Thursday, January 31, 2013

American Culture, Obesity, Violence, and Other Factors Influencing Longevity and Health
Culture is on the horns of this dilemma: if profound and noble, it must remain rare; it common, it must be mean.
George Santayana (1863-1952),  The Life of Reason

When I hear the word “culture,” I reach for my pistol.
Hans Johst (1890-1978), German Playright  and Nazi Poet Laureate, Sclageter

January 31, 2013 -  Tomorrow my new book,  The Physicians Foundation: A New Voice for Physicians, comes out.  You can order it  for $19.95.  
Today I am thinking about my third book in the series Rhyme, Rhetoric, and Reality.  This book will concern American culture and its influence on our longevity and health.  
A  nation’s health system shapes its culture.  Our culture cherishes independence, individualism, choice,  and freedom to do what one wants, when one wants,  and to be what wants.   We believe in equal opportunity for all, but not necessarily in equal outcomes for all.   We are a capitalistic democracy, but we are also a meritocracy that believes that those with merit and skills should have the opportunity to rise  above those less skilled .
This cultural philosophy poses dilemmas and  health problems.
·         Take obesity.  We are the fattest country on the planet. We worship thinness  but practice fatness.   We love fattening fast food outlets, which populate every community in America,  but  we believe we can fix fatness by participating and joining  in Weight Watchers and the myriad of other weight -loss franchises.  We  gobble up “fat-free” or “cholesterol-free” foods, which are rich in sugar and carbohydrates to make them taste good and make us fat.   We have fitness centers everywhere,  but we sit glued to our computers and television sets between sessions at the gym with the work-out machines.  We are obsessed with obesity and weight loss.  I learned this yesterday when my blog post,  “Obesity, Myths, Presumptions, and Facts” attracted nearly 2000 hits, i.e. page views.

·         Consider gun violence.  The debate over how to control mayhem and death from guns now occupies the political center stage, due to the senseless  massacre of 20 innocent children and 6 adults at Newtown.   The Obama administration  has thought of  or proposed bans on assault weapons,  national gun registration, tighter controls on guns,  better mental health screening, and armed guards at every schoolhouse door  as parts of a comprehensive solution.   We need a solution,  for if one subtracts deaths from our national statistics,  we would lead the world in longevity and would decongest our costly emergency rooms.  But alas, there’s the  Second Amendment.  There’s 300 million guns out there,  many illegal guns easily purchased on the mean streets.  There are 150 million legal gun owners bent on protecting themselves,  their families, their homes, and their places of business.  There are small and big game hunters,. There’s a pervasive and persistent  paranoia that if all guns are registered government can confiscate the firearms.   Besides,  gun violence sells movies, television programs, video games,  and media market share.  I maintain our congested media markets, with their endless appetite for news on gun deaths  feeds the media gun market violence monster,  making it bigger than it actually is, for the number of gun deaths and mass killings had dropped significantly over the last 20 years.  Nevertheless, I am of the “don’t do nothing, do something school” even if it prevents one needless death
Tweet:  American culture shapes our health system, creating dilemmas influencing  our attitudes towards obesity,  gun violence, and our health

Wednesday, January 30, 2013

Obesity Myths , Presumptions, and Facts
We identified seven obesity-related myths concerning the effects of small sustained increases in energy intake and expenditure, establishment of realistic goals in weight loss, rapid weight loss, weight-loss readiness, physical-education classes, and energy expended during sexual activity. We also identified six presumptions about the purported effects of eating breakfast, early childhood experiences, eating fruits and vegetables, weight cycling, snacking, and the built (il.e human made) environment.
Krista Cazazza, PhD and 19 co-authors, representing the National Institutes of Health,
“Myths, Presumptions, and Facts about Obesity, “ New England Journal of Medicine, January 31, 2013

January 30, 2013 – This New England Journal of Medicine  report is timely when one considers that weight loss has become a multi-billion-dollar industry and that weight-loss formulas and approaches are often unsuccessful, in light of the reality that obesity and diabetes has become a national epidemic.
     Seven Myths

·         Myth Number 1: Small sustained change in energy untake and expenditure will produce large, long-term weight changes. 

