansion in 82 hospitals. This is a drop in the bucket in increasing the number of primary care doctors practicing out there across the country. Besides, will more U.S. primary care physicians be the centerpiece of a more effective U.S. health care system, when one considers certain features of U.S. culture? If the failure of managed care’s gatekeeper campaign in the 1990s to dampen referral to specialists is any indication, probably not. U.S. health consumers do not like to be told where and to whom to go for care. The fact that applications for primary care residencies increased by 20% from 2009 to 2011 is a good sign, but the reality that specialists make on average $150,000 per year less than some specialists remains a powerful deterrent to medical students deeply in debt.

Tweet: Health experts believe more primary care doctors are key to effective health reform and 15,000 more of these doctors are needed.

Sunday, February 12, 2012

Big Data, Big Doctoring, Big Savings?

It’s a revolution. We’re just getting underway. But the march of quantification, made possible by enormous new sources of data, will sweep through academia, business, and government. There is no area that is going to be untouched.

Gary King, director of Harvard University’s Institute for Quantitative Social Science, “The Age of Big Data,” New York Times Sunday Review, February 12, 2012

Big Doctoring is what the generalist does: doctoring that embraces the whole person that values comprehensiveness. that welcomes the richness and the complexity of the complete human being.

Fitzhugh Mullan, MD, Big Doctoring in America: Profiles in Primary Care, University of California Press, 2002

February 13, 2012 - The Big Question for the day is: Will Big Data and Big Doctoring save Big Money?

It is not an idle question, nor is it theoretical.

Let me explain.

Big Government and Big Data

Big Government is banking on Big Data to save Medicare, Medicaid, and other entitlement programs. The Affordable Care Act is counting on Big Data to save Medicare by making care more affordable and better. For these purposes, CMS has created an agency called PCORI (Patient-Centered Outcomes Research Institute)to save the government money as part of the Affordable Care Act.

PCORI. its advocates proclaim, will deploy rigorous and transparent data analysis to help people make informed health care decisions to improve care and outcomes while saving money.

The initial budget for the pilot PCORI project is $50 million. This is peanuts by federal standards. The budget will surely grow to meet its good intentions and expectations. Whether it will save money is questionable. No doubt it will require more federal employees.

Big Insurers and Big Data

Big Health Plans, like UnitedHealthcare, are counting on Big Data. America’s biggest insurer is changing how it pays hospitals and doctors based on Big Data. By 2015, United plans to roll out a data-geared plan eventually covering 50% to 70% of the 5500 hospitals and 550,000 doctors in its network.

“This “says Sam Ho, MD, United’s chief clinical officer, “is not just an exercise or pilot.” United is planning Big. Ho says Big Data will save from $1.35 to $3.27 per member per month. It will earn twice as much as it costs.

Savings for hospital will be tied to Big Data on readmissions, mortality for certain diseases, hospital-acquired infections, and patient satisfaction.

For doctors, data will be collected and analyzed for hospital admissions, ER use, total cost of care, and number of patients receiving immunizations and preventive screening.

The Big Assumption, I assume, it that hospitals and doctors can control these Big Variables, and doctors should be rewarded or punished on that basis.

Big Doctoring and Big Data

This Big Data gathering, analyzing, and mongering will be linked to Big Doctoring – more primary care practitioners directing and controlling care in Accountable Care Organizations, more bonuses and incentives for generalists for improving data-based outcomes and practicing in patient-centered medical homes offering preventive, coordinated, and continuous care with fewer duplications of care. If only primary care doctors play a bigger roll, the reasoning goes, care will improve and so will efficiency and outcomes.

Tweet: CMS & insurers plan data-based payments to hospitals and physicians to change clinical behavior,save money,and yield better outcomes.

Search for Health Care Startups

Ask and it will be given, seek and you shall find.

Matthew 7:7

Attempt the end, never stand in doubt,
Nothing’s so bad, but search will find it out.

Robert Herrick (1591-1674)

February 12, 2012 - Yesterday I was reading The Health Care Blog (THCB). There I ran across “Startups: The Other Health Trend Revolution” by Rick Choi. Choi is a San Francisco pediatrician and Internet nerd. He was just back from The Health Innovation Summit, organized by Rock Health, an incubator California firm in search of venture-fundable startups.

