Quote to Note: ACOs Are Just Failed HMOs, but With More Power, WSJ, Letter to Editor, October 31, 2014

“ACOs closely resemble health –maintenance organizations in their basic structure of a lump-sum payment to cover a bundle of services, with financial risk for spending more than this sum.”

“Both create srong disincentives to refer, to hospitalize or so spend money taking care of sick patients."

"Both create strong incentives to cherry-pick health patients. This is how these organizations make money, if successful. Any profit will mostly go to fill corporate coffers and bloated executive paychecks. A few dollars my trickle down to those actually providing care.”

“If HMOs had lived up to their hype, why should we now need ACOs?"

Richard Amerling, MD

President, Assocation of American Physicians and Surgeons, New York

Physician Nightmare over ObamaCare

ObamaCare has turned into a nightmare.

A physician commenting on health exchange health plans

It'e Halloween, four days before midterms, and it’s turning into a nightmare, not as portrayed by horrifying ghosts and goblins, but as realities for practicing physicians, health exchange patients, and ObamaCare partisaans who foresee spooky dangers lurking around the corner and political ghoulies that go bump in the night.

The nightmare? The Medical Group Management Association (MGMA), the largest association representing physician groups, has just announced, based on a survey of its members, that 214,524 physicians, out of 893, 851 practicing physicians(Kaiser Health estimate) will not be accepting patients who enrolled in health exchange plans. The number, 214, 524 is staggering because it represents one-fourth of practicing physicians, 24.0% to be precise, and the U.S. already has physician shortages of 50,000 or more.

Physician Nightmare

To physicians, millions of new health exchange patients represent a potential nightmare.

Why so?

1. Low reimbursements – 40% less than private plans, 20% less than Medicare, on par or less than Medicaid which is less than Medicare.

2. A tsunami of new patients, sicker than most, superimposed on already overloaded and overbooked practices.

3. Health exchange patients, 75% of whom have high deductibles, which low-income patients must pay, leaving doctors stuck with unpaid bills.

4. ObamaCare says patients must be covered for 90 days, insurers will cover for 30 days, leaving the doctors with a collection nightmare, the number one reason doctors and their practice managers give for not accepting these newly government insured patients.

There is another likely reason – physician suspicion and lack of support of ObamaCare. In a recent Physician Foundation survey of 20,000 physicians, 46% gave a ObamaCare a grade of “D” or “F”, and only 4% gave it an “A”.

In any event, ObamaCare is asking doctors to take sicker patients for less with greater risk of not getting paid. The MGMA summarizes the problem, “ Chief among them (reasons for not accepting exchange problems) is the fact that exchange plans are more likely to offer significantly lower reimbursement rates than private market plans, confusion among consumers about the obligations associated with high deductibles, and fear that patients will stop paying premiums and providers will be unable to cover their losses.”

Health Exchange Patient Nightmare

These numbers raises questions: What good is federally-subsidized insurance for patients if too few doctors exist to care for them? What happens if it becomes exceedingly difficult to find doctors? Or if long waiting lines make access to physicians and health care burdensome? There is Medicaid, of course, but the number of doctors accepting Medicaid, is 30% or less, and well below 50% in many regions of the country. And there are community clinics, designed to care for the poor and the uninsured. But for some patients, Medicaid and community clinics smack of social welfare and low-quality care, even if these attitudes are not deserved. And, increasingly, there is more self-care and more direct cash-only care in walk-in clinics and concierge practices.

Political Nightmares

For physicians and politicians there are political nightmares. Physicians will be portrayed as more interested in money than in the health of their patients. And ObamaCare backers, particularly Democrats who voted for the health law without a single Republican vote, will be viewed as supporting an unpopular President and an unpopular law, a law which the latest CBS/WSJ poll indicates only 36% of Americans favor while 55% disapprove.

For the moment at least, four days before the midterms, the Good Ship ObamaCare seems to be listing, in danger of sinking.