·         Myth Number 2: Setting realistic goals for weight loss is important, because otherwide patients will become frustrated and loss less weight.

·         Myth Number 3: Large, rapid weight loss is associated with pooer long-term weigh-lost outmes as compared with slow, gradual weigh loss. 

·         Myth Number 4: It is important to assess the state of change or diet-readiness in order to help patients who request weight-loss treatment.
·         Myth Number 5: Physical-education classes , in their current form, plan an important role in reducing or preventing childhood obesity.
·         Myth Number 6: Breast-feeding is protective against obesity.
·         Myth Number 7: A Bout of sexual activity burns 100 to 300 kcal for each participant.
Six Presumptions
1. Regular eating breakfast protects against obesity.  Most often no effect
2. Early childhood habits influence weight later in life, i.e. fat kids become fat adults, Often true.
3. Eating fruits and veggies results in weight loss. True.
4. Weight cycling, ie. yo-yo dieting, is associated with increased death rates. True.
5. Snacking contributes to weight gain and obesity. Yes.
6. The environment, i.e. sidewalk and park availability, influences obesity. May affect obesity.

     Nine Facts
1.    Heredity is not destiny

2.      Diets reduce weight.

3.      Increase in exercise increases health

4.      Physical activity in sufficient doses helps weight maintenance 

5.      Continuing conditions that promote weight loss helps maintain lower weight

6.      With obese kids , programs involving parents promotes weight loss and maintenance
7.      Use of meal-replacement products promote greater weight loss
8.      Some drugs help weight loss as long as drugs continue to be used.
9.      Bariatic surgery results in long-term weight loss and reductions in  incident diabetes and mortality.

Herein are obesity myths,
With  facts set forth forthwith,
By 20 National Institutes of Health experts,
Interested in reducing your ample girths,
It’s all here, presented herewith

Notable and Quotable:  The Doctor's Office as Union Shop
January 30, 2013, Wall Street Journal, David Leffell, MD, practicing physician, former CEO of Yale Medical Groupand a professor at Yale School of Medicine

“As the country moves toward the effective start date of the Affordable Care Act in 2014, the operational and economic elements of this vast legislation are becoming clearer. Yet one likely outcome of the act that will directly affect the quality of patient care, and could affect its cost, has gone virtually unnoticed and unreported: the increasing trend for physicians to become employees, rather than self-employed. This development represents a potentially radical factor in the transformation of health care—the doctor as union worker. “

“hysicians have historically practiced either in small groups or alone. Unlike hospitals, which operate under the rubric of large regulatory agencies, physicians have been much more difficult to regulate and monitor. For cost control to be effective, the professional autonomy and independent clinical judgment of the physician and other providers must in some measure be sacrificed to standardization. This can't be accomplished by overseeing thousands of doctors in thousands of offices and medical complexes, each conducting its own symphony.”
“The Obama administration, by intent or accident, has effectively driven a major change in the status of physicians. By reducing the reimbursement for certain office-based specialists while enhancing related payment to hospitals, the administration is compelling more and more physicians—many of them with an any-port-in-a-storm fatalism—to seek employment with health systems or large physician groups.”
Comment:  Standardization and homogenizatio of physician practices, as dictated by the Obama administration, comes at a price - labor unrest among physicians.