Of the HIT revolution he has just witnessed in action, Choi observed “The revolution ushered in electronic health records (EHR) is less about technology than the widespread impact it will have on patient care.”

Like Choi, I am in search of health care startups. I may include them in a book I may be collaborating on about health care startups and lessons learned from successful and failed ventures.

The word “search” encapsulates the Internet's promise. With its search engines, the Web is transforming medicine. These search engines, with Google as the grand daddy of them, facilitate searches by physicians and patients for solutions, options, everything, and anything related to health care.

That is why health care start ups want to move up the SEO (Search Engine Optimization) scale to get their ideas and products noticed and funded.

Choi lists these ideas and start-ups as candidates for venture funding.

Cardioo – a device measuring heart rate in a few seconds by scanning your face.

Health Tap, Inc – a startup based in Palo Alto, California. It seeks advice from participating physicians about treatment options and was recently featured in the New York Times (“Advice for the Ill, and Points for Doctors”.

Docphin, Inc - This firm has developed sensors to help monitor and measure posture causing back pain. It says that 80% of Americans suffer back pain sometime in their life and that back pain costs us more than $50 billion each year.

Azumio, Inc - This firm quantifies levels and psychological and physical stress and has raised $2.5 million from Founders Fund, Accel Partners, and Felisce Ventures. Its devices can be accessed by Smart phones.

@Budge – Its product are being promoted via Twitter and are designed to help you systematically improve your health. @Budge has issued 251 tweets and has 655 followers.

I have no idea whether these firms' ideas and products will succeed. I do not know if they will receive the funding they seek. I do know search engines are transforming the health care landscape. And I know I have favorite startups of my own.

These include:

The InstantMedicalHistory(It allows patients, guided by a clinical algorithm, to generate their own medical record from home or the reception room, generates a narrative history, and saves doctors 6-8 minute a patient by quickly getting to the core of the patient’s problem);

Share Medical Systems (It markets a portable, no-risk device that permits a physician to evaluate the cause of shortness of breath, separates pulmonary from cardiac causes, and prints out the risks of hospitalization and death);

Emmi solutions ( it markets its product, which features video previews visually showing patients what to expect from a procedure of a medical problem, to hospitals and physicians).

Tweet: Venture capitalists are searching for ideas and products with a return on investment and the potential for transforming the health system.

Saturday, February 11, 2012

Is It True?

We hold these truths to be self-evident.

Declaration of Independence, 1776

February 12, 2012 – In any political campaign, each side seeks to convince voters that the truths it declares are self-evident, that it stands for social justice, individual freedom, and equity in all realms of life, business, government, and health care.

But all truths are not self-evident. Truths depend on how one spins them. This is true in health-care as well as other forms of human activity.

Is it true that the United States compares unfavorably to other countries in terms of longevity? Yes, it is true, but only if you just look at raw numbers. If you subtract U.S. deaths from violence and accidents, we rank right up there with the longest living in other nations. Violence seems to be one price one pays for freedom to behave as one pleases.

Is it true that doctors and hospitals are responsible for the high cost of care? Yes, it’s true. We health care professionals order and perform the tests that cost so much. But it’s also true that poverty and need, not greed, drives costs, and doctors and hospital cannot control poverty or the stage at which patients arrive with their illnesses. We can only respond to these factors and to other social forces beyond our control.

Is it true malpractice costs are high because of doctor negligence, carelessness, or chasing that extra buck? Yes, on rare occasion. But it is also true doctors are reacting to the U.S. “legal casino” system. By its rules, winners win big and losers lose nothing. And, it’s also true, if you’re a doctor, you cover your assets by practicing defensive medicine.

Is it true that women’s health issues in America have been neglected? They have been neglected, but only if you believe women are entitled to unlimited federal largess, if you classify routine or unwanted pregnancies as a “disease” rather than as ordinary health issue; if you believes sterilization, abortive drugs, oral contraceptives, and early abortions ought to be “free; and if you ignore the reality that the U.S, probably spends much more on breast cancer awareness than prostate cancer awareness, despite the more common occurrence of prostate cancer.