Complexity May Kill ObamaCare

Complexity stalks through the land.

Anonymous

If ObamaCare follows the path of Prohibition , and dies off, or is repealed, it will be because it cannot keep pace with complexity – its inabilities to deal with complexities of regulating the law, enforcing its mandates, collecting its penalties, monitoring its billions of transactions, reducing health care costs, and preventing its frauds and abuses. It will be because ordinary consumers, policy experts, and health care providers are unable to comprehend, coordinate its promises, and to subdue or cope with its complexities.

The Hospital - An Example of Unbridled Complexity

A good example of the difficulties is the modern hospital. Peter F. Drucker (1909-2006) observed, “The hospital is the most complex form of organization ever devised.” It is made up of scores of specialists, each with a different agenda, different skills, different equipment, different jargon; its work forces, its managers and its health professionals, including its work force, 80% of whom are nurses, have different cultures; its customers, physicians and patients, have different sets of expectations, its supply chains are fragmented and it moves to the beat of different sets of regulations – local, state, federal, and professional.

Two Paths around Complexity

As I see it, there are two ways to circumvent or to minimize these complexities.

One is by reducing complexity and the technology that feed it. This can be done by escaping the confines of the hospital, and delivering care outside the hospital in decentralized settings. This is being carried out today in various ways – by setting up independent outpatient facilities, by treating ambulatory patients differently from bed-bound sicker patients, and in the case of physicians, by acting independently of the hospital, and providing direct pay, independent outpatient care free of third party rules and regulations.

Two is by using technology to simplify and consolidate existing technologies. This may seem like a contradiction in terms. But, according to a company called SAP (sap.com/runsimple), it is possible to use technology to simplify technology. SAP is a cloud –based company serving 20,000 organizations and 263, 000 consumers in 190 countries. Its CEO, Bill McDermott says, “We can’t let complexity win.”

I cannot personally vouch for SAP, nor do I have affiliation with it. But I like SAP’s premise: that you can use technology to beat technology. To date, technology has both simplified and complicated our lives. If complexity can be reduced, from a platform in the clouds, as an overall simplifier, and if it can be used to save us from ovwerwhelming complexity for all rather than having complexity kill us all, I am all for it.

In the case of SAP, which just ran a full two page ad in the WSJ, I admire the work of its ad writer.

Here are samples of his/her prose:

• “The exponential proliferation of mobile devices, social media, cloud technologies, and the staggering amount of data they produce have transformed the way we live and work.”

• “Complexity is becoming the most intractable issue of our times, an epidemic of wide-ranging projects, affecting our lives, our work and even our health.”

• “Complexity comes at enormous costs – sixty three percent of executives cite complexity as a primary issue in escalating costs.”

• “If we simplify everything, we can do anything. We just need to run simple...It will generate new opportunities for innovation."

Quote to Note: Post-Election Timebombs

“With the midterm elections looming, the White House has delayed controversial decisions and appointments...All of these matters have been high profile and potentially deeply divisive. That is why the White House is postponing any announcements. When the administration finally does speak, it will unleash a political storm, even if Democrats hold the Senate. If Republicans win, those winds will reach hurricane force, since the president will likely try to ram everything through a lame-duck Congress. If that happens, consider boarding up the windows.”

Charles Lipson, Professor of Political Science, University of Chicago, “Obama’s Post-Election Policy Blowout," WSJ, October 29, 2014

ObamaCare’s Delayed Political Time Bombs Set to Explode

Delay is preferable to error.

Letter from Thomas Jefferson to George Washington, 1792

President Obama is a master not only of timely executive action but of timely executive delays.

He has initiated 38 delays at last count. These delays have time fuses, most set to go off just before or just after the midterm elections. These delays of what to do have a strong political flavor rather than a medical coloring, the naming of Ron Klain, a lawyer and political insider, as Ebola “Czar” being the latest example.

