Wednesday, February 27, 2013

Unleashing Health Care Innovation – A Proposal
Nothing limits achievement like small thinking; nothing expands possibilities like unleashing imagination.
William Arthur Ward (1925-1994), author of Foundation of Faith
In search of the spark – and the next big thing.
John Bussey, Wall Street Journal Editor, In “Unleashing Innovation,” Journal Report, February 26, 2013

Health care innovation in the age of health reform is not one thing. 
It is many things. 
It is recognizing that reform is a two-edged sword – government controls and creative means of minimizing those controls.
It is a state of mind – that’s all right to try and try again, and to fail.
It is thinking outside the box. 
It is knowing there is a box – and regulations and codes create that box. 
It is acknowledging what is and what could be.  
It is believing that patients are very smart people, capable of learning what is good and bad care and acting upon that knowledge.  
It is giving people the means of spending their own money in ways they see fit. 
It is looking unblinkingly at what data and science says.
It is believing in the potential power of the robot and the computer, but knowing limitations of both.  
It is believing humans should have the power to trump protocols and algorithms.  
It is making failure acceptable.
It is  knowing wild and crazy individuals have wild and crazy ideas that are worth a try,  and that organizations can foster these individuals by giving them space to dream.
It is being aware rules, regulations, and bureaucracy can dry up creativity.  
It is about getting real and seeing that capital is the fuel for applying imagination solutions.
It is about looking at wider world and seeing what drives innovation – GPS, IPhones, social media, and virtual information – and applying and connecting that knowledge to the health care world.  
Finally, it is about communicating your ideas and ideas of others on innovation to your fellow caregivers.
That is what I try to do with the following proposal.

Dear Fellow Health Care Innovator.
In 2005, I wrote a book Voices of Health Reform, Interviews of 45 National Health Care Stakeholders at Work. In 2007, Jones and Bartlett published my book Innovation-Driven Health Care: 34 Key Concepts for Transformation.  That same year, I started the Medinnovation Blog.  Today, 2700 blog posts later, I have 700 readers each day, 789 yesterday.  Over 125 of my blogs have been on innovation.  I am working on  my latest book, Innovation and Health Reform, which will be available  in several months and will contain 100 of my blogs on innovation.
New Venture and a  Proposal
I have embarked on a new venture:  Interviews with Health Care  Innovators,  of whom you are one.
My proposal is this:  
For an introductory price to be negotiated,  I will personally  interview you for your ideas of innovation and what your company is doing to promote health care innovation.  I will then publish  your interview on my blog, along with an ad approved by your organization, which will appear as an integral part of the blog post.   You may then take my blog post and distribute it to your customer base and to potential clients.   I will also send you an autograph copy of my new book Innovation and Health Reform.
My intent is to develop a forum  for innovation thought leaders in which you can express yourself in your own words.
If you have any interest , let me know  at 1-860-395-1501 or, so we can schedule time for an interview.

Richard L. Reece, MD

Tuesday, February 26, 2013

Age of Discontinuity and Disruptive Innovation Converging in Organizations with Wherewithal That Understand Markets,  Consumers, and Physicians
Everything That Rises Must Converge
Title of 1965 story by Flannery O’Connor (1925-1964)
For hospitals and doctors, the age of discontinuity and disruptive innovation  has arrived in the form of organizations with the wherewithal that understand the needs of patients and doctors.   Things will never be the same again once these organizations gain traction.
This is because of the rise of these economic and social forces.
·         Soaring health care costs

·         Demand for cost containment by the public,  employers, and patients

·         Health reform,  government and private

·         Digital revolution,  informational  and technological

·         Hospitals and integrated health organizations as replacements  for doctors’ offices and coordinators of care

