Saturday, March 31, 2012

The Great Deceit:  Insurance Does Not Equal Care       

Everything that deceives enchants.

Plato (426-348 BC), The Republic

One who deceives will always find those who allow themselves to be deceived.

 Niccolo Machiavelli  (1469-1527),  The Prince XVIII

At the heart of heart of the multi-headed abominable creature know as Affordable Care Act, aka Obamacare, there lies a singular deceit…Insurance does not equal care. One patient’s needs can get in the way of another’s needs. My waiting room is like so many others in America, and when it is clogged with several patients with low-paying highly-regulated insurance, the waiting time goes up and the access to quality medical care goes down.

Marc Seigel, M.D., Practicing Internist and Professor of Medicine at NYU, “What a Doctor Knows about Obama care,"New York Post, March 31, 2012

March 31, 2012 –  Perhaps the cruelest irony of Obamacare is that under its rules, regulations, and mandates,  people will receive less not more care

In other words,  the health law promises more care but delivers less care. The enchantment of Obamacare is, of course, is that it will provide universal  insurance coverage, hence automatic medical care, for all Americans. In medical practices, that is not the case.

In today’s New York Post,  Marc Seigel. M.D.,  demolishes this myth, or “deceit,” as he likes to call it.   In no uncertain terms, he says federally-mandated insurance will not translate into more care, patients will have a harder  time finding a doctor to care for them,  many people will lose their employer-based insurance,  and Medicaid patients and the newly uninsured will clog emergency rooms.

Here are excerpts from the Seigel article:

“A false premise of ObamaCare is that mandating insurance for all somehow enables the ERs take care of all comers. In fact, studies show that Medicaid patients are much more likely to use the ER unnecessarily than are the uninsured. This clogs the ER and interferes with life-saving treatments for other patients.”

“Plus, the states, overburdened with administering the Medicaid expansion, will inevitably cut reimbursements to the hospitals, lowering the bottom line payments a hospital receives even as its volume increases.”

“Though politicians may even have the best of intentions when they compel you -- in defiance of the Constitution, in my opinion -- to purchase a product known as health insurance, in fact they are not even achieving their stated goal of providing for the public good, since this insurance doesn't equal care.”

“Two years ago, when the law was passed, there was a pocket of patients who worked part time, had no health insurance, and looked forward to the day when they would be covered. But that early group of optimists has given way to a much larger group who worry that they will lose the employer-provided coverage they now have, and end up being forced to the state exchanges where they will be compelled to purchase (if the mandate survives) a policy they can’t afford with an inadequate federal subsidy.”

“Most of my patients are rooting for the Affordable Care Act to unravel especially if the individual mandate is declared unconstitutional. -- Transcripts and audiotape from the court this week make this possibility appear likely.”

“If ObamaCare somehow survives with or without the mandate, 16 million new Medicaid patients will quickly find out what current Medicaid patients already know; that it is very tough to find a doctor or network of doctors who will work with your insurance.”

“ObamaCare’s Independent Medicare Advisory Board and other regulatory committees and mandates will make it more and more difficult for doctors like me to practice and to order the tests and treatments we feel our patients need. We will require more staff hours to deal with all the red tape. As more of us drop out and no longer accept insurance, another unconstitutional mandate will become necessary to compel doctors to participate again.”

“Doctors everywhere are hoping and praying that dreaded day never comes. Even though the individual mandate and perhaps all of ObamaCare now appears to be in serious jeopardy thanks to the Supreme Court, doctors and their patients are not yet starting to breathe easier.”

Tweet:  Under the Affordable Care Act, aka Obamacare, the cruel deceit is that access to care by doctors is likely to decrease not increase.

Friday, March 30, 2012

A Blog on National Doctor’s Day
Honor a physician with the honor due onto  him, for the uses  of which ye may have of him.


It is an art, based to an increasing extent on the medical sciences but comprising much that still  remains outside the realm of any science.

Francis Peabody, MD (1881-1927), Care of the Patient

March 30, 2012 -  Do doctors make too much?  It’s an age-old question. Doctor often submit their fees when many patients are most  vulnerable and patients may not have enough information to judge their doctors  or to ask them to justify their charges.   This, being National Doctors Day, is an appropriate time to revisit the question: Do doctor make too much?   I don’t know, but I recall  a surgeon’s wife telling me:  “They don’t make enough.”

Do Doctors Make Too Much? Something to Think About on National Debate on Health Reform

By Phillip Miller, VP of Communications, Merritt Hawkins and Associates, Irving, Tecxas

“Imagine if every January your employer or your top client threatened to cut your earnings by as much as 30 percent."
"That’s the bind physicians are in today, with no resolution in sight. Because of cost overruns, federal law requires that cuts be made to physician Medicare fees in order to balance the ledger. Each year Congress delays the cuts, but they continue to loom, and everyone knows something has to be done about it. A commission that advises Congress recently came up with a plan for fixing the problem. It suggested that Medicare fees to physician specialists be cut by six percent for three years and then be kept flat thereafter."

"While Congress hasn’t agreed yet on how much physician pay should be reduced, the idea that doctors can afford a financial hit appears to be generally accepted. The fees doctors are paid by both government and private payers have been flat or declining for years, while practice expenses have increased. Many physicians have had to see more patients just to tread water. Thousands have given up on private practice altogether and have become hospital employees. There even have been recent reports of doctors going out of business."

"So far, however, no one is protesting in the street. After all, everyone knows doctors make too much."

But Do Doctors Make Too Much?

"Or do they? Primary care physicians such as family doctors and internists earn an average of about $180,000 a year. That’s after completing four years of college, four years of medical school, and three to four years of residency training. Typically, they accumulate $150,000 or so in debt in the process. Though they make a good income, primary care doctors still have to sweat their mortgages, worry about college tuition, and live the comfortable but constrained lives of normal middle class people. That fancy yacht at the marina or luxury car in the parking lot does not belong to your local FP."