Is it true that that Americans lack access to care for diabetes, cancer, and to the technologies that restore life and life-style? Not if you consider comparative national statistics showing Americans survive cancer longer than in other nations, that they receive treatment for diabetes quicker, that they are referred to specialists faster, and that they receive hip and knee replacements within 6 months more expeditiously that other nations.

Is it true that that the American system lacks “value”; that it is “inefficient”, that it is bereft of “quality”, that fee-for-service encourages doctors to do more rather than provide “better care”, and that it lacks “coordination,” and promotes “duplication”? Sometimes, but 82% of Americans like the system the way it is, and we live in an imperfect democracy that believes in individualism and choice.

Is it true government can solve these problems by paying doctors to participate (and punishing them if they do not) in accountable care organizations, primary care groups, patient-centered medical homes, and by measuring and rewarding hospital quality (rate of readmission, imaging use, mortality and hospital infection rates patient satisfaction) and doctors (rates of hospital admission, ER use, total cost of care, percent of preventive tests recommended)? If you think this is a convoluted question, just wait and see how convoluted a bureaucracy it will take to enforce it. Still, itschampions say it's worth a try, even if private plans, market competition and incentives could do just as well – at less cost, more efficiency, and better outcomes.

Is it true we can do better? Absolutely, but it’s also a question of how we get from here to there, and how much by government controls and how much by private incentives.

Tweet: When one listens to health care promises during the national political campaign now underway, ask yourself “ It is true what they say?”

Friday, February 10, 2012

Is It Fair?

All’s Fair in Love, War, and Running for President

Title of 1994 book, by Mary Matalin and James Carville

February 10, 2012

“Is it fair that the richest 1% of Americans pay nearly 40% of all federal income taxes, and the richest 10% pay two-thirds of the tax?

Is it fair that the richest 10% of Americans shoulder a higher share of their country's income-tax burden than do the richest 10% in every other industrialized nation, including socialist Sweden?

Is it fair that American corporations pay the highest statutory corporate tax rate of all other industrialized nations but Japan, which cuts its rate on April?

Is it fair that Americans who build a family business, hire workers, reinvest and save their money—paying a lifetime of federal, state and local taxes often climbing into the millions of dollars—must then pay an additional estate tax of 35% (and as much as 55% when the law changes next year) when they die, rather than passing that money onto their loved ones?

Is it fair that after the first three years of Obamanomics, the poor are poorer, the poverty rate is rising, the middle class is losing income, and some 5.5 million fewer Americans have jobs today than in 2007?

Is it fair that roughly 88% of political contributions from supposedly impartial network television reporters, producers and other employees in 2008 went to Democrats?

Is it fair that the three counties with America's highest median family income just happen to be located in the Washington, D.C., metro area?

Is it fair that wind, solar and ethanol producers get billions of dollars of subsidies each year and pay virtually no taxes, while the oil and gas industry—which provides at least 10 times as much energy—pays tens of billions of dollars of taxes while the president complains that it is "subsidized"?

Is it fair that those who work full-time jobs (and sometimes more) to make ends meet have to pay taxes to support up to 99 weeks of unemployment benefits for those who don't work?

Is it fair that those who took out responsible mortgages and pay them each month have to see their tax dollars used to subsidize those who acted recklessly, greedily and sometimes deceitfully in taking out mortgages they now can't afford to repay?

Is it fair that thousands of workers won't have jobs because the president sided with environmentalists and blocked the shovel-ready Keystone XL oil pipeline?

Is it fair that some of Mr. Obama's largest campaign contributors received federal loan guarantees on their investments in renewable energy projects that went bust?

Is it fair that federal employees receive benefits that are nearly 50% higher than those of private-sector workers whose taxes pay their salaries, according to the Congressional Budget Office?

Is it fair that soon almost half the federal budget will take income from young working people and redistribute it to old non-working people, even though those over age 65 are already among the wealthiest Americans?

Is it fair that in 27 states workers can be compelled to join a union in order to keep their jobs?

Is it fair that nearly four out of 10 American households now pay no federal income tax at all—a number that has risen every year under Mr. Obama?

Is it fair that Boeing, a private company, was threatened by a federal agency when it sought to add jobs in a right-to-work state rather than in a forced-union state?