·         Nurse practitioners,  physician assistants, and home care caregivers 

·         Physician fragility,  fragmentation, and role reallocation

These forces are converging into organizations that have the credibility – and the administrative, technological, capital, and marketing resources, and innovative capacity - to do what needs to be done.
Peter Drucker (1909-2006), the father of modern management and social philosopher, spotted this converge 45 years ago in his book, The Age of Discontinuity.
Every single social task of major impact . . . is increasingly entrusted to institutions which are organized for perpetuity and which are managed by professionals, whether they are called ‘managers,’ ‘administrators,’ or ‘executives.'
Drucker also noted that government, because of its distance from the point of care, its bureaucratic impediments, and its inability to innovate, is not up to the task of reforming health care.
The best we get from government in the social welfare states is administrative incompetence. Every country reports the same confusion, the same lack of performance, the same proliferation of agencies and programs, of forms, and the same triumph of accounting rules over results.
Into the health reform arena has stepped Clayton M. Christensen, a Harvard Business School professor, who explains disruptive innovation, or disruptive technologies this way.
Disruption enables less-skilled people to do more sophisticated things. Disruptive innovation enables a large population of less-skilled population to do things in a more convenient, lower-cost setting, which historically could only be done by specialists in a less convenient setting.
Like Drucker, Christensen is skeptical government can effectively do health reform.  In last week’s  February 16 Wall Street Journal, “The Coming Failure of Accountable Care,” Christensen and colleagues doubted that government efforts to bring down costs through Accountable Care Organizations would succeed. They say Accountable Care Organizations, which are nothing more or less than updated HMOs. will fail because of flawed assumptions about doctor and patient behavior.  The conclude” “what ACOs most assuredly will not do  is deliver the disruptive innovation that the U.S. Health care system urgently needs.”
 In essence,  Obamacare throws a bunch of ideas in the form of demonstration  projects stretched out over the next 3 to 5 years on the wall to see if any of them stick.  These include ACOs,  medica homes, bundled payments,  teams delivering care in patients’ homes, reducing hospital readmissions,  pay for performance based on evidence and  outcomes ,  paying less if health care records are not adopted and if “meaningful use” criteria are not adopted,  and enforcing their ideas through  Independent Payment Advisory Board .  These ideas are disruptive but they are not necessarily innovative. I am doubtful that iron fist of government will make them stick .  Only innovative organizations that understand markets, consumer. and physician can do that.
Tweet:  Ideas to lower costs and make health care better are converging in innovative organizations that understand markets, consumers, and physicians.

Monday, February 25, 2013

“Fragmented and Fragile Workforce: A Discussion on Cultivating Hospital-Physician Cooperation.” A Review of a 64 Slide Powerpoint Slide Presentation by Kurt Mosley, Vice-President, Strategic Alliances, Merritt Hawkins,  AMN Healthcare
There are very few human beings who receive the truth , complete and staggering, by instant illumination. Most of them acquire it by fragment, on successive development, cellularly, like a laboratory mosaic.
Anais Nin (1903-1977), The Diary of Anais Nin
Live in fragments no longer.
Edward Morgan Forster (1879-1970), Howards End
Freedom is fragile and must be protected.
Germaine Greer (born 1939)

Recently Kurt Mosley of Merritt Hawkins AMN Heathcare, sent me a 64 slide presentation he is giving before hospitals,  physician organizations, and healthcare management associations across the country.
 In his talk,   Mosley describes the fragility and fragmentation of physicians,  as they try to respond to health reform pressures,  and how hospitals and doctors might react to lessen these pressures.
Hospital physician relations are a fragile thing.  
As a hospital CEO once explained,  “You can’t live with physicians and you can't live without them.” 
Under reform, the same is now true of physicians.   They can’t live with hospitals.  Indeed, they often compete with hospitals.  Increasingly, physicians  can’t live without hospitals .   Physicians simply don’t have the administrative,  technological, capital, and marketing resources to deal with the regulations,  rules,  demands, and mandates of Obamacare or of  similar  pressures of managed care and health plans.
In a sense,  hospitals,  or the so-called integrated health care organizations with hospitals at their core,  are replacing doctors’ offices.  This is understandable when you consider  in any given city in the U.S.  hospitals are the biggest business in town,  are the largest employer,  have the most political clout, and are the best equipped to deal with administrative demands of Obamacare.
That is why physicians are flocking to hospitals for employment,  why hospitals are growing to counteract Obamacare, why dominant hospitals can negotiate the best contracts with hospitals,  and why hospitals may own 75% of physician practices by 2020.
Mosley and Merritt Hawkins know this realities. 
 As a large physician recruiting firm, Merrit Hawkins knows:

·        More and more of their physician recruiting business comes from hospitals.