The delays include:

• Delay of the employer mandate and $2000 penalties for violating that mandate

• Delays in the individual mandate and paying the $95 penalty for not being insured

• Delays in announcing premium increases in key election states, such as Colorado, Iowa, and Florida

• Delays until after midterms in announcing those millions of health plan cancellations

• A delay in starting that second health care exchange enrollment period until November 15, 2014

• Delays in Medicaid and health exchange expansions, which will expand the national budget deficit

These delays are understandable politically, for their implementation would manage Democrat political prospects.

But like all time bombs, the delays have time fuses that cannot be delayed indefinitely and have an end point.

That end point is the November 4 midterm elections. How to switch from delays to implementation or continuing the delays or even repealing or replacing the health law with a market-based alternative will depend on the outcome of the elections on the national Congressional level and at state houses.

ObamaCare Horse Race

Gwine to run all night!

Gwine to run all day!

I’ll bet my money on the bobtail nag-

Somebody bet on de bay.

Camptown Races(1850)


As we enter the home stretch of the midterm horse race, Democrats and Republicans are spending unprecedented amounts of money on political ads and voter mobilization.

Each party has different views. That’s what makes political horse racing possible. If everybody.including TV stations and political victors, had the same view, nobody would make any money.

As Mark Twain observed, “ It is difference of opinion that makes for horse racing.”

For Republicans, opposition to ObamaCare in the horse race is a winning bet. They see nothing but red ink and public dislike for the law, and in red states , they are pummeling Democrats who voted for ObamaCare. If the GOP had a horse in the race, they would likely call it Big Red.

For their part, most Democrat candidates are mum on ObamaCare because of Obama’s low approval ratings and his political toxicity. Their horse may be named Big Avoid, or Big Blues.

Although most Democrats have been silent, the New York Times has now spoken out on the ObamaCare issue. On October 26, the Times published “Is the Affordable Care Act Working?”

Yes, says the Times, for the most part, the law is working. The Times team of seven reporters gives this seven part analysis.

One, the number of uninsured Americans is down 25%.

Two, federal subsidies has lowered costs for people, although some have seen premium rises.

Three, the jury is out whether it will improve outcomes, but in the long term, it may.

Four, exchanges in the next year may even work, but there will be challenges.

Five, Wall Street analysis see a financial boon across much of the health care spectrum.

Six, Twenty three of fifty states have balked at Medicaid expansion, but eventually they will see the light.

Seven, the trajectory of costs has leveled off for many reasons, not all attributable to ObamaCare, some due to economy stagnation and the slow recovery.

The Times and its coterie of seven reporters concluded:

“After a year fully in place, the Affordable Care Act has largely succeeded in delivering on President Obama’s promises, an analysis and data research shows. But it has also fallen short in some ways and given rise to a powerful conservative backlash.”

The reporters did not comment on President Obama’s three main failed promises: You can keep your doctor, you can keep your health plan, and your premiums will drop by $2500 for each family.

In any event, So speaketh observers and analysts on Planet Obama.

As for the rest of us on Planet Earth, we caste our ballots, we pays our money, we takes our chances, and we make our choices.

Simplicity, Simplicity, Simplicity: New Health Care Mantra

Simplify, simplify.

Thoreau(1817-1862), Walden

KISS (Keep It Simple, Stupid!)

American Idiom

In the wake of ObamaCare, the incredibly, unbelievably, and massively complex health law, a health care counterrevolution has surfaced – direct pay independent medical and surgical practices.

ObamaCare has ushered in a series of confusing uncertainties – whether you can keep your doctor or your health plan, how soon and when your health plan might be cancelled, how high will be premiums and deductibles in your old or new plan, if you will have to pay co-pays, co-insurance, and deductibles before you see the doctor or enter the hospital, if you will be obligated to return your subsidies if your income or citizenship papers are not up to snuff, when those delayed penalties will kick in you or your employer are not covered, and in the greater world, how long ObamaCare will survive given its enduring unpopularity and uncertain political fortunes.