To Innovate and Transform , Think Globally, Act Locally
Think globally, act locally.
Maxim for Entrepreneurs
January 30, 2013 - Ideas invented in the garage of a local inventor or fledging capitalist enchant Americans.    Creators of Hewlett Packard,  Apple, and Microsoft come to mind.  Many of us believe the best innovations and the most profound transformations come from the bottom-up rather than the top-down.  Take it for a test drive on the local streets before you go on the federal highway.
Two press releases today, remind me of the importance of the “think globally, cat locally”maxim.  What has changed is that local innovations often start with organizations rather than individuals.
The idea behind this joint effort with community health systems is to transform Patient-Centered Medical Homes to provide communities with the resources to coordinate improved outcomes, quality, with reduced costs.
  • The second press release appeared in Kaiser Health News and reads as follows. For Medicare Innovations – Think Locally

By Ankita Rao, January 29, 2013
"Reforming Medicare – from changing the way doctors are paid to streamlining patient care – could benefit from a grassroots approach, according to experts and physicians at a policy summit held by National Journal Live in Washington, D.C., Tuesday.
“We need to focus more on responding to and joining local initiatives,” said Len Nichols, director of George Mason University’s Center for Health Policy Research and Ethics. As an example, he pointed to an initiative in Rochester, N.Y., that brought local doctors and hospitals together to successfully reduce hospital readmissions.
The panelists agreed that solutions to address the system’s inefficiencies should begin at the ground level with physicians, community members and patients, who could provide valuable feedback and ideas when designing new approaches to quality care and cost control.
“What the ACA has done is to set up an environment where there is support for new innovation,” said Gail Wilensky, an economist who previously directed the Medicare and Medicaid programs.
With much of the health law going into effect in 2014, the U.S. will likely see increased coverage, insurance marketplaces and an expanded Medicaid program.
But Wilensky said the health law’s limited role in changing payment models and encouraging patient engagement in the health system operations could prove to be a “fatal flaw” in what should be an overhaul of the system. “These are huge constraints in how and how fast Medicare can move,” she said.
Dr. Edward Murphy, a professor of medicine at the Virginia Tech Carilion School of Medicine, said physicians’ attachment to the status quo was slowing down efforts to move to a system that rewards better health outcomes and lowers consumer costs. He said doctors need to adopt fundamental new practices.
“To get a broadwave movement of change across the country, it seems to me, we need a cultural shift,” he said."

Tweet:  To be effective,  health reforms must start at the local rather than the federal level.


Tuesday, January 29, 2013

Squeeze on Hospitals and Physicians
The tighter you squeeze, the less you have.
Thomas Merton (1915-1968), American Trappist Monk

Managing is like having a dove in your hand.  Squeeze it too hard and you kill it, not hard enough and it flies away.
Tommy Lasorda (born 1927), baseball manager

January 29, 2013 -  The Affordable Care Act has put the squeeze on hospitals and doctors by systematically cutting what doctors and hospitals  will be paid from Medicare and Medicaid over the next 10 years.  
The government’s  reasoning  is obvious.  Hospital and doctors account for 50% to 55% of total health costs.   To reduce total health costs,  you therefore have to squeeze payments for hospitals and doctors.
Consequently,  the health care hills are full of talk about how to best achieve hospital- doctor “alignment”  for mutual survival.  The government figures if you can bundle hospitals and doctors into the same organization,  known as an Accountable Care Organization, you can then more conveniently squeeze  out high cost juices   and reduce the size of the organizational lemon.
Don’t  squeeze  hard enough to close hospitals or drive  doctors out of practice.     The ensuing hospital bed and physician shortages might reduce access enough to cause the public to revolt – and to fly away from Obamacare.
Don’t  squeeze physicians out of traditional practice into concierge or cash-only medical practices outside the reach of government. Squeeze just hard enough to make hospitals and doctors squeak but not squeal – to make changes that save government money.  As you’re squeezing,   divert the public’s attention with euphemisms  that the squeeze will “enhance, integrate care, and coordinate care,” “reduce duplications,” and “increase efficiencies.”   Avoid talk about the bitter juices that may emerge from the squeezing,  like independent doctor complaints, public grousing, higher costs,  fewer choices,  lesser access,  tighter restrictions that limit referrals to hospital-based specialists.
Tweet:  Obamacare is  squeezing hospitals and doctors by reducing their federal pay,   forcing them to join together and to “align”  to survive.