·        The physician union is fragile and fragmented , with just 50% of physicians saying they will practice as they do now over the next three years,  with the other 50% fragmenting becoming  hospital employees, retiring,  not accepting new Medicare and Medicaid patients, working part-time, working locum tenens or in concierge practices, or seeking employment either in or outside of medicine. 
The end result may be a physician shortage of unprecedented  magnitude with 83, 000 physician assistants and 155,000 nurse practitioners try to pick up the slack  to relieve physician shortages.  
What can hospitals do in concert with physicians to avert am access crisis?  New practice models? New innovations, such  as mobile. apps triage, virtual visits , mobile electronic  health records , in home implantable devices.
This talk spells out the options of “realignment, “ “collaboration, “ and “cooperation between hospitals and physicians, both of whom face decreased funding and reimbursement under Obamacare for the next ten years.
Tweet:  Over the next 10 years,  hospitals and physicians must cooperate and innovate to mitigate the effects of Obamacare  to contain costs.

Sunday, February 24, 2013

Imagining Being a Young and Restless Physician
A tough, but nervous, tenacious restless race; materially ambitious, but prone to introspection, subject to waves of religious emotions... A race that typical member is torn between a passion for righteousness and desire to get on in the world.
Samuel Eliot Morison (1887-1976)
“You can actually make a lot of money and do a lot of good in the world.”
Andrew Goldman, Interview with Peter Henry, dean or N.Y.U’s Stern School of Business,  February 24, 2013, New York Times Sunday Magazine
I awoke this morning imagining what I would think as a young medical student physician about to select a residency knowing what I know now.  In my imagining, I was 25 years old and married to a fellow medial student.  Together, we were $250,000 in debt.
I would be torn whether to become a primary care physician or a specialist.    Most of my mentors on the medical school faculty have been specialists, but   I would know that
·        The United States desperately needs primary care physicians, they do a world of good, it would be the righteous thing to do,  and they are in short supply, particularly in rural America and in inner cities.

·         Foreign medical school graduates and osteopaths are a growing proportion of primary care physicians. 

·        Most of my classmates envision working for hospitals or large medical groups because starting a practice on your own is difficult, and it is impractical to practice solo or to get financing to do so.

·         Specialists make 2 to 3 times what specialists make, but that Obamacare plants  to  raise primary care doctors by 10% a year over the next 4 years while cutting specialists’  pay.

·         Getting residences is competitive for the ROAD (Radiology, Orthopedics or Ophthalmology, Anesthesiology, and Dermatology), all of whom have shorter work hours, higher incomes, and more balanced life styles.

·        Working for a salary for a hospital or a group was probably my destiny, and I would be interested in a 40 hour work week, fringe benefits, health care premiums, payment of my medical school debt, and malpractice premiums.

·        I would be aware the end-game of health reform was still highly uncertain and my ultimate fate after completing 3 to 5 years of training was unknown as well as where I would fit into the system.
But, given economic conditions for the economy, with a huge national debt and high unemployment, I was not unhappy in my decision to become a doctor.   After all, because of the doctor shortage and the rise of health care as the leading economic growth sector, I was virtually assured of gainful employment.
That was more than I could say for many of my college classmates.  Some had gone to law school. Half of them were unemployed 6 months after receiving their law degrees.  Even those who received their MBAs were having trouble finding work.   Both of which might explain why those seeking admissions to law school and business schools had dropped precipitously y over the last 4 years.   The information technology sector was,  but the financial sector wasn’t going anywhere.    At least,  my wife and I would have the means of paying off our college, medical school, and post-graduate training debts.  All I wanted was to do good and to do well, and I still thought I could do both by becoming a doctor.
Tweet: Knowing what I know now, becoming a physician is  positive thing, especially when one  factors  in conditions of the overall economy.