To complicate matters, surveys indicate 6 of the 10 Americans, particularly the uninsured, do not understand the language of health insurance, and 9 of 10 are unaware of new health exchanges start-up signups begins on November 15, 2014 and lasting until February 15, 2014.

Confusion and uncertainty stalk the health care land. Because of the two-headed confusion and uncertainty monster, a new form of medical practice has reared its head. It goes by the name of direct pay, independent practice, and its hallmarks are simplicity, simplicity, simplicity.

• Simplicity in that you do pay directly without worry about co-pays, deductibles, or co-insurance. You simply pay your doctor or your ambulatory surgery center in cash, and the health care service or surgical procedure is provided on the spot. Furthermore, you know upfront, either by asking the doctor or consulting the practice website what your care will cost.

• Simplicity in that no insurance company or government program is involved. Your care in between you and your physician and surgeon. Between you decide what is necessary or appropriate. No delayed notices, no waiting for the bill, no collection agencies, no wading through a bureaucratic maze to see if you qualify for care, or if your procedure or test or treatment is “authorized” by powers-that-be-far-removed-from-the patient-physician evaluation-and-treatment-site.

• Simplicity in that your health care services are generally “bundled” – in a primary care office, most services will be offered for one fee, which may be under a monthly or annual retainer, which may include discounted fees from specialists to whom the primary care doctor refers; in ambulatory surgery center, the fees include the anesthesiology fee and the fee for the facility and the recovery room.

For more information, consult Google for concierge or ambulatory surgery centers in your area, or order Direct Pay Independent Practice – Medicine and Surgery, an E-Kindle book now available on Amazon.com.

Whither, Wither, Obama, ObamaCare

To what place? Where? To what end, point, action or the like? What place? To which place?

Whither

To dry up and shrink wilt, fade, or decay, to loss freshness of vitality.

Wither

With nine days left before midterms, I’ve been groping for words to describe President Obama’s and ObamaCare’s future. Two words came to me in the middle of the night, and they were Whither and wither.

Whither poses questions about the future. Wither describes the current state of affairs. The Democrat’s state of affairs at the moment look grim, with 64% to 87% of prediction models forecasting a GOP Senate victory, hinging on President Obama’s unpopularity with a 40% approval rating.

Consequently, Democrats are distancing themselves from the President. A headline in today’s New York Times reads “ On Campaign Road, Uneasy Democrats Show Obama Their Tail Lights.”

The campaign road, however, could easily take another fork. Many of the Senate races are extremely close, with polls indicating less than 4% differences between contenders. Favorable news could switch odds in favor of Democrats. But the road could fork the other way too, with more U.S. Ebola cases, a 500 drop in the Dow, and ISIS threatened capture of Baghdad. The political situation remains fluid.

Republican Senatorial candidates continue to hammer at ObamaCare, citing broken promises about keeping your doctor and health plan, rising premiums and deductibles, and waves of hundreds of thousands health plan cancellations.

With a Republican Senate victory, the questions remain: whither or wither?

Whither will we go with ObamaCare in face of certain Obama vetoes over such issues as Individual or Employer or Contraceptive Mandates or compliance with those 10 essential benefits with every health plan, or those financial penalties for failing to comply. Whither more ObamaCare marching forward or if market-based policy changes such as ending the $2000 penalties for not covering 50 time employees in businesses, excise taxes on medical innovation companies, restrictions on health savings accounts, tax reform with leveling of health care tax deductions for individual will wither ObamaCare.

Will Obama power wither? Maybe we will return to the Constitutional Checks and Balances, but the odds are the President will continue to try to act autonomously and to more heavily exercise his powers of executive privilege.

Thomas “Mack: McCarty, forme chief of staff for President Clinton, believes President Obama will step up to the plate, exert leadership, and save his presidency (“How Obama Cans Salvage His Last Two Years,” October 20, Wall Street Journal).