"Medical specialists are in a different category. They typically earn $250,000 to $400,000 a year, and some earn considerably more. This puts them in the same general class as successful attorneys, stock brokers, corporate executives, bankers and entrepreneurs. Unlike other professionals and business people, however, medical specialists have little control over what they charge. In an open market, a top surgeon might be able to charge one million dollars to repair a wealthy hedge fund manager’s heart – and get it. Or, perhaps competition would lower the going rate for quadruple bypass surgery and other complex procedures to a few hundred dollars."

"It is unlikely we will ever know, but I am inclined to think the public would put a high premium on the skills of those who can diagnose illness, repair a heart, reverse cancer, ameliorate pain, restore motor function, or give back to a child her smile. Reducing the rewards given to those with such skills assures that they soon will be fewer in number -- and they already are in short supply. Compensating physicians well is entirely appropriate given the high bar to entry to their profession, the responsibilities they assume, and the lives they save or enhance."

"Just something to think about on March 30 – National Doctor’s Day.”

Phillip Miller is Vice President of Communications for Merritt Hawkins and Staff Care, companies of AMN Healthcare. He can be reached at

Tweet:   Do doctors make too much? It depends.  Primary care doctors scrambling to survive economically, well-paid specialists saving and improving  lives, or patients benefiting from skills of both and paying doctor bills?

Thursday, March 29, 2012

Health Reform Law: It’s a Long, Long Time from March to November

Oh, it’s a long, long time

From May to December

But the days grow shorter

When you reach September.

September Song (1930)

March 29, 2012 -  In politics, a month is a lifetime, and 7 months is an eternity.   It’s four months  from now to late June when the Supreme Court issues its ruling on the health law,  and it’s seven months until the election.  

No one knows what will happen between now and the election. But whatever occurs,  it will be a psychological and political time.  

Democrats will put on a brave face. They will say  it’s not over until it’s over and the fat lady sings, that the individual mandate was originally a Republican and Romney idea,  that the justices will come to their senses,  that this whole exercise is a moral not a constitutional issue.

Republicans will say that  the health law is  a train wreck, that it was rooted in ego and arrogance of an overly ambitious president,  that Democrats poisoned the whole politics process by completely  ignoring the other party and the American  public, and that the whole idea  of individual and Medicaid mandates is toast.
 If they are smart, and there is no guarantee of that,  the GOP  will issue a detailed alternative plan resting on incremental market reforms with proper government oversight.

Inaction “ on Massive Scale

Over the next seven months,  we are likely to have “inaction,” if I may borrow a term from the hearings,  on a massive scale.   

·       The states, particularly the 27 who brought the suit to the Supreme Court,   will stall or stop implementation of health exchanges.  

·       The Obama administration  will  step back and concentrate on campaigning on other issues to divert attention from its failed health reform law.  

·       The Romney team will focus on economic growth to distract from Romney’s Massachusetts  health care legacy.

·       American businesses, large and small,  may hire at a modestly increased pace but will hold back because of continued uncertainty.

·       The Medical Industrial Complex- hospitals, physicians,  health plans, drug companies, nursing homes, rehabilitation  centers, drug  companies, medical device makers, and health IT companies – will continue to prepare for the nest millennium, with or without Obamacare.

Trends in Motion Stay in Motion

However,  certain trends in motion will stay in motion.

Paramount among these are:

·       Decline in private practice

·       Migration of physicians into concierge and other direct pay practices outside the province of 3rd parties

·       Consolidation of hospitals, physicians, and insurers into bigger entities to fend off government  and for leverage to negotiate with government

·       Renewed emphasis by employers on health savings accounts,  high deductibles,  and other cost-lowering strategies.

·       Decentralization of the system into smaller units outside the hospital and other non-institutional settings.

·        Increased use of telemedicine  and technologies to monitor and reach patients  in virtual  non-face-to face ways.

·       Altered behavior patterns by physicians and patients alike, prompted and accelerated by  social media and health IT corporations, as the nation seeks  more sensible and affordable approaches to health care.

Tweet:  The likely demise of current health law will retard its implementation but will not reverse reform trends already in motion.

Wednesday, March 28, 2012

Fee-for-Service Not Responsible for Health Cost Inflation

I like to be in America!

O.K. by  me in America!

Ev’rything free in America

For a small fee in America!

Stephen Sondheim (born 1930),  America (1959). Song in West Side Story

March 28, 2012 -  I agree with the sentiments expressed in the following blog, written by Greg Scandlen  for John Goodman’s Health Policy Blog, dated March 28, 2012. As an aside,  In my opinion,  Accountable Care Organizations are an elaborate and expensive  way around a problem that may not exist in the first place., but which has been created by a 3rd party payment system that creates a false illusion - that health care is free or virtually free. Health Savings Accounts with high deductibles sensitizing patients to true costs of care is an around the problem.

 Is Fee-For-Service the Problem?

Almost everyone involved in health care will tell you that the greatest problem in our system is that we pay on a fee-for-service basis. Almost everyone is wrong.

The logic is obvious – paying a fee for a service encourages providers to get more fees by providing more services. Ergo, we consume too much and spend too much. Ipso facto, getting rid of fee-for-service would result in fewer services and less spending. Case closed.

Well, maybe not.

In fact, almost everything we do in the course of our economic lives, we do on a fee-for-service basis. When we go to the movies, get our oil changed, have our roof replaced, buy a computer, get a haircut, hire a baby sitter, buy a steak dinner, get someone to do our taxes or defend us in a suit, we do it on a fee-for-service basis. None of it is particularly inflationary.

Yes, the providers of these services would like to sell us more units of service. But we have good reason to resist – we don’t want to waste our money on services we don’t need.

What is unique about health care is not fee-for-service, but third-party payment. Only in health care is there someone else picking up the tab for our spending.

If we applied the same third-party payment technique to any other segment of the economy we would get the exact same inflationary spiral we see in health care. I buy donuts from time-to-time. If those donuts were free at the point of purchase, I would buy (and eat) a whole lot more than I do today. The stereotype of cops eating donuts came about because the donut shops gave them away to the cops for free.

When I was working as a state-level lobbyist for the Blue Cross Blue Shield Association, I would attend meetings of the National Association of Insurance Commissioners (NAIC), the National Governors Association (NGA), the National Conference of State Legislators (NCSL) and a bunch of other organizations. These groups typically held their meetings in the ritziest hotel in Kansas City, New Orleans, San Diego, Boston or some other place that was easy to get to.

Never, not once, did I ever inquire what the room would cost when I checked in. Why should I? Blue Cross was paying for it. The cost made no difference to me whatsoever. Some years later when I went into business for myself and tried to attend the same meetings at my own expense, I became very interested in the cost of the rooms. Most of the time, I would stay at a cheap motel on the edge of town and drive to the meetings.

Ah, but health care is different, you might say. Yes it is. It is different because of third-party payment and for no other reason. The other reasons usually given are easily rebutted –

  • Information asymmetry (the providers know more than the patients). Of course, but that is also true of, say, criminal law or engineering.

  • Health care is essential to life. But it is far less essential than food or housing, which do not require third-party payment.

  • Patients are too fearful to make rational decisions. More fearful than if I were arrested and locked up at Riker’s Island?

·         Health care is complicated. As complicated as an iPad? I don’t think so.

Efforts to move away from fee-for-services or to control it never work very well. Witness capitation under managed care, or the RBRVS system of paying physicians under Medicare. Medicare’s system of price controls leads to absurd complexity yet does not reward physicians for the things that are most important to patients, such as kindness, patience, communication ability, friendliness – the qualities that humanize the medical transaction and that would be rewarded in any other segment of the economy not dominated by bloodless third-party payers.

It is about to get worse with the advent of the ICD-10 codebook. This will offer 140,000 separate billing codes, according to The Wall Street Journal, including “codes for injuries in opera houses, art galleries, squash courts, and nine locations in and around a mobile home, from the bathroom to the bedroom.”

It is not fee-for-service that is the problem, but the burden third-party payers put on patients and providers alike, without adding any value whatsoever.

Tweet:  The problem behind health care inflation is not fee-for-service charged by avaricious practitioners but third party payers who create the illusion that health care is free.

March 28, 2012., 8 AM

Supreme Court  - Day 3 –  Constitutionality of Medicaid  Mandate

You’re entitled to Medicaid regardless of your income.  Don’t worry about your health care.

Max Baucus (born 1941), Democratic senator who led effort to create the health law

March 28,2012 , 8 AM – Today the Supreme Court takes on the issue of Medicaid expansion in the States.  
The attorney generals of  27 States have challenged the federal  government to prove the constitutionality of expanding Medicaid to 32 million more recipients in 2014.

·        Florida, South Carolina, Nebraska

. Texas,  Utah, Louisiana

. Alabama, Colorado, Michigan

·        Pennsylvania, Washington, Idaho

·        South Dakota, outh Dakota, Indiana

·        Mississippi, Nevada, Arizona

·        Georgia, Alaska, Ohio

·        Wisconsin, Maine, Iowa

·        Wyoming, Kansas, Virginia

These  27 States assert  Obamacare exceeds the limit of the federal government to  regulate interstate commerce, smf thereby violates the 10th Amendment and the Commerce Clause/
In the words of Maine Attorney General, William Scheiber,

“The federal government reform mandates that all citizens purchase insurance pay    a  costly penalty.  This would be an unprecedented  expansion of federal power, o the 10th Amendment and the Commerce Clause of the Constitution.”
In his latest budget proposal,   Paul Ryan(R) of Wisconsin says  that all states  should  be issued a block grant  to cover Medicaid patients and  to pay 100% of amounts that exceed the limits of the grant.    Ryan  claims his proposal would save the federal government $810 billion over 10 years.  Unfortunately under current  conditions,  critics say his proposal would eviscerate  State budgets.
On average, the  federal government now pays two-thirds of Medicaid costs while  state government picks up the remaining third.  Yet.  in most states, Medicaid is the single largest expense,  and comes at the cost of cutting funds for education,  highway repair, and other social programs.  By 2012, it is estimated 110 million Americans, nearly one-third of the population will be on Medicaid..  This may be a reasonable projection since 60 million are now on Medicaid, and another 32 million are scheduled to be added in 2014 under the health care law.
Attorney Generals of the 27 states claim the Accountable Care  Act  will not check growth of costs inherent in their present Medicaid population and  will not cover costs of processing 32 million more recipients.
Many progressives believe the sovereignty of the federal government takes precedence over the sovereignty of individual states and therefore the health law will prevail.  The counter argument  may be that the individual  mandate and  the Medicaid mandate  are so intertwined and inseparable that they  must fall or faii  together.

Tweet:  Today, day 3, of the Supreme Court hearings on the health law, the Court will consider the claim that the  Medicaid Mandate  violates the Constitution.

Tuesday, March 27, 2012

Supreme Court – Day 2- Democrats on Verge of Snatching Victory from Jaws of Defeat

We fight for lost cause because we know our defeat and dismay may be the preface to our successors’ victory, though that victory itself will be temporary; we fight rather to keep something alive in the expectation that anything will triumph.