Obamacare, Hamburger, and Job Flipping
If it’s flipping hamburgers at McDonald’s, be the best hamburger flipper in the world, whatever it is you have to do to master your craft.
Snoop Dog
I hate to be flippant, I really do, but Obamacare has a problem. 
The law requires firms with 50 or more employees to offer comprehensive health coverage to those  who work more than 30 hours a week.   If the firm reaches or exceeds the magic 50 and does not cover them, it faces a $40,000 penalty. 
This comes down to a $2,000 tax for each hire over 50.  The fine goes to $60,000 over 60 workers.   This is tough to do if you are a franchisee or owner of a fast-food hamburger business with average profits of $50,000 to $100,000 and average margins of 3.5%.
How  are McDonald’s , Wendy’s, and Burger King coping with the new rule, soon to take effect in 2014?  They are still hiring workers to flip burgers, but only for 29 hours a week, barely time enough to master their craft.  
And the firms  are talking to each other, or so it is said, about sharing part-time workers, thereby dodging the 50 worker Obamacare rule and staying in business rather than going out of business.
And what are workers doing?  They are flipping part-time jobs, rather than working full-time.  They may work the morning shift at McDonald’s, then go to a nearby Burger King or Wendy’s  to create a full-time work week in order to pay their bills, including  health insurance that the Obamacare individual mandate requires them to buy.
The end result is that employers are stuck with hiring part-time workers,  and workers are stuck with part-time jobs.
To conclude:
Somehow Obamacare’s full-time worker health coverage rule,
Requiring firms to pay for health plans in the 50 or over pool,
For incentives to  owners, this seems  perverse,
For workers, this  seems economically in reverse,
and to full-timer workers, job flip-floppers, and preparers of  Big MacWhoppers,
It all seems to be unfair and even cruel.
TweetObamacare requires firms with 50 or more workers to provide provide them with halth insurances, whih fast-food firms say they cannot afford.

Saturday, February 23, 2013

The Sequester

How bad, pray tell, will be the dreaded sequester
It is of the total  budget only a 2.4 % cutting measure ,
It is not Armageddon or draconian,
But to the true blue Washingtonian.
It is an ominous political harbinger.

How dare they question our nobler intentions?
How dare they engage in federal interventions?
How dare they criticize government spending?
Everything we do is bleeding heart rendering,
To this largess there should be no abstentions.

When it comes to the question of sequestrations,
We aim to close tight the richs' tax fenestrations,
We seek to protect government takers,
They seek to enrich the profit-makers.
To us government is the final salvation.

 But how can President Obama explain the sequester concept?
When everyone knows it came from Obama and the left?
Bob Woodward notes Obama proposed and promoted it,
Never believing in the the real world  it would ever hit .
It’s easy – he can blame the compassionately bereft.

In Search of Physician Leaders
Without the ability to identify true leaders the future is bleak.
Donald J. Palmisano, MD, JD, On Leadership: Essential Principles for Business, Political, and Personal Success, Skyhorse Publishing,  2008, 2011

For the last ten years, I have been on the board of medical advisors for a New York City- based publishing company Castle Connolly Limited.  Among its activities, Castle Connolly publishes an annual book America’s Top Doctors. Through nominating process, Castle Connolly identifies 3000 or so of these doctors and publishes their names in its national and regional publications   
Castle Connolly also sponsors an annual National Physician of the Year Awards evening, akin to an Academy Awards,   for physicians.
This year those being honored include:
2013 National Physician of the Year Awardees

Lifetime Achievement:

Michael R. Harrison, M.D.
Professor Emeritus of Surgery, Pediatrics, Obstetrics, Gynecology & Reproductive Sciences
Founding Director, Fetal Treatment Center
University of California, San Francisco

Sterling Williams, M.S., M.D., Ph.D.
Vice President of Education, American College of Obstetricians & Gynecologists
Clinical Professor of Obstetrics & Gynecology, George Washington University Medical School