Charles Krauthammer, MD, psychistrist turned political commentator, disagree ( “Barack Obama, Bewildered Bystander,” Washington Post, October 24, 2014), Krauthammer does not believe the President, by this background and his previous actions as president, has the capacity to lead the nation out of the political and crisis-laden wilderness.

Coordination, Consolidation, and Costs – Three More New Cs

The Rule of Three Perplexes me,

and its Practice Drive me Mad

Anonymous

In 2006, James Hawkins and I wrote a book Sailing the Seven “Cs” of Hospital Physician Relations.

The Seven Cs were:

• Competence

• Convenience

• Clarity

• Continuity

• Competition

• Control

• Cash

Three More Cs

To these seven Cs, I would like to add three more Cs- Coordination, Consolidation, and Costs.

Over the last six years or so, there has been a big push to “coordinate” care.

Surely, the theory goes, if only hospitals and doctors would work together closely, care would improve, costs would come down, care would not be duplicated, and community continuity and population health as a whole would be better served.

The Obama administration picked up on this theory, and in ObamaCare, the concept of Accountable Care Organizations was lauched, with 22 “Pioneer ACOs,” established integrated health care organizations, recruited as exemplars of what was to come. Hospitals and physicians would work together to save money for a defined Medicare population, and the “savings” would be shared by hospitals and physicians.

There are signs ACOs might be a failed dream. Big successful integrated organizations – Mayo, Kaiser, and Geisinger – declined to join the ACO ranks. Medical specialists, two thirds of the physician workforce, were skeptical. And more recently three pioneer ACOs dropped out of the savings race.

Then came the big crunch - increased costs. As ObamaCare kicked in, and hospitals and doctors got caught up in the reimbursement and regulation squeezes, inherent in the health law, hospitals and medical groups began to consolidate to protect their bottom lines. Hospitals began to acquire physicians, both primary care and specialists, at a record, unprecedented rate, with less than 50% of doctors left in private practice.

It has become apparent that when big hospitals buying out and merging with small hospitals, and hospitals acquiring physicians, costs of care rise, not fall.

John Commins details the rises in cost in an October 23 Healthleaders.media.com articles “Debate Over Health Care Consolidation Effect Rages On.”
James Robinson and a research team at the University of California in Berkley studied 158 major medical groups and 4.5 million patients in California (“Physician Practice Competition and Prices Paid by Private Insurers for Office Visits,” Journal of the American Medical Association, October 22-29, 2014).

Costs were 19.8% higher for practice visits in physician groups owned by large multi-hospital systems compared to practice groups owned by physicians, and 10.3% higher for visits to practices owned by local hospitals compared to physician owned groups. The bigger the hospital the higher the prices for physician-owned groups.

Why higher costs? It’s simple, or perhaps I should say complex. Hospitals are big multi-layered complex organizations with lots of overhead. In the words of Commins, “They have ambulatory services centers they want to keep full. They have imaging equipment they want to use.” And the physicians they own know implicitly they are obligated to use the hospital’s imaging, laboratory, and other services even though the consolidated organization’s prices are higher than competing outside organizations. Employed physicians are not in the game to save the hospital money.

The AHIP (American Hospital Insurance Plans) says hospital consolidation axiomatically means higher costs, and hospit rhetoric about greater efficiency of consolidation and coordinated Accountable Care Organizations doesn’t match reality.

The AHA (American Hospital Association) counters by saying: 1) sure, safety and quality regulations make costs automatically higher; 2) but hospitals have higher safety and quality standards; and 3) anyway, continuity of care offered by hospitals is better and more comprehensive than episodic physician care. For these reasons, hospitals do not need to meet the prices offered by independent physicians and those retail prices being offered by Walmart, Walgreens, and CVS Health and like-minded retail outlets.

America is in a new era with ObamaCare-driven high deductible plans. Consumers are smarter and more cost-conscious, and many are gravitating to less expensive, some direct pay, independent physician groups, who require no co-pays or deductible and who offer upfront transparent pricing, and to retail clinics, who are similarly free of co-pays and deductible impediments.

Whether consumers will buy the safety and quality arguments of hospitals remains in question. Lower costs and direct and quick access with a minimum of bureaucracy are powerful inducements in the current health care environment.

Satisfaction with Physicians High, Trust in Medical Profession Low

The October 23 issue of the New England Journal of Medicine contained an article “Public Trust in Physicians – U.S. Medicine in International Perspective” which contained contradictory findings among 29 ranked countries.

Country Rank,Satisfaction with Last Visit,Trust in Medical Profession
Switzerland 1, 1
Denmark 2, 2
United States 3. 24
Australia 4, 10
Norway 5. 12

In plain language, the United States ranked third in patient satisfaction, but 24th in trust of the medical profession. The former is cause for pride, the latter should cause deep concern.

Why does satisfaction with doctors during the last visit rank so high and trust in the medical profession rank so low?

The three authors , Robert Blendon, John Benson, and Joachim Hero, all from Harvard, offer the following speculation from a 29 country survey conducted from March 2011 to April 2013.

1) Some countries ranking above the U.S. 24th trust ranking had universal health systems, which the authors say “seems unlikely as a dominant factor."

2) Broad nonspecified cultural changes in the United States, resulting in only 23% of the public expressing a "great deal or quite a bit of confidence in the system" (Gallup).

3) 47% of Patients with low incomes are significantly less trusting, but ranked 7th in doctor satisfaction.

4) Medicare patients were significantly more likely than young Americans (69% to 55%) to trust doctors, and men were more likely than women to trust doctors (63% to 55%).

5) The U.S. political process, with extensive media coverage, makes physician advocacy “more contentious” than in other country.

6) The U.S. medical profession does not share in the management of the health system, as it does in other countries.

7) High health costs tend to make the public less trusting of doctors.

The authors vaguely conclude, without being specific, that trust in physicians could be improved “if the medical profession and its leaders deliberately take visible stands favoring policies that would improve the nation’s health and health care.” In my opinion, most professional associations have done so, but their stands have been lost in the media fog and controversy surrounding ObamaCare and its implementation.

Benefits and Limits of Health Care Intervention

No participant in controversial , unfinished enterprises can pretend to unblemished objectivity. No claim is made that the discussion here is confined to the facts or the facts as presented are argued with scientific detachment.

Townsend Hoopes, Undersecretary of the Air Force, in Limits of Intervention, David McKay and Company, 1969

As ObamaCare, as we know it and President Obama meant it, draws to an end, the words of Townsend Hoopes resonate. Hoopes was describing the approaching end of the Vietnam War, and how military intervention was being de-escalated. Similarly some ObamaCare aggressive health reform policies will be modified or reversed.

It strikes me we are in a period of reversing many, but by no means all, of the policies embodied in the Patient Protection and Affordable Care Act. Some of these policies, such as expanding the pool of the insured and recognizing the plight of minorities and the poor, are beneficial. Other policies, intervening in the private affairs and choices of citizens, are harmful and have reached their limits.

Limits of Government

Government , and its intervening bureaucracies, can do only such much to improve the health of the nation. Government can purify the water, eliminate environment hazards, introduce public health measures to prevent and contain infectious disease, outlaw or make prohibitively expensive drugs and cigarettes, monitor deleterious human behavior, and supplement and regulate the education of health professionals.

But government cannot eliminate poverty, guarantee family cohesion, enforce education, change the negative ways they choose to live, limit their freedoms and choices, or redistribute health and wealth benefits without disrupting society. Nor can government ignore the consent of governed, or the activities of political enemies, domestic and foreign, should either consistently oppose , flaunt, and undermine government programs.