Is it fair that our kids and grandkids and great-grandkids—who never voted for Mr. Obama—will have to pay off the $5 trillion of debt accumulated over the past four years, without any benefits to them?”

Source: Stephen Moore, “ A Fairness Quiz for President Obama,” Wall Street Journal, February 6, 2012

Tweet: All’s fair in love,war,and politics, as long as it involves other peoples’taxes, and as long as you do what I say and not do what I do.

Thursday, February 9, 2012

The SGR Has Failed

Have something to say.
Say it.
Stop when you have said it.

An Editor’s Advice

February 9, 2012 - The Congressional formula for paying doctors and keeping health costs down, the SGR (Sustainable Growth Rate) Formula, has failed.

• It has failed because Congress can’t figure out how to fix it without busting the budget.

• It has failed because if the SGR were to go into effect this year with a 27.4% cut in doctor pay, physicians would flee Medicare and Medicaid in droves, leaving in its wake recipients of these entitlement programs without doctors to care for them

• It has failed because Congress has had to back off its implementation each year for the last 10 years, for fear of alienating seniors by depriving them of access to doctors, two-thirds of whom receive Medicare payments.

• It has failed because it fails to address the problem, indeed it exaggerates it, of a looming physician shortage, now 50,000, and growing daily.

• It has failed because it ignores the fact that physician incomes have remained flat for the last decade while practice expenses have risen 3-5% annually.

• It has failed because it fails to take into account that the typical medical school student now graduates with a debt of $150,000, the highest in the world

• It has failed because repaying this debt draws inordinate numbers of medical students into specialties in order to repay that debt.

• It has failed because Congress fails to acknowledge the present coding system, which it signs off on, underpays primary care physicians and requires the average doctor to hire a staff of 2 or 4 to figure out how to be paid.

• It has failed because it cannot admit that any government general formula, like the SGR, or the soon to fail ACO, has so far failed to save government or taxpayers money.

• It has failed because it fails to address the insatiable thirst of the public for access to doctors and for the technologies only they can deliver.

• It has failed because it fails to answer fundamental fairness questions, such as, “Is it fair that policies taxing America’s “rich,” those making over $200,000, which include many physicians, has caused the American “rich” to pay more in taxes than any other country in the world, including socialistic Sweden? Is it fair that the 3 richest zip codes in the U.S. are Washington, D.C. zip codes? (Stephen Moore, “A Fairness Quiz for the President,” Wall Street Journal, February 6, 2012).

• It has failed to show it understands that Medicare will go broke soon and that decreasing doctor pay will not ward off Medicare bankruptcy.

• It has also failed to say you cannot pay for the SGR fix by cutting hospital Medicare and Medicaid payments.

• It has failed to consider the alternative of “competition and market forces,” whose supporters have offered innovative ideas to save taxpayers and the government money.

There, I have said it. I will stop now.


Kaiser Health News – February 9, 2012 – 1. “Congress Struggles to Tackle Doc Fix”; 2) Discussion of SGR Fix Heats Up.”

The SGR formula, enacted by Congress in 1997, to contain doctor pay, has failed to lower costs and instead drives doctors out of practice.

Wednesday, February 8, 2012

“For- Profit” HCA Vs. “Not-for-Profit" Hospitals: Which is to be the Master

No margin, no mission.

Sister Irene Krause (1924-1998), CEO of Daughters of Charity National Health System

Profit is a condition for survival.

Peter Drucker (1909-2006), Social, Business, and Management Philosopher

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

Lewis Carroll (1832-1898), Through the Looking Glass (1892)

February 8, 2012 – Well, the news is out. HCA Holdings, Inc, the nation’s largest “for-profit” hospital system, with revenues of $33 billion, is making profits again and rewarding its investors. On February 6, HCA Holdings reported better-than-expected fourth quarter earnings and recorded a one-time gain from an investment, sending its shares up 6%. HCA says it did so by controlling expenses and reducing debts, even though its surgical volumes were down for the 3rd straight quarter. It also approved a special dividend of $2 per share for its stockholders.