Monday, January 28, 2013

Hospital Fees for Work Done in Physician Offices Owned by Hospitals
Old hospital administrators never die, they just charge hospital fees elsewhere.


January 28, 2013 -  I once took a course on health care management at the Harvard Business School.  As part of the course,  the instructor would pose a situation and ask the class to respond to it.  The instructor might have said, for example,  the federal government  had passed a law slashing hospital fees. Hospital administrators in the class always had ingenious responses circumventing or mitigating the intent of the law.  I thought of the class when I read in the,  the following story in an article entitled “Hospital Fees Minus Just One Thing: A Hospital.” 
Robert Reed’s visit to a suburban dermatologist’s office last year seemed ordinary: He was led into a small exam room with a scratchy paper-covered table, where the doctor inspected his skin and squirted liquid nitrogen onto three pre-cancerous spots
The statement he received a month later appeared anything but ordinary: It included $1,525 in “operating room’’ and hospital “facility’’ charges. Surely, Reed thought, it must be a mistake. There had been no hospital, no anesthesia, no surgical nurse
And these charges were far more than what the doctor billed for her services — just $354. “I feel like I’ve been taken advantage of,” said Reed, a 57-year-old financial analyst. “They need a reality check on what they are charging.’’
The realities , Mr. Reed, are these:
·         Obamacare is slashing hospital and doctor fees over the next decade.
·         Doctors are responding by going to work for hospitals in such record numbers that hospitals now own more than half of physician practices.
·         Hospitals are responding by charging hospital “facility fees” for work done in doctor employees’ offices, even if those offices are physically located away from the hospital.
The Lahey Clinic, who owns the dermatologist’s practice, defends the facility fee.  Lahey’s general counsel, says Medicare permits hospitals to bill facility charges for care in a physician’s office as long as they inform patients in advance. At the Wall Street dermatology office in Burlington where Reed had his procedure last January, signs posted in the lobby tell patients, “The offices at this location are operated as part of the main hospital facility. Because of this, the care you receive may have a hospital facility charge in addition to a provider charge.’’
The American Hospital Association and the Massachusetts Hospital Association also rationalize  the facility fee.
A senior associate director at the American Hospital Association, says the extra fees are a way to have patients served at all of a hospital’s locations cover overhead costs unique to hospitals, such as having emergency room staff available 24 hours a day.
Many doctors’ practices are losing money and would be forced to close if a hospital did not step in to support them, said the, general counsel for the Massachusetts Hospital Association. “One of the greatest challenges for hospitals is to find the resources to subsidize physician practices so they stay in their communities,’’ he said, explaining that facility fees help pay for technology and staff and meeting regulatory requirements in these offices.
I predict hospital facility fees will soon be outlawed, but hospitals will find another way to make up for their losses under Obamacare and from losses incurred from buying physicians’ practices.
I’m reminded of this metaphor:  when government pushes the cost balloon down from the top,   costs pop out below.
Tweet  :Hospitals are charging an extra “facility fee” for work done in physician practices the hospitals own. The fees may be 4-5 times the doctor's fee.

Obamacare Offers Free Breast Pumps: What Next for Nanny State?
Nanny state is a term of British origin (and primary use) that conveys a view that a government or its policies are overprotective or interfering unduly with personal choice.  The term "nanny state" likens government to the role that a nanny has in child rearing.
January 28, 2013-   From Kaiser Health News and NPR News comes the following article,  dated today.  This will help  keep you abreast of the latest developments relating to the Affordable Care Act, also known  LWR ( Law for Womens' Rights) when one adds free contraceptives to the mix.
Nursing Moms Get Free Breast Pumps From Health Law
By Zoe Chace, NPR News, January 28, 2013
“Health insurance plans now have to cover the full cost of breast pumps for nursing mothers. This is the result of a provision in the Affordable Care Act (aka Obamacare), and the new rule took effect for many people at the start of this year.
It’s led to a boom in the sale of the pumps, which can cost hundreds of dollars.
Yummy Mummy, a little boutique on New York’s Upper East Side, has suddenly become a health care provider/online superstore. The company has been hiring like crazy, and just opened an online call center and a warehouse in Illinois. Yummy Mummy even hired somebody to talk to customers’ health insurance companies.
And new moms now seem more likely to splurge on fancy new breast pumps. Caroline Shany, a Yummy Mummy customer, spent her own money to buy a breast pump for her first baby. She may buy another one now because insurance will pick up the tab.
‘Why not?’ she says.
Weird things happen when you take price out of the equation for consumers. For one thing, they stop looking for the best price. But even though breast pumps are free for new moms, somebody has to pay for them.
“Health insurance premiums are driven by how much we spend on health care,” says Harvard health economist Katherine Baicker. “The more things that are covered by health insurance policies, the more premiums have to rise to cover that spending.”
Advocates of requiring insurance companies to pay for breast pumps say that the measure will pay for itself in the long run.
UCLA’s School of Public Health Dr. Linda Rosenstock, who chaired the team that recommended this provision, says the science is unequivocal. Preventive-care spending upfront leads to fewer health problems down the road. Babies who are breast fed tend to be healthier, and paying for breast pumps should mean more babies are breastfed.
Economist Baicker isn’t sure that eliminating the cost of the breast pumps really induces much extra breastfeeding. She thinks that most of the money spent will go towards people who would have been breastfeeding anyway. “So the question is whether the value that those people get from the breast pumps is worth the cost in terms of increased health spending and increased premiums,” she says.
The outcome may depend partly on how the new rules are implemented. Insurers are still trying to figure out whether to pay for extra-fancy breast pumps, or just basic models.”
Tweet:  Under Obamacare, women will get free breast pumps in 2014. This news  has led to a boom in sales of breast pumps,costing hundreds of dollars.

Sunday, January 27, 2013

Six  Balanced Views of President Obama
The management of the balance of power is a permanent undertaking not an exertion that has a foreseeable end.
Henry Kissinger (b. 1923), The White House Years (1979)
January 27, 2013 -  I have a dear friend who says my blogs lack balance. Perhaps they do.  This may be because I regard Obamacare as a mistake,  born of good intentions but not carefully thought through and riddled with adverse consequences.  Be that as it may,  I have positive views of President Obama as well. It is important to consider and to listen to all sides of issues and to take  the long view.
Good News  and Bad News
One - Obamacare
Good news  -It protects those with pre-existing illness and young adults under their parents policies until age 26, keeps seniors from tumbling into donut hole, and expands coverage for uninsured and those who cannot afford care. In the long run, it may be a step towards wider access and even universal coverage.

Bad news- To date, it is full of broken promises- to lower costs,  to lower premiums,  to allow patients to keep their doctors and health plans, and, besides,  its cost will be  prohibitive - $2.6 trillion through 2024, if one accepts Congressional Business Office projections.  As for the present,  it slashes  benefits for seniors,  reduces provider pay, and  produces a doctor shortage.

Two-  Budgetary Matters
Good News -  Obama may have saved  the country and automobile industry from deeper recession, depression and even bankruptcy with his $831 billion stimulus bill.
Bad News – In the process, he increased the national debt – $ 16.5 trillion headed toward $20 trillion at the end of his 2nd term- with few signs of a growing economy or greater employment.  He has spent more and accumulated more debt than all previous presidents combined.  Twenty three million Americans remain unemployed or underemployed, 47 million are on food stamps, and 49% depend on government transfer payments. Obama takes no responsibility for the slowest recovery on record in recent years.  Instead, he blames his predecessor.
Three, Role Model  for Minorities
Good News -  He gives minorities hope for the present and the  future by serving as a role model and proving a man of color has the  intellect, dignity, and decorum to rise to the top. He is a devoted family man and shows no sign of personal corruption.   He represents the ascendancy of a man of color to a national leader, the capstone of the civil rights movement and the Martin Luther King legacy. His presidency has helped erase the image of America as a racist country.
Bad News -  He partially achieved this status by disparaging achievements of the successful  by saying, “You didn’t built that.” Presumably government did. He seems to have forgotten that America is not only a democracy but a meritocracy – where people of merit are rewarded for their skills and successes, regardless of race or ethnic origin.  
Four, Political Astuteness

Good News -  Obama out-organized and out-maneuvered Hillary Clinton and the Republicans by building a powerful and loyal political team  catering to the political “have-nots” and those at the bottom of the economic and social ladder.  In short, Obama is a brilliant politician, which is important if you are to be a national leader.

Bad News – Obama  has shown no signs or engaging, listening, or compromising with opponents in an evenly divided country, creating a deep partisan divide. In his inaugural speech,  the issues that concern many – reining in national debt,  cutting  government overspending,  reforming entitlements -  received no mention.  In his mind,  he is the government, not Congress or the Surpreme Court. Nobody else, it seems,  matters.
Five, Speaker with Persuasive Powers
Good News -  Obama is  a powerful and persuasive speaker, and he takes full advantage of the bully pulpit and his constant presence in the national spotlight to push and defend his agenda.
Bad News -  Words and their presentation matter.  The Republicans have no one to match him nor do they have the fawning admiration of the national media.  
Six, Ideology
Good News -   To his followers,  President Obama has emerged as a true man of the left, a champion of downtrodden, underprivileged,  and forgotten in .the face of a stubborn recession.  He is delivering on his promise of a “transformational presidency.”
Bad News -  His ideology too often comes across as anti-business, anti-entrepreneur, anti-employer.  This attitude, and his pro-tax and pro-regulatory stance are anti-growth and slow the economy recovery. Corporations are sitting on their cash and not hiring. His ideology has not advanced the economic status  of minorities.  It shows he does not understand America’s center right, capitalistic culture.

Tweet:  When it comes to playing the game of balance of political power, the Obama presidency has positives and negatives.

Saturday, January 26, 2013

What’s Upfront in My New Book: The Physicians Foundation – A New Voice for Physicians
Up-Front – Frank or straightforward
January 26, 2013 -  I’ll be frank.  I’m writing this because my new book is coming out next week. The book will be 400 pages and will sell for $22.50. In essence, it is the history of the Physicians Foundation since 2003, when it was founded, until the present.
Here, up-front,  is the  upfront section of the book.
Dedication Page
Dedication: To Tim Norbeck, Lou Goodman, and Walker Ray who mobilized the doctors and helped found the Physicians Foundation, and to Phillip Miller of Merritt Hawkins, who helped articulate and define doctors dilemmas under Obamacare
Quotation Page
Draw your chair up close to the edge of the precipice and I’ll tell you a story.
Francis Scott Fitzgerald (1896-1940),  The Great Gatsby (1925)
This is the second of a series of books on health reform. These  books are based on blog posts I have written over the last 5 years in my Medinnovation blog. The first book was Physicians, Parodies & Poems.
This series of books will consist of revised daily posts or fragments of those posts.
The first book contains poems that appeared as posts, at the beginning or the tail end of posts.

The other books that will follow will include posts on these subjects, not necessarily in this order:

American Culture and Physician Culture


Medicare and Medicaid

Patient-centered care

Surveys of U.S. physicians

Primary care and specialty care

Book reviews on health reform

Accountable Care Organizations

Medical innovation

Electronic Records and Information Technologies

Malpractice and tort reform

Richard L. Reece, MD

February 1, 2013