Limits of Medicine

Modern medicine has its benefits. It has effectively eliminated infectious disease in developed countries, developed drugs and surgical interventions to cure disease and degenerative conditions, and, by one means or another, lengthened life spans from 47 at the turn of the century to the 80s and beyond today.

But medicine has its limits. It cannot expand life expectancy indefinitely. It cannot reverse the end of life or the conditions that produce that end. It cannot reverse the irreversible. It cannot alter one’s genetic predispositions. It cannot, in most cases, change the life style or embedded behaviors of patients, whom it sees only occasionally and then only for limited times. People lead their lives outside of bounds of medicine. It cannot change the career choices of its practitioners, who tend to choose lucrative specialties, who prefer to practice in attractive urban surroundings, who like to exercise their clinical judgment and practice autonomously rather than bow to government mandates.

Limits of Technology

We live in an age of technological marvels. These marvels include the Internet, artificial intelligence, social media connectivity, robotic substitutions, genetic engineering, space exploration, satellite monitoring of earth, air conditioning, hydraulic extraction (fracking), data measurements of health care population outcomes, and instructional and mandatory protocols. These activities have unquestionable benefits.

But they do not replace personal human interactions. They do not replace human narratives. They do not replace human creativity and collaboration. They are supplemental, not elemental in improving the human condition. One cannot change humankind through technology alone.

Are Democrat Senate Races and Obamacare Fixable?

If I were to write a campaign jingle for vulnerable Senate Democrats, it would go like this.

Change it.

Rearrange it.

Fix it.

But don’t nix it.

I say his because of the jumble in the political jungle. Although Americans oppose ObamaCare by 51% to 38% on average in national polls, Hart Research Associates and Public Opinion Strategies found 54 percent of respondents say they want lawmakers to repair ObamaCare, while 28 percent say they want to eliminate it. Another 17 percent say they want the law to remain as is. Still, Real Clear Politics predicts the GOP will win the Senate by a 53-47 margin.

According to the latest polls, with 12 days to go before midterm elections, Democratic Senators are vulnerable but their races are close enough to be fixable.

• Mark Udall, Colorado, trails 47% to 44%

• Mark Begich, Alaska, behind 48% to 45%

• Jeanne Shaheed, New Hampshire, ahead 48% to 45%

• Mary Landrieu, Louisiana, trails 48% to 43%

• Kay Hagan, North Carolina, in lead by 46% to 44%

• Mark Pryor, Arkansas, behind 47% to 41%

The key for Democrats to fixing their races may lie in changing and rearranging their relationship to the President and to ObamaCare itself. The Senators have responded in different ways – by distancing themselves from the President, by not inviting him to their campaign events, by not admitting they voted for him, by not mentioning they voted for ObamaCare, by simply not mentioning him by name, by saying they will fix the health law but not replace it or repeal it.

In a Real Clear Politics video, Chris Matthews, that stalwart Obama supporter, takes umbrage at Democrats for refusing to say they voted for Obama by saying “It’s like Obama had Ebola.”

The New York Times, the pro-Obama litmus test and the Bile of Liberalism, complains of a “Democratic Panic.”

A Republican backed American Commitment ad headline reads, “Democrats Will Never Fix ObamaCare.”

Karl Rove, who has been called the " Republican Architect,” “Bush’s Brain.” and the “Texas Terminator,” writes an article in today’s WSJ entitled “ObamaCare Returns as an Election Albatross,” citing waves of policy cancellations and price increases as portents of doom for Democrats on election day. Rove chortles,” Democrats created ObamaCare, passed it , own it, and will suffer because of it. The holy grail of liberalism for decades, the present health law may end up as a decisive cause of two epic midterm defeats for the Democratic party.”

I would not be so sure. The Democratic albatross is a sea bird that can stay aloft for decades, feeding on Republicans in its talons. President Obama and his formerly fellow Democrats are masterful politicians, capable of flying high and seizing victory out of the beaks of defeat.