This news may offend social purists. They insist there is no place in the hospital world for profit-making. One can have “ margins” to maintain facilities, update equipment, and pay employees, but one should not “profit” and certainly not reward stakeholders.

About two-thirds of U.S. hospitals are not-for-profit. The remainder are split between for-profit and government ownership. As yet, there is little sign for-profits are taking over the hospital universe or depriving the public of charitable care.

Instead, for-profits and not-for profits co-exist. There is room for both. They provide similar services for similar mixes of patients, contract with the same insurers and government payers, operate under the same regulations, employ staff with the same training and ethical obligations, and have the same needs to maintain margins to survive. Both are obligated to treat those who show up on their ER doorsteps.

The fundamental difference between the two is tax exemption for not-for-profits. Other than that, there may not be a “dime’s worth of difference,” other than chest thumping about the moral virtues of serving the community rather than investors.

Certainly, there are few signs of dire evolution of the dangers of a profit-making medical industrial complex predicted in 1980 by Arnold Relman MD, editor of the New England Journal of Medicine.

Thirty two years ago, Relman said,

“The new “medical industrial complex “may be more efficient than its nonprofit competitors, but it creates the problems of overuse and fragmentation of services, technology overemphasis, and ‘cream skimming,' and it may also exercise undue influence over medical health policy.”

Last year in the New York Review of Books, Relman extended his concern over profits to physicians by saying, in essence, “Thou shalt not profiteer.”

“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’s concerns may have been overblown. If anything, the not-for-profit sector has the same need for margins as its for-profit counterpart. Not-for-profit hospitals places the same emphasis on marketing, technology, and specialty profit-lines to maintain margins. These similar behaviors will only intensify as the health law cuts Medicare margins, and as the states struggle to meet Medicaid obligations by slashing hospital payments.

No doubt, on occasion, both sectors put profit before people to maintain margins. Whether for-profit hospitals are “fair” and have the right mix of equity, social justice, and profit-distribution, is in the eye of the beholder and is another ball of wax.

For both for-profit and not-for-profit hospitals, the same rule applies: Be Good, Do Good. Have a social mission and carry it out well enough to stay in business.

Tweet: For-profit and not-for profit hospitals have similar staffs, sources of payment, regulations, and social missions.. Both need profit to stay in business.

Tuesday, February 7, 2012

Coronary Artery Disease, Abraham Lincoln, and Me

It is true you may fool all of the people some of the time; you can even fool some of the people all of the time, but can’t fool all of the people all of the time.

Abraham Lincoln (1809-1865)

February 7, 2012
- When I think of coronary artery disease risk factors, I think of Abraham Lincoln.

As someone who had a coronary three years ago and as a doctor, I know you can reduce some of the risk factors some of the time; you can even reduce some of the risk factors all of the time, but you can reduce all of the risk factors all of the time.

If you have coronary artery disease, soon or late, some devilish risk factor may get you. You don’t know how. You know when. The first sign 30% of the time is sudden death. As with John Wilkes Booth, that risk factor may come when you least expect it.

It may come from adverse blood lipids – a high total blood cholesterol, an elevated LDL, a low HDL, high triglycerides, an unacceptable LDL/HDL ratio – or some combination therein. But luckily, that is not the case with me. Besides you can control lipids with statins.

It may come from persistently high blood pressure but again you can control that with drugs, exercise, or weight loss.

It may come from diabetes – which I don’t have.

It may come from life style overindulgence – eating too much of the wrong thing too much of the time – or from under-indulgence in exercising – which you control by following caloric guidelines on or by fitness programs pedometer-goal setting of 10,000 steps a day.

It may come from subtle inflammations – such as gout flare-ups or infections like urinary tract infection, prostatitis, and gingivitis – which you can identify and treat.

To some extent, you can control or anticipate these inflammatory conditions by measuring your blood counts or by recording your high-sensitivity C-Reactive Protein , which tends to be elevated in patients with coronary artery disease lurking in the shadows. You can even check for your CAC (coronary artery calcium).

There are factors you can minimize – like anger and unnecessary emotional and physical stress.

But alas, there are always those things that are beyond your control – your age and gender.

Tweet: When you have coronary artery disease, to a certain extent you can control its risk factors, but you can’t control your gender and your age.