Clinical Excellence

Gopal Badlani, M.D.
Professor and Vice Chair for Clinical Affairs
Department of Urology, Wake Forest Baptist Medical Center

Jo A Hannafin, M.D., Ph.D.
Professor of Orthopaedic Surgery
Weill Cornell Medical College
Hospital for Special Surgery

Jerry A. Shields, M.D.
Director, Oncology Service
Wills Eye Institute
Professor of Ophthalmology
Thomas Jefferson University

National Health Leadership

Dawn Halfaker
President and CEO, Halfaker and Associates, LLC
President, Board of Directors, Wounded Warrior Project

It occurred to me a similar search might be conducted for Physician  Leaders of the year. A dearth of physician  leadership exists.  When the American Medical Association backed Obamacare,  it created a leadership vacuum.   Tens of thousands of physicians resigned from the AMA. Why? Physicians felt powerless and leaderless. Though national surveys, the Physicians Foundation ( has documented this concern about lack of leadership.  
Physicians are angry because Obamacare systematically decreases their reimbursements,  attacks the  fee-for-service reimbursement system,  hassles them with burdensome regulations,  increases practice expenses through mandatory EHRs and electronic prescribing,   forces them into accountable care organizations,  creates physician shortages,   dries up access to physicians,  and drives up cost of care.  
In any event,  physicians are looking for physician leadership to lead them out of the health reform morass and abyss.
My nominations for established and emerging physician leaders are:

·         Donald J. Palmisano,  MD, JD,  former AMA president (2003-2004), founder of Intrepid Resources ®, a Patient Safety and Risk Management Company, and an authority of leadership.

·         Ben Carson, MD,  head of pediatric neurosurgery at Johns Hopkins, who advocates health savings accounts for all from birth to death.

·         Delos “Tony” Cosgrove, MD, CEO of Cleveland Clinic, who stresses accommodating to Obamacare by building more effective  integrated health organizations, increasing their outreach,  and emphasizing cost consciousness

·         Marcy Zwelling MD of California, and David McKalip of Florida,  AMA members who criticize the parent organization and suggest  reform alternatives

·         Walker Ray, MD, retired pediatrician and VP of the Physicians Foundation,  who has been active in leading development of white papers ,  national surveys, and grants to improve physician practices.  

You may be interested in identifying other leaders.   Send your nominees to me at, and I will publish them in my blog.
As you do so,  consider these essentials of leadership, as identified by Dr. Palmisano.
A true leader:
·         Does the necessary “homework.”

·         Demonstrates courage.

·         Is persistent; doesn’t give up when faced with challenges; is relentless in pursuit of goal.

·         Fully understands both the mission and the goal.

·         Has integrity; is ethical.

·         Is decisive.

·         Doesn’t fail to act in absence of either instructions for an unexpected  crises or the desired data on which to base decisions.

·         Ie good listener and an effective communicator.

·         Does not depend on the approval  of others to build self-esteem.

·         Understands that unity adds to success and division leads to failure.

·         Leads “from the front.”

·         Inspires others and engages them using his or her passion and authentic behavior

·         Never asks others to take risks that he or she would not take.

·         Doesn’t get rattled in crises.

·         Seeks opportunities  to advance  the mission.

·         Knows how to identify those who are sincere in internal relations.

·         Is trustworthy and learns quickly whom to trust.

·         Is dependable, adhering a company’s or a movement’ mission without compromising  principles .for personal benefit  or enrichment.

·         Becomes a loyal follower  and supporter of other  leaders once they are identified.

·         Realizes that leadership is not an ego trip.
Tweet:  Practicing physicians are concerned about a loss of physician leadership.  They should set up a nominating process to identify their leaders

Friday, February 22, 2013

Why the Medical-Industrial Complex Is Killing Us
I got the idea for this article when I was visiting Rice University last year. As I was leaving the campus, which is just outside the central business district of Houston, I noticed a group of glass skyscrapers about a mile away lighting up the evening sky. The scene looked like Dubai. I was looking at the Texas Medical Center, a nearly 1,300-acre, 280-building complex of hospitals and related medical facilities, of which MD Anderson is the lead brand name. Medicine had obviously become a huge business. In fact, of Houston’s top 10 employers, five are hospitals, including MD Anderson with 19,000 employees; three, led by ExxonMobil with 14,000 employees, are energy companies. How did that happen, I wondered. Where’s all that money coming from? And where is it going? I have spent the past seven months trying to find out by analyzing a variety of bills from hospitals like MD Anderson, doctors, drug companies and every other player in the American health care ecosystem.
Steven Brill,  “Bitter Pill: Why Medical Bills Are Killing Us,l “  Cover Story, Time Magazine, February 20, 2013
Frankly, I was astonished when I read Steven Brill’s article on the use and abuse of chargemaster accounts to bill patients in U.S. hospitals.  
  • To begin with, the story is over 24,000 words long. That’s long enough for a book.
  • Secondly, it is full of horror stories about patients being overbilled compared to Medicare rates. 
  • Thirdly,  it is critical of hospital administrators,  who run multibillion institutions,  that are the major employers in many American cities. 
  • Fourthly, there seems to be no accountability, no rhyme or reason, for the excessive bills and no attempts to fix them.
  • Fifthly , it is   harsh in its criticism of America’s hospitals’ charges, a major driver of our health costs, which exceed  those of other nations by at least 27%.
Brill writes:
“When you crunch data compiled by McKinsey and other researchers, the big picture looks like this: We’re likely to spend $2.8 trillion this year on health care. That $2.8 trillion is likely to be $750 billion, or 27%, more than we would spend if we spent the same per capita as other developed countries, even after adjusting for the relatively high per capita income in the U.S. vs. those other countries. Of the total $2.8 trillion that will be spent on health care, about $800 billion will be paid by the federal government through the Medicare insurance program for the disabled and those 65 and older and the Medicaid program, which provides care for the poor. That $800 billion, which keeps rising far faster than inflation and the gross domestic product, is what’s driving the federal deficit. The other $2 trillion will be paid mostly by private health-insurance companies and individuals who have no insurance or who will pay some portion of the bills covered by their insurance. This is what’s increasingly burdening businesses that pay for their employees’ health insurance and forcing individuals to pay so much in out-of-pocket expenses.
Steven Brill
I asked myself – Who is  Steven Brill?
Here's what Wikipedia has to say.
Steven Brill (born August 22, 1950 in Queens, New York)] is the founder of CourtTV and American Lawyer magazine. His most recent venture is Journalism Online, which he sold to RR Donnelley in 2011 for a reported $45 million and now has more than 400 publications using its Press+ service to charge for digital content. He also founded Verified Identity Pass, Inc., a New York-based company that operated the Clear airport security fast-pass, a pre-cursor to the current Federal Trusted Traveler program. In 1998, Brill created Brill's Content, a widely-acclaimed magazine with a critical eye to the media. He also launched, which was to be a clearinghouse for the buying and selling of web text, news, and info of all sorts. In addition to writing a column for Newsweek, he has written magazine articles for The New Yorker, The New York Times Sunday Magazine, Harpers and TIME. He is the author of The Teamsters (1978), After: How America Confronted the September 12th Era (2003) and Class Warfare: Inside the Fight to Fix America's Schools (2011).
This is a very entrepreneurial guy who knows how to turn a buck.     
I have no criticism of his research which is well documented and based on  scrutiny of hospital bills.  Nor do I disagree with some of his conclusions – institute tort reform, outlaw chargemaster accounts, scrutinize and limit non-doctor executive incoms  or this concluding paragraph,
“Over the past few decades, we’ve enriched the labs, drug companies, medical device makers, hospital administrators and purveyors of CT scans, MRIs, canes and wheelchairs. Meanwhile, we’ve squeezed the doctors who don’t own their own clinics, don’t work as drug or device consultants or don’t otherwise game a system that is so gameable. And of course, we’ve squeezed everyone outside the system who gets stuck with the bills.
Tweet:  In any given city, hospitals are often the biggest business in town,  the largest employer, and the most profitable business enterprise.