(Doctor Reece, author of over 3600 Medinnovation blogs over the last 7 years, with over 2.1 million readership views, is available for speaking engagements on the future of health reform. For more information, call 1-860-395-1501 or write doctor.reece@gmail.com)

Eight Business ObamaCare Penalty Escapes

We cannot escape history.

Abraham Lincoln (1809-1965)

Firms Try To Escape Health Penalties.

Anna Mathews and Julie Jargon, title of WSJ front page article, WSJ, October 22, 2014.

When the history of ObamaCare is written, it will record that American businesses sought multiple ways to escape the $2000 penalty on businesses.

The penalties were supposed to start this year, but for political reasons, the Obama administration delayed them until after the November midterm elections for firms that employ 100 people or more.

Small businesses, which employ over 90% of Americans, say the health law penalties retard employment of full-time workers and cut profitability, especially for firms with primarily low-wage workers.

There are basically eight ways to avoid health law penalties.

• One, hire fewer full-time workers.

• Two, hire more part-time workers, working less than 30 hours a week, and not offer health care benefits.

• Three, push full-time workers into Medicaid, which state and federal governments jointly fund, and for which the employer pays no penalty.

• Four, offer bare bones, or “skinny” plans, that cover preventive care but exclude major benefits like hospital care.

• Five, hire part-time workers when full-time workers leave.

• Six, offer workers Health Savings Accounts plans with high deductibles which encourage workers to pay out-of-pocket to meet deductiblea.

• Seven, stop enrollment in plans of spouses, families, and domestic partners.

. Eight, don't expand.

Some cynics say the Medicaid switch is part of the ObamaCare strategy to use Medicaid expansion as a prelude to a universal single payer system.

Others say shunting patients into Medicaid is shifting people into a substandard care system, in which delays are legendary and in which only 45% of doctors are now accepting Medicaid patients (Jeffrey Singer, MD, “ ObamaCare Shunts My Patients into Medicaid, “ WSJ, October 21, 2014).

Ultimately, patients will learn their costs are increasing NS their care is suffering , albeit in the name of increased “health care coverage.”

In the end, the Medicaid shift may backfire on employers and government.

As Abraham Lincoln explained, “ If you once forfeit the confidence of your fellow citizens, you can never regain their respect and esteem. It is true that you may fool all the people some of the time’ you can even fool some of the people all of the time, but you can’t fool all of the people all of the time.”

(Doctor Reece, author of over 3600 Medinnovation blogs over the last 7 years, with over 2.1 million readership views, is available for speaking engagements on the future of health reform. For more information, call 1-860-395-1501 or write doctor.reece@gmail.com)

The Choice

The difficulty in life is the choice.

George Moore (1851-1933), The Bending of the Bough

Whether Americans know it or not or appreciate it or not, the November 4 midterms offer a choice.

Depending on your philosophy or ideology, the choice may be between.

• Economic growth and Economic Stagnation

• Prosperity and Social Justice

. Free Enterprise and Government Regulation

• Equal Opportunity and Equal Results

• Promises and Performance

• Lifting All Boats and Mooring All Boats

• Ethnology and Homogeny

• Self- interest and Public-Interest

• Reality and Rhetoric

• Facts and Feelings

• Objectivity and Subjectivity

• Magic and Illusion

• Concreteness and Abstraction

• Liberalism and Libertarianism

• Ayn Rand and Barack Obama

You know about Obama, but you may not know Ayn Rand. Ayn Rand (1905 – 1982) was a Russian-American novelist, philosopher, playwright, and screenwriter. She is known for her two best-selling novels, The Fountainhead and Atlas Shrugged, and for developing a philosophical system she called Objectivism. Born and educated in Russia, Rand came to the United States in 1926. She achieved fame with her 1943 novel, The Fountainhead.

In 1991, the book-of-the-month club conducted a survey asