Speech Repeat: Health Reform and Loss
of Physician Freedoms
These posts contain redundancies. Of
these redundancies, I would simply say: some things are worth repeating and
Richard Reece, The
Health Reform Maze: A Blueprint for
Physician Practices, (Greenbranch
June 1, 2012 -
In a May 10
post, I printed a copy of my talk before
the Physicians Insurers Association of America given in Washington, D.C.. Because of unexpected demands for copies of
the speech, I’m reprinting it now.
This may be
a good time for a reprint. June is
busting out all over with expectations and speculations what the Supreme Court
will decide in June 25 on Obamacare, and people want to know what physicians
think about health reform and the election.
I visited a
Yale cardiologist today for a routine follow-up visit. He said
he agreed with my thesis that private practice is in sharp decline. None of the fellows in the Yale cardiology program,
he observed, are entering private
practice. Hospitals will employ them
all. They are becoming employed to escape
administrative hassles and declining reimbursements and to repay their
In any event,
here is the talk as given.
know it, we will be knee deep in June, June will soon be the past, and reconstituted health reform will be the
Reform and Loss of Physician Freedoms: Consequences, Trends, and Alternatives*
before Physicians Insurers Association of America, Leadership Camp, May 9,
2012, J.W, Marriot Center, Washington, D.C.
10, 2012– What follows is a presentation
I gave yesterday before physician leaders of the leadership camp of the Physician
Insurance Association of America. I have edited the talk to accommodate changes
I made while on the podium and to fit this print version.
of PIAA leadership camp. Given the unsettled state of tort reform and the
looming uncertainties of health reform law, I am assuming you are not all happy
would like to thank Dr. Donald Palmisano, one of your distinguished leaders and
former president of the American Medical Association(2003-2004) for that
generous introduction, which I so richly deserve but so seldom get. Before you
know it, I will be a legend in my own mind. Not to worry. As my wife of 50
years explained to me, “Be humble. You have a lot to be humble about.”
theme today is preservation of physician and patient liberties and your future.
I deeply care about these liberties and what lies ahead. Otherwise I would not
have written 2300 blogs, 1300 tweets, and 11 books on the subject.
Everything I say today will revolve around the freedom theme,
preserving individual liberties, improving the system, and lowering costs
me begin with a quote from a Wall Street Journaleditorial, “Liberty and
Obamacare,”dated March 23, 2012, Obamacare's second birthday.
stakes are much larger than one law or one president. It is not an exaggeration
to say that the Supreme Court’s answers may constitute a hinge in the history
of American liberty and limited and enumerated government. The Justices must
decide if those principles still mean something.”
When he invited me to give this presentation, Dr. Palmisano
instructed, “Give an unbiased picture of the future of physicians during and
after reform and leave plenty of time for questions.”
will leave time for questions, but I can’t give an unbiased view. I am biased
in favor of physicians. I want clinicians to retain freedom to make decisions
independently of bureaucrats and managers.
any event, here we are in Washington, D.C. Among critics of Obamacare,
“D.C.”stands for “Darkness and Confusion.” Among advocates, “D.C” is known
as“Destination - Control.” My job today is to describe the darkness, clear up
the confusion, and warn of excessive control.
marching orders from your meeting planner are to speak for 45 minutes, leave 15
minutes for questions, and use less than 36 slides, It is now 1:55 PM. That
gives my 35 minutes to make my case. I shall wrap up by 2:30 P.M.. As a
pediatrician friend of mine once remarked, “You may now circumsize your
Blunt Message – Raw Deal
shall be blunt. Your future stinks under current reform law. You are getting a
raw deal If Obamacare goes forward as planned, you will lose clinical freedoms
is a watershed period for your future. Either we go the way the U.S. or the way
of Europe. Your future depends on the Supreme Court decision in late June or
the election in early November.
I am not here to curse the darkness or to confound the
confusion. I am here to say we must offer alternatives. We must lead, and we
must light candles of innovation to find our way out of the bureaucratic swamp.
you are feeling hemmed in by a law that promises to decrease your income;
regulate your decisions through protocols on evidence-based practices as dictated
by “clinical effectiveness research”; trap you into a coding straight jacket ;
stifle your innovative spirit; and reduce our choices and options.
compound matters, you are feeling loss or lack of leadership. The AMA endorsed
Medicare, and partly as a result of physician discontent with that decision, it
lost members. Today only 15% to 17% of physicians belong to the AMA. In a
speech before the AMA in Chicago on June 15, 2009, President Obama declared, “
If you like your physician, you can keep your physician. Period. If you like
your health plan, you can keep your health plan. Period. Nobody can take that
away from you. No matter what.”
"No Matter What" Has
“no matter what” has arrived. Employers are in the process of dropping as many 20
million employees from health plans, and the doctors who go with those plans
the other Obama promises - lower premiums costs by $2500 by 2016 for a family
of four, greater access to doctors, and higher quality – are looking more and
more like a fantasy. Period.
of punctuation marks, I am reminded of the story of the grammarian who
developed colon cancer. He thought his life was coming to a period. But a
surgeon resected his cancer, and it came only to a semi-colon. President
Obama’s dream is now a semi-colon. We have yet to see if it will end in a
period, and it may, come June or November.
Back to Darkness and Raw Deal
see it, there will be:
· No permanent SGR fix, barring a GOP
sweep. Politicians simply don’t have the guts to fix it because it would add
$300 billion to the current $16 trillion national deficit.
· No physician income rise. Instead
Obamacare proposes systematic cuts in Medicare fees for specialists over the
next 10 years, with token increases for primary care, with Medicare fees less
than Medicaid fees by 2019 for all physicians.
· No national tort reform, which is
unlikely as long a the Trial Lawyers remain heavy political contributors.
· No market-driven incentives -
shopping across state lines, HSAs, HRAs, and variants with high deductibles,
individual plan ownership, tax credits for all, individual plan ownership.
· More dependency on government –
with 110 million on Medicare and Medicaid- now 1/3 of population, growing to ½
by 2020 – with more of GDP going to government. In France, 54% of spending is
by government. The French, by voting in a socialist government, want even more
government spending, whether or not government has the money.
· More mandates - for individuals,
physicians, hospitals, employers, and states.
· An expanding bureaucratic alphabet
soup – CMS, HHS, IRS, PCORI, CER. PHM, EBN, IPAB, ACOs, EHRs, HIT, and, of
course, with 159 new agencies, commissions, boards, and of course, POTUS
(President of the U.S.)
· D. C. directed and dominated health
exchanges at state level.
· Continued coding straight-jacket,
which will not allow physicains to innovate or reprice and repackage their
· Zero-sum health care income game –
If doctors go up, hospitals go down, and vice-versa.
if I may, I will sum up what I have just said, in rhyme, I do so in honor of my
son, Spencer, who is an internationally acclaimed poet and because using prose
is simply too painful
There will be no SGR fix, at least not with the current political
Medicare fees will fall over the next decade, bundled,
capitated, or prepaid.
Market-based incentives, like HSAs will not occur, those on the
Don’t count on national tort reform, barring a perfect political
Swing states could swing the right way, but as of now, the polls
don’t look that way
Let us hope the Justices will do ther right thing, and voters
will remember, come November.
this talk, I shall:
with a touch of levity.
In short, I shall be terse,
for nothing is worse,
than verbal longevity.
friend of mine once told me, “Dick, I always knew you were full of pith.” Which
gives me a title for my next book, which will be mercifully brief, Obamacare: Pith and Vinegar.
that you will now who is telling you this, here is my background
· Pathologist (A specialist who knows
everything but it is too llate), editor, blogger, tweeter, author
· Practice experience (Connecticut,
Minneosta, North Carolina, Oklahoma)
· Longest practice time n Minnesota
(25 years, 1967-1990)
· Editor, Minnesota Medicine
· 11 books, 2300 blogs, 1300 tweets
· Latest book – Health Reform Maze
(Greenbranch Publishings, 2011)
· Blog and Tweets now internationally
syndicated by Newstex, com
Box on Cover of My New Book – The Health
There's a picture of the bureaucratic box on the cover on my
book, It'a condensed version of the 2801 page health reform law. The law
stretches for 2801 pages, longer than War and Peace, and of its length,
then House-Speaker Nancy Pelosi famously said, “We’ll have to pass it to see
what’s in it.”
Depending on your point of view, you could call this box a
progresscive blast-off platform. a conservative bureaucratic burial ground, a
consultant's bonanza, or physician's burden to bear.
you call it, what's in the box is a massive new bureaucracy, with 159 new
boards, agencies, commissions, at parade ground for at least 5000 new
bureaucrats and technocrats, and 16,500 new IRS agents to enforce mandates and
to collect new taxes.
The bureacratic box has an entry but no exit. This law, in one
way another, will be with us through eternity even if the Supreme Court or the
Election rules most of it null and void, or Republicans repeal it.
Whatever happens, the law's effects will linger, and health
plans and other buyers will adopt some of its provisions. Your practice will
never be the same again. In one fashion or another, by a public or private
entity, your performance will be digitized, audited, and measured.
as physicians, do you disentangle yourself from this byzantine bureaucracy or
even understand it? My advice is for you to follow the lead and read the works
of the Physicians Foundation. This non-profit organization, which was founded
in 2003 as the result of legal settlement with major managed care companies ,
represents 17 state and 3 county medical societies, and the majority of U.S.
physicians. It has issued over $25 million in grants to physician organizations
to improve quaIity and has done groundbreaking surveys to see what doctors
think and how they are likely to react to health reform. I commend for your
reading its 2010 survey Health Reform and Decline of Private Practices,
and I recommend you look out for the results of its 2012 e-survey of 650,000
doctors, now being conducted, which will be released before the November
elections. Its website is physiciansfoundation.org
I get into the consequences, trends, and alternatives to Obamacare, Its
important that you understand where I am coming from.
· I believe, Because
of the nature of the bureucratic beast, government is poor at innovation.
Because of its special interest constituencies, its ability to print money to
keep going, and its reliance on good intentions rather than results, it can
never admit failure and shut anything down.
· I believe in market-driven
competition and innovation as the best means of raising quality, achieving
excellence, and lowering costs.
· I believein physician
entrepreneurship and innovation.
· I believe constructive reform is
not possible without engaging physicians and health consumers as the driving
forces - 90% of factors determining health and longevity - patient behavior,
genetic predisposition, the environment, social deprivation, homicides and
accidients - are beyond the physician's control and occur outside the office.
Therefore, patient must be engaged if health reform is to succeed).
· I believe the future depends, not
solely on the Supreme Court and the American electorate, but on external events
like the economy, the price of gas, a possible Israeli air strike, terrorist
attacks, and you. Without you, there is no health system,
· I believe in what previous leaders
have said: Reagan “The government is the problem, not the solution,” Churchill
"The inheret vice of capitalism is the unequal sharing of blessings; the
inherent virtue of socialism the equal sharing of miseries,” and Thatcher “The
only problem with socialism is that sooner or later you run out of other
· Finally, I give two cheers for
capitalism and one cheer for government. An enlightened partnership is
necessary to reform care, but, as a practical matter, one cannot never do away
with dependency induced by entitlement programs, Once this dependency is established,
its tends to grow and metastasize.
main themes of this talk are the loss of clinical and individual freedoms due
to an overreaching government. The subthemes are the consequences, trends, and
alternatives secondary to this overreach.
· What are the consequences?
According to the Congressional Budget Offiice and the Office of Management and
Budget, costs will run $1.76 trillion by 2022 and $2.5 trillion by 2024, two to
three times more than original 2010 estimate of $940 billion by 2020.
· Strangling rules, regulations,
protocols, mandates, taxes, and IRS and government electronic surveillance, all
of which stifle innovation.
· Continued political discontent with
roughly 15% more favoring repeal than acceptance, and a startling 76% to 19%
saying individual mandate is unconstitutional.
· A civil war between the majority of
states and the federal government, which lead to the necessity of the present
Supreme Court deliberations.
· An evolving consensus that
personal, religious, and clinical liberties are at stake and that the American
people do not like being told what to do.
· Decreasing physicians acceptance of
new Medicare and Medicaid patients, in the 30% to 60% range, with more to
follow if Obamacare continues.
· Physicians shortages, 50,000 now
and up to 150,000 by 2020.
· Physicians abandonment of 3rd
party arrangement with private and public plans, with the rise of direct cash
arrangement in urgicenters, Simple Care networks, retail clinics, and concierge
· Medicare cutbacks for physicians,
especially high tech specialists.
· Continuation of the SGR formula,
which will drive more physicians out of practice.
consequence of these consequences, I foresee a nightmarish political crisis of
unprecedented magnitude three or four years out, as 78 million baby boomers
enter the Medicare rolls at the rate of 10,000 to 12, 000 a day, as 32 million
more Medicare, and more likely 50 million citizens, qualify for Medicaid in
2014, and as the physician shortage escalates.
· The strongest trend is hospital
employment and health system employment. Hospitals already own more than half
of practices. Physicians are streaming into hospital employment because an
administrative infrastructure is needed to deal with government and health plan
payers if one is to negotiate from a position of strength.
· The second strongest trend, related
to the first, is accelerated consolidation at all levels of the system,
followed quickly by waves of decentralization as large organization seek
marketing power through greater patient convenience.
· The third strongest, also related,
is brisk care migrations out of hospitals to minimall invasive diagnostic and
treatment centers and to the home itself, in turn accelerated by the
· The fourth strongest is the push
for bundled bills, dropping of fee-for-service to rationalize and coordinate
· The fifth strongest will be the
search for some business model that favors evidence-based quality and outcome
addition to these trends and intermingled with them, you will experience
profound changes in practice patterns secondary to IT and mobile devices such
atIPhone, IPod, and IPad; accelerated adoption of EHRs by physicians secondary
to newer and cheaper and better business models, computing in "the
cloud", widespread use of speech recognition software, more waviers from
Obamacare by organizations seeking refuge from Obamacare expenses.
alternatives, as I see them, are:
· Leadership from people like Dr.
Palmisano and the Physicians Foundation.
· Practices innovations, many of
which I imention in my blog and in my books
· Political activism and your part
and the 19 physicians now serving in Congress.
just a word and a list of what I see as viable practice models.
· Specialty centers with
decentralized free-standing centers performing cataracts, endoscopies, hernia
and other minor surgeries, bariatric procedures, cosmetic procedures, and any
minimally invasive procedure.
· Specialty centers, common in
orthopedic world, offering one-stop shopping, - minor surgeries, consultation,
physical therapy, lab work, x-rays, and imaging.
· Primary care medical homes wurg
coordinated, continuous, and integrated case.
· Virtual group practices uniting
doctors in regions.
· Worksite clinics (already 30% of
corporations offer these clinics on site, run by on-site primary care
physicians and wellness consuelors.
· Clinics in retail settings.
· Geographic mega-clinics like Mayo,
Geisinger, Carillion, and academic centers, which now care for about 10% - 12%
· Practices featuring telehealth,
e-visits, and home and work visits.
· Practices featuring
patient-generated histories and other forms of telecommunciations not
necessarily requiring face-t-face visits.
· We have done enough bleeding, now
is the time to do some leading.
I Have Told You
have told you
· Your future is bad under the
current health reform law
· Your future depends to a great
extent on Supreme Court and the elections in November
· You can brighten your future
through leadership, practice innovatiohn, new practice models, and political
friend inquired , "What do you really think of Obamacare?
What image does it conjure up in your mind?"
Here, tongue-in-cheek, is my answer.
think of Obamacare as an octopus – an amphibious (actually triphibious because
it can fly), ambidextrous (actually octodextrous because it has 8 tentacles),
omnivorous ( capable of offering everyone a free lunch and then eating them for
lunch), and omnipotent (at least in its own mind ) – creature . It is highly
mobile and aggressive. It glides across the floor of society, sucking up
everything in sight on the bottom or then rising to the top, confiscating
assets and wealth.
Obamacare Octopus has a huge head – monstrous and swollen and tilting to the left.
It has a brain with two large lobes - Medicare and Medicaid. The corpus
collosum is the department of Health and Human Services. The midbrain is
Kathleen Sibelius. The hindbrain is Congress. The spinal cord is the White
has a blinking, flashing large Cyclops quarely in the middle of its forehead.
The monster's eye eeriely resembles a large TV screen. Instead of esyelids,
however, teleprompters ring the eye. It has an ample mouth, the mainstream
media. It has a four chambered ink sac on its under belly- containing black,
red, green, and purple ink. The black sac is the smallest and is rarely used,
except in the name of “savings.” The red sac continually gushes huge gobs of
red ink. The green sac squirts ink at anything that moves – a windmill,
rotating solar panels, and electric cars. The purple sac continuously blasts
out purple , sometimes subtle prose, mostly to obscure the other inks.
has 8 tentacles with powerful suction cups on the undersurface. These suctions
money and liberties from Americans.
· The first tentacle extracts a
projected $2.5 trillion from taxpayers over the next 12 years.
· The second tentacle takes $575
billion out of Medicare for 10 years.
· The third tentacle pulls $300
billion to $400 billion out of pockets of physicians and hospitals.
· The fourth tentacle vacuums $60
billion to $70 billion in taxes out of the drug firms, device makers, health
plans, and other members of the medical industrial complex.
· The fifth tentacle takes $100
billion or so from the young and healthy.
· The sixth tentacle sucks up $400 to
$500 billion out of the coffers and profits of large and small businesses.
· The seventh tentacle suctions $400
billion to $500 billion out of State Medicaid budgts, and awy from social
services, transportation, and education.
· The eighth tentacle is required to
hire 5000 new CMS employees, including $16,500 IRS agents to enforce the
individual mandate and to collect the new taxes.
much for my image of Obamacare. It is a distortion of reality. You may think it
grotesque. Still, as Mike Pence (R-Ind) observed , "Only in Washington,
D.C . could you say you’re going to spend a trillion dollars and save the
taxpayers money.” And only in D.C. could you say you’re going to add 32 million
to Medicaid rolls, subsidize every family of four up to $88,000 , save money,
make everything more efficient, and elevate quality.
If you believe these things, I have a bridge I would like to
sell to you.
- Bumpy Road
onto your hats and wallets, fasten your seatbelts, strap on your lifejackets,
jock straps, and chastity belts, and pray the Supreme Court and the electorate
makes the right decisions.
Above all, hold onto your freedoms. It’s going to be abumpy
contact me, go to email@example.com, or call 1-860-395-1501 in Connecticut. To read me, procede to
amazon to buy my books, call Greenbranch publishing (1-800-933-3711) to order
my latest book The Health Reform Maze, or Google me at Medinnovation to
insert a comment or ask a question.
has been a gloom-filled talk. Do notdespair. There’s always gloom for
Tweet: Physicians’ futures depend on Supreme Court , the elections,
and what physician do to defend themselves and to innovate to improve the
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