T.S. Eliot (1881-1962), American Poet turned British Citizen, Francis Herbert Bradley

March 27, 2012 3PM - If the audio transcripts of this morning’s Supreme Court session on the constitutionality of the individual mandate are any indication,conservative and liberal commentators concede that the Court is headed towards the Court declaring the mandate unconstitutional.

These opinions rest mainly on Justice Anthony Kennedy’s line of questioning. Kennedy is considered the swing vote should the final decision come down to a 5-4 votes. Kennedy's questions expressed profound skepticism, even hostility, over the mandate’s infringement on individual liberties.

But fear not. Liberal commentators are in the process of seizing victory from the jaws of defeat.

A Victory in Disguise

Their argument - that a defeat would actually be a victory in disguise- goes like this.

The defeat of the individual mandate at the hands of conservative majority on the Court would be a deplorable sign and symptom of America's moral failure and of conservative partisan judicial activism that would deprive Americans of the fruits of universal coverage and moral high ground. We would be a moral outcast and disgrace among civilized nations. A defeat would ignite and mobilize the Democratic base to do the right thing - assure all Americans people of reduced costs, equitable access, and improved quality.

Why the President Should Be Re-Elected

Furthermore, the defeat would demonstrate beyond any reasonable doubt that President should be re-elected to :

a) salvage and implement what remains of the health reform law;

b) guarantee in the future that he can appoint more liberal Supreme Court justices;

c) continue to carry the torch of universal entitlements in the form of universal coverage, perhaps in the form of Medicare for all;

d) carry on the impossible dream and reach the unreachable star.

This wishful-thinking evokes a scene from Macbeth in which Macbeth challenges MacDuff to a final duel by saying, “Dream on, MadDuff and damn’d be him that first cries, “Hold Enough!”

Actually, Macbeth said “Lay on, MacDuff” but the meaning is the same, that the dream will not die in a fatal duel after the final political gauntlet has been run.

Tweet: Audio recordings from today’s Supreme Court session on the individual mandate’s constitutionality indicate the mandate may be headed for defeat.

Can Obamacare Survive without an Indispensable, Indivisible, Independent, Inseparable , and Inseverable Individual Mandate?

Onomatopoeia – The formation or use of repetitive words referring to previous words that imitate the sound associated with the thing or action in question, echoism.

Dictionary Definition

March 27, 2012 - I plead guilty to occasional useof onomatopoeia; I like to deploy sounds of words to imitate words that preceded them for rhetorical or poetic purposes.

I find onomatopoeia useful in describing the debate over the individual mandate, which is scheduled to take place today in the hallowed halls of the Supreme Court.

The questions at stake today are:

• Can Obamacare survive without the individual mandate, or will it collapse like a house of Congressional playing cards?

• Can the individual mandate continue to exist separable or severable from the 2700 page Patient Protection Affordable Care Act?

• Can President Obama survive without the continued existence of the Affordable Care Act?

• Can America’s individualistic health system survive in the face of government control of health care decision making?

• Can individual freedom exist as an indivisible concept, or must it depend on government protection?

• Can we continue to be one nation under God, indivisible, with liberty and justice for all if government intrudes too much upon our lives?

• Can individual taxes, coerced by penalties and government oversight of interstate commerce be considered in the same light?

Each of these questions has two sides. I do not have an answer to these daunting and profound questions. I say: let the justices decide, and let us abide by their decision.

In the meantime, let us admit the current U.S. health system, despite its obvious strength - open and prompt access to some of the world's best care for 80% of its citizens, needs fixing.

We need and deserve a better system – with more economic security and more affordable reliable coverage and care.

We do not need a more bureaucratic, government centralized command and control, standardized and homogenized system that expands government power, requires massive new entitlements, makes us more dependent on government, imposes more insufferable tax hikes on us all, impedes economic growth and hiring, micromanages doctors, rations care, and ignores personal responsibility and behavior.

Let us imagine a better replacement system.

Tweet: Today is day 2 of the Supreme Court debate over the health law’s constitutionality of Obama care and the individual mandate.

The Supreme Court - Day One Hearing - May 26, 2012

March 27, 2012 – According to Donald J. Palmisano, MD, JD at, the constitutional case of Obamacare will not be delayed under the claim of the Anti-Injunction Act of 1867. The power of the federal government to regulate inactivity to force a citizen to buy a private product or pay a penalty (The Individual mandate) will be considered today, March 27, 2012. The entire manuscript of the day one proceedings is available at: #cot#tiot##GOP#Dems#law#hcr.

Monday, March 26, 2012

President Obama Embraces "Obamacare" Label

A word is half his that speaks it and half his that hears it.

Montaigne (1533-1592), Essays

When I use a word, Humpty Dumpty said, in a rather scornful tone, “It means what I choose it to mean – rather more or less.”

Lewis Carroll (1832-1898), Through a Looking Glass

March 26, 2012
- At last, I don’t need to feel guilty about using the word “Obamacare.” The President says it’s OK to use it because he cares.

Here in today's Washington Post, part of his chorus, Obama embraces use of “obamacare” as a positive, not a perjorative.

‘You want to call it Obamacare — that’s okay, because I do care,’ Obama said at a fundraiser in Atlanta late last week. Then on Friday, the White House urged supporters of the law to tweet why they backed it with the hashtag ‘#ilikeobamacare.’

And on Sunday, White House senior adviser David Plouffe threw down the political gauntlet on the term; ‘I’m convinced at the end of the decade, the Republicans are going to regret turning this term Obamacare into a perjorative.’

The decision to throw their arms politically around ‘Obamacare'— initially a pejorative term coined by Republicans to deride the Affordable Care Act and compare it to Hillary Clinton’s failed ‘Hillarycare’ effort — is a significant shift in how the president and his team talk about the law.

For much of the two years since Obama signed the bill into law, the incumbent — and his party — have played defense on it, attempting to convince a skeptical public that it was a much-needed reform and not an unnecessary government takeover.

Democrats now acknowledge they lost that message fight — and the results of the 2010 election, in which Republicans ran hard against the law and picked up a whopping 63 seats in the House, is evidence of that fact.

Even now polling suggests a majority of the American public — 52 percent in an early March Washington Post-ABC News poll — oppose the law.

What the White House and the Obama reelection team in Chicago clearly believe is that the Supreme Court case amounts to the opening of a new front of the message wars surrounding the health care law. And, if they lost the first fight because they played too much defense, now they are doing their damnedest to get on offense — early and often.

‘On Obamacare, Republicans spent hundreds of millions branding Obamacare as a negative, and we believe we can turn that to our advantage,’ said Stephanie Cutter, a spokeswoman for Obama’s campaign. ‘The term is incredibly popular with the president’s supporters, who will fight to the end to defend the law after 70 years of work to pass health reform.’

Embracing the term ‘Obamacare’ is a recognition that the president owns the law politically-speaking no matter what the court decides.

That reality means he must re-define ‘Obamacare’ in the eyes (or, more accurately, ears) of the public.

‘Obamacare’ currently stands for everything people don’t like about the law. The White House has to make it stand for all the good things in the law.

We’ve written previously that the lack of movement in the Affordable Care Act’s poll numbers leads us to believe that very few people are either undecided or persuadable on the issue.

The White House begs to differ, and the embrace of ‘Obamacare’ ’is a leading edge of a strategy to change minds on what the law means.

Even if they’re wrong, the White House has decided not to give up on health care as a political issue without a fight. And judging from how Republicans view the law, a fight is why they will have. “

Tweet: President Obama says it’s OK to use the term “Obamacare” because he cares.

The Supreme Court Circus is Coming to Town

Every country gets the circus it deserves.

Erica Jong (born 1942), American writer

March 26, 2012, Washington, D.C. – Hear Ye! Hear Ye!The circus is coming to town. It starts today. It ends in three days. Get your tickets now while they're hot!

The circus has everything. It has men in dark suits bearing 136 briefs, six men in black robes, three ladies in black gowns, arch conservatives, leaning liberals, a swinging judge, juggling lawyers, legal beagles, a posse of pundits, braying donkeys, dancing elephants, googling journalists, four hundred rapt politicians in the tent goggling the greatest show on earth, busloads of people from afar milling outside, protesters jeering and cheerleaders cheering, and a vast outside world awaiting news and wondering what’s going on inside.

It even has a child's poem explaining what’s going on.

Here they come
The circus is back in town.
It’s the greatest show around
The biggest thing since Bush and Gore,
How could you ask for anything more.
Yessir! The circus is coming to town.

There are jugglers, lawyers, too
The judges have much to see and do
Now that the circus is back in town.

Donkeys will prance, elephants will dance
Nothing could ever be so grand!

Don’t be left behind
They’re starting today right on time
Cause the circus is back in town
Only four hundred got tickets to see it
Because the circus is back in town.

Here they come
They’re back in town
It’s the greatest show around
Because the circus is back in town.

They’re men in gowns, ladies in robes too
The judges have so much to hear and do
Now the circus is back in town.

The libs will roar, the T's will party,
Nothing could ever be so grand!

The left won’t be left behind
The right will start right on time,
Because the circus is back in town.

In and out,around the circus ring they'll go
Where they'll stop everyone wants to know,
Everyone's on the high wire getting emotional,
All of them asking: is it constitutional?

Tweet: Hear Ye! Hear Ye! The Supreme Court circus is back in town.It has everything you ever wanted to see or hear.

Sunday, March 25, 2012

Bundled Payments for Episodes-of-Care and Conditions That Cost Government a Bundle

In the quest to manage the spiraling cost of U.S. health care, one approach has generated great interest. The philosophy behind much current policy — including the Affordable Care Act (ACA) — is that aggregating fee-for-service reimbursement into payments for broader bundles of care will lead to greater efficiency in the provision of care and thus lower costs.

Under the accountable care organization model, perhaps the best-known example of this strategy, medical reimbursements are aggregated to the person-year level. Other programs aggregate reimbursement for episodes of care — for example, care for a particular cardiovascular or orthopedic condition. The Episode of Care Payment Demonstration project, which is authorized by the ACA, requires the Centers for Medicare and Medicaid Services to experiment with bundling Medicare Part A and Part B payments for inpatient care.

David Cutler, PhD, Kaushik Ghost, PhD, Department of Economics, Harvard University, and National Bureau of Economic Research, both in Cambridge, Mass., “The Potential for Cost Savings through Bundled Billing Episodes, New England Journal of Medicine, March 22, 2012

Definition of Bottleneck – DELAY IN PROGRESS a delay caused when one part of a process or activity is slower than the others and so hinder overall progress.

Dictionary definition of Bottleneck

March 25, 2015 - I find it inevitable that two PhDs steeped in data analysis from Cambridge, Massachusetts, would write on the theoretical effects of bundled billing as proposed by the Accountable Care Act. Dr. Cutler, after all, is the principal health care advisor for President Obama. Cutler and Ghosh reside in Cambridge, where many of the architects of Obamacare reside and where President Obama received his law degree at Harvard.

I interviewed Dr. Cutler in 2004, wrote oftenn about bundled billing in previous blogs, and have on-the-ground experience in creating episode of care blogs for a community hospital and its medical staff.

In their NEJM article, Cutler and Kaushik say that by moving from a FFS model to bundled payments for episodes of care could save the health system as much as $10 billion. They list these 17 conditions as accounting as the top most expensive in spending for Medicare.

1. Osteoarthritis, $7.3 billion

2. Coronary and other heart disease, $6.5 billion

3. Fracture of neck of femur, $5.8 billion

4. Congestive heart failure, $5.8 billion

5. Acute cerebrovascular disease, $4.8 billion

6. Pneumonia, $4.7 billion

7. Cardiac dysrhythmias, $4.4 billion

8. Acute myocardial infraction, $.4 billion

9. Complications of device, implant, or graft, $3,2 billion

10. Spondylosis, intervertebral discs, other back problems, $3.1 billion

11. Septicemia, $2.7 billion

12. COPD, bronchiectasis

13. Urinary tract infections, $2.3 billion

14. Respiratory failure or arrest, $2.1 billion

15. Acute or unspecified renal failure, $1.8 billion

16. Other fractures $1.8 billion

17. Heart value s, $1.6 billion
Total spending $64.8 billion


The $64 billion question is, will bundled billing lower the cost of health care? But even if government decides that bundling will help do away with fee-for-service payment for costly procedures for episodes of care, vexing questions remain.

For brevity’s sake, let’s call these bundled billing bottlenecks “bundlenecks.”

Here are my questions.

• Should government bundle by per episode of care, or should governmet bundle by per person-month, as envisioned for accountable care organizations by government bureaucrats? Cutler and Ghost clearly prefer bundling per episode at the more practical approach. In the following paragraph towards the end of their article, they indirectly indicate the process may not be easy,

“Broadening the unit of payment will require reaching across different types of providers and helping to stitch together real delivery systems where now there are none.”

• Based on my experiences on the ground, these bundlenecks emerge. Who should take the hit on “savings,” which will come at the cost of either decreased hospital revenues or diminished doctors’incomes? What if health plans do not choose to pay for bundles, instead preferring to negotiate separately with hospitals and doctors ? What about episodes-of-care complications, which will drive costs above the original estimates for costs per episode? How does one pay for the cost overruns? By reinsurance policies or by punishing hospitals and doctors? And what if a critical specialty group, such as radiologists, decides not to participate? How does one bring them into the episode-of-care fold?

I do not wish to be a bundling, or bungling, devil’s advocate, but as with any new billing process involving provider incomes, one must anticipate bottlenecks.

Tweet: Bundled billing for episodes of care is an attractive model for saving money, but there are practical pitfalls and bottlenecks.

Saturday, March 24, 2012

Alternatives to Obamacare

What is freedom? Freedom is the right to choose; the right to create for oneself the alternatives of choice.

Archibald McLeish (1892-1982)

March 24, 2012 - However the Supreme Court rules on Obamacare and however Americans vote in November, alternatives to the health reform law are underway.

It is clear to everyone that something must be done about soaring health costs, and something is being done. For thoughtful Americans, it is a Life or Debt decision, as the national debt nears $16 trillion and as health costs become a leading cause of personal bankruptcies.

Alternatives to the present health system are cropping up across the healthcare landscape,. And why not? People want choice and alternatives. Besides, as George Burns said of what he thought about becoming 100, “It’s better than the alternative.”

Although many of these alternatives are occurring right under our noses, we tend to ignore them because they are incremental and segmental.

Alternatives include:

• Employers offering wellness programs.

• Employer giving bonuses to employees who stay healthy.

• Health plans lowering premiums on wellness stats.

• Over 30% of employers offering health savings accounts tied to high deductible plans.

• Insurers covering retail clinic expenses.

• Growing numbers of worksite clinics among employers with 100 or more employees and among coalitions of small employers.

• Sweeping decentralization of care with more care being offered in less expensive home care and out-of-hospitals and out-of-physician office settings.

• More emphasis on self-care, enhanced by new technologies and new products allowing patients to diagnose themselves and to monitor their own care.

• More awareness of what constitutes healthy foods.

• More fitness centers in more communities.

• A new breed of physicians saying, “ Your health is what you do for yourself, not what I can do for you.”

• An older breed of physicians who are dropping out of 3rd party insurance arrangements and offering cheaper, more convenient care in concierge and direct pay practices.

• Websites offering fitness and caloric advice and data on how to stay healthy on your own without visiting health care professionals.

• Medical tourism whereby patients are going outside the U.S. to seek cheaper alternatives for high cost medical and dental procedures.

Taken together, these various developments given patients the freedom to opt out the present setting.

So Much for Bottom-up Changes

This blog would not be complete if I did not mention top-down suggestions for alternatives to Obamacare, should it collapse .

The principle alternatives most often mentioned are:

• Shopping across state lines for insurance coverage.

• Tax-credits for all individuals, rather than just for corporations and employers.

• Tort reform.

Some business leaders, like John Mackey, CEO of Health Foods, are quite specific in recommending alternatives.

• Remove the legal obstacles that slow the creation of high-deductible health insurance plans and health savings accounts (HSAs).

• Money not spent in one year rolls over to the next and grows over time/

•  Equalize the tax laws so that employer-provided health insurance and individually owned health insurance have the same tax benefits.

•  Repeal all state laws which prevent insurance companies from competing across state lines

•  Repeal government mandates regarding what insurance companies must cover.

•  Enact tort reform to end the ruinous lawsuits that force doctors to pay insurance costs of hundreds of thousands of dollars per year.

• Make costs transparent so that consumers understand what health-care treatments cost. How many people know the total cost of their last doctor's visit and how that total breaks down?

• Enact Medicare reform. We need to face up to the actuarial fact that Medicare is heading towards bankruptcy and enact reforms that create greater patient empowerment, choice and responsibility.

•  Finally, revise tax forms to make it easier for individuals to make a voluntary, tax-deductible donation to help the millions of people who have no insurance and aren't covered by Medicare, Medicaid or the State Children's Health Insurance Program.

Tweet: Employers and individuals are reacting to high health costs by developing a series of alternatives and choices that lower costs.

Friday, March 23, 2012

Lighting The Innovation Candle at Obamacare's 2nd Birthday Party

Better to light a candle, rather than curse the darkness.

Modern version of Chinese Proverb

March 23, 2012 - Well, here we are at Obamacare’s 2nd birthday party. I thought I would celebrate by lighting a candle for innovation. There’s plenty of darkness surrounding the event. I will not be a party pooper. I choose not to spread gloom but to shed light by lighting a birthday candle.

Besides, according to Washington Wire, a publication of the Wall Street Journal's Capital Bureau, there's only one person missing at the 2nd birthday celebration: Obama. See Laura Meckler, March 22 WSJ, "No Health Care Celebration for Obama." Obama says he would rather be outside campaigning rather than inside champagning. Anyway, Obama says doctors and nurses should do the celebrating not the President.

It's better to distinquish myself by lighting one of his birthday candles rather than trying to extinguish his reform plan.

Two events inspire this birthday blog.

1) A call from a 37 year old invasive cardiologist who wishes to remain independent and solo by creating a blog to educate patients on the benefits of health savings accounts.

2) The arrival of the March issue of the HBS Alumni Bulletin with a lead story on Angie Hicks, creator of Angie’s list. More than 20 years ago, I graduated from a 2 month course on health system management at Harvard BS. Two months was just long enough to make me dangerous.

What makes for successful innovation for physicians? Innovation is one way out of the health care tunnel. Unfortunately, many physicians see no light at the end of that tunnel.

Innovation starts with an idea, But to go from an idea to a successful innovation requires a great deal of support and collaboration.

Surround yourself with similarly minded people, who will give the courage to try, fail, redo, and try again.

Act locally, think globally. As the editor of the HBS Alumni Bulletin says, “The biggest advances are been seen at the local level, where innovation is winning the day.”

So appoint a chief innovation officer among the members of your office staff. Invite wild and crazy ideas.

Compile an e-mail list of your patients. Ask them for innovative ideas.

Network – talk to other physicians who have been there and done innovation, successfully and unsuccessfully.

Read books on innovation and entrepreneurship - Peter Drucker’s classic Innovation and Entrepreneurship (1985), Clayton Christensen’s equally classic The Innovator’s Dilemma (1997), Luis Peraras’ neo-classic Innovation and Entrepreneurship in the Health Care Sector(2011) or my Innovation-Driven Health Care (2007).

Experiment – Get your toe in the water. Start a website, go forth with your idea, and see if someone salutes it.

Ask yourself five questions. Is my idea better than what it’s replacing? Is it compatible with the way people currently do things? Is it simple enough to use? Can I try it small doses? Can I find other people to use it – and watch other people try it out?

Never forget. Innovation is a process, requires a structure, and money to make it work. Be persistent. It’s hard work.

Sometimes you have to burn the candle at both ends. You have to light one candle before you light a thousand more candles.

Tweet: This blog seeks to light the candle of innovation on Obamacare’s 2nd birthday rather thancurse the darkness surrounding health reform.

Thursday, March 22, 2012

Charm and Harm of the Health Reform Law

There is no charm equal to the tenderness of heart.

Jane Austin (1775-1817), Emma

As to diseases, make a habit of two things-to help, or at least, to do no harm.

Hippocrates (460-377 BC), Epidemics

March 22, 2012 - Tomorrow is the 2nd anniversary of the Affordable Care Act (ACA). This is a good time to analyze its charm and its harm.

Brace yourself. You are going to hear a lot about the law’s charm by government officials. Critics will cite the harm of its intertwined proposals. It’s a massive sprawling law with plenty of cannon fodder and food for thought for both sides.

Tomorrow’s “celebration” and “condemnation,” depending on your point of view, will pit positive spin against negative spin. The spin will carry over until March 26, when the Supreme Court begins its six hours of hearings on the health law. The length of these hearings is unprecedented in the history of the Court. The hearings and speculation about their outcome will be the talk of the town from now to late June, when the decision will be announced.

The Charm of the Law

For progressives, the law’s charm is undeniable. It shows the tenderheartedness of government. The message goes: Trust your government. It will protect you against all eventualities. Its leader, President Obama, is undeniably a charmer. Personal charm is his most endearing, enduring , and, perhaps, his winning trait.

Some say the health reform law is the work of dreamy “bleeding heart” liberals. I do not agree. It is the work of stout-hearted pragmatic charmers. They see it as a sure path to political power. This is especially true when one can make more citizens dependent on government than not, and when one can define, dictate, measure, and enforce the rules of patient-doctor engagement and payment.

The health law offers concrete provisions that will protect certain segments of the population against the slings and arrows of disease and economic misfortune and makes them dependent on government.

The uninsured, These include 32 million who will now qualify for Medicaid. It may also include an estimated 5 million to 20 million more as employers drop coverage due to the expense of meeting the conditions of government-regulated plans. These formerly insured people may land in Medicaid.

Those with pre-existing illness – 129 million Americans have at least one disease. Government estimates 50,000 Americans will sign up for plans covering pre-existing illness, although only 20,000 have so far.

• Seniors falling into the “doughnut hole.” These individuals are unable to afford the cost of brand name drugs and have reached a certain threshold of expense They number perhaps 3-5 million out of 45 million Medicare recipients.

Seniors who want to take advantage of “free” preventive screening tests - The precise number desiring to do so is not known, although 5.5 million is one government estimate.

Young adults up to age 26 who will now be covered under their parents’ plans. The government puts the number of young people affected at 2. 5 million.

All told, as of now and by 2014, as many as 50 million Americans may directly benefit from the Affordable Care Act. The exact number is evolving and will depend on the success of government marketing of the health reform act, the number of people who become aware of its benefits, the bureaucratic complexities of qualifying for its provisions, and, ultimately, on trust of people in their government and quality and convenience of the benefits.

I have seen estimates of as many as 100 million on Medicaid and 70 million on Medicare by 2020. This means, I suppose , that we could then make a Declaration of Dependence and abandon the Declaration of Independence.

So far, the health law shows no sign of delivering on its three major promises: 1) to provide health insurance coverage for all Americans ( the Congessional business office says 27 million Americans will remain uninsured in 2022); 2) to redue costs for individuals, businesses, and government (the converse seems to be true); 3) to increase quality and value for each government dollar spent (this is very much in doubt, but it's still early).

The Harm of the Law

Conservative and independent critics have their lists of potential harm of the ACA. Some of this harm is theoretical and imagined, such as loss of individual freedom and bureaucratic malfeasance, and some parts of it real, such as soaring costs and losing one’s health plan.

These “harms” include:

Loss of health insurance by employed Americans, due to uncertainty of employers, who are fearful of costs of government regulated plans. Estimates of these victims of health reform vary from 5 million to 80 million, with most projections in the 20 million range.

Loss of control to federal bureaucrats in 159 new ACA agencies and boards in Washington, D.C. This may be more of an emotional rather than a real threat.

Physician shortages, now pegged at 50,000 by most, but some project 160,000 more physicians will be needed when the 32 million new Medicaid and 78 million Medicare-eligible baby boomers hit the entitlement streets..

Long waiting lines to see, or even to find, a doctor, already the case in Massachusetts, which ironically has the 2nd highest number of physicians per capita after Washington, D.C., but the nation’s longest wait times.

Increased insurance premiums, up 9% in 2010, another 9% in 2011, where it stops no one knows.

Loss of privacy. Health and Human Services has ruled that all private insurers must send their data to a central data bank in the nation’s capital – without patients’ permissions.

• Medicare cuts of $575 billion for seniors and provides to pay for the younger have-nots and uninsured joining Medicaid.

Loss of specialists in many fields secondary to systematic cuts in Medicare reimbursement.

Higher taxes on medical device makers, drug firms, and health plans which will be passed on to consumers and which may discourage innovation.

Staggering increases in the national debt. The debt now nears $16 trillion. The Office of Management and Budget has just announced the true cost of ACA will be $1.76 trillion rather than the $940 billion originally projected.

Federal rules, regulations, and protocols which will dictate what insurance to purchase, what insurance will pay for, what medical specialists will be paid, what treatments and diagnostic tests will be allowed, what tests will be permitted, who can own and operate hospitals, and what taxes will be imposed on individuals, businesses, and participants in the medical industrial complex

Tweet: The health reform law has its 2nd anniversary tomorrow; its advocates have a list of its charms. Its critics have their list of its harms.

Wednesday, March 21, 2012

Health Reform Law - Raw Deal for Physicians

I pledge you, I pledge myself, to a new deal for the American people.

Franklin Delano Roosevelt (1882-1945), Speech accepting Presidential Nomination, July 2, 1932

“Big F----ing Deal.”

Joseph Biden (born 1942), 47th Vice-President of the United States, comment on signing of health reform law, March 23, 2010

March 21, 2012
- A deal is usually thought of as an agreement, arrangement, or transaction, that benefits all. There are New Deals, Fair Deals, Square Deals, Sweet Deals, Big “F---ing” Deals, Small “F—ing” Deals, Bad Deals, Good Deals, and Raw Deals.

In minds of physicians, the Health Law Reform Deal, falls into the “Raw Deal “ category – an unfavorable deal. It is unnfavorable not only for themselves but for taxpayers and patients because, among other things, according to an estimate last week by the Office of Management and Budget, it will cost $1.76 trillion rather than the original estimate of $940 billion.

In a survey of 60,000 physicians conducted by the Physicians Foundation in 2010:

• Most physicians (67%) were either “somewhat negative” or “very negative", about the health law.

• Most physicians (54%) thought the law would increase their patient load.

• Most physicians (68%) said the law would decrease the financial viability of their practices.

• Most physicians (59%) thought the law would cause them to spend less time with patients.

• Most physicians (74%) said they would not be able to practice as usual over the next 3 years.

• Most physicians (51%) said they would close their practices to Medicaid patients, or significantly restrict access to Medicare patients (57%)

Most physicians, in other words, thought of the Affordable Care Act as a “raw deal.” This should surprise no one, nor should the consequences.

A recent survey by the Doctors Company, the nation’s largest malpractice carrier, revealed that 90% of doctors would not recommend medicine as a profession, and 43% said they were contemplating retirement within 5 years.

Adding to the gloom are these realities.

• Congress is unwilling to fix the SGR formula, which was modestly adjusted this year but which will call for a 32% cut in Medicare physician fees in 2013 because it would result in a $330 billion boost in Obamacare costs.

• The ACA calls for a $575 billion cut in Medicare, most of which will come off the hide of physicians and hospitals. Hospitals are to be cut by $52 billion and physician Medicare fees are projected to be below those of Medicaid by 2019.

• A deal on national tort reform is unlikely because a huge Democratic contributor, the trial lawyers group, the American Association of Justice, declares national tort reform a political no-no.

• Obama and his political base adamantly oppose incremental market-based reforms, such as shopping across state lines and unfettered health savings accounts, which would rely on sensible bottom-up consumer intelligence and judgment rather than sweeping top-down, dumbed-down decision making.

• Independent physician practices are in sharp decline as physicians find themselves unable to deal economically with reimbursement declines, practice costs raises, regulations, rules, protocol, and electronic record distractions that pull them away from patients, their main source of income.

Tweet: Most physicians regard the health reform law, now about to celebrate its 2nd anniversary, as a “raw deal” for themselves, taxpayers, and most American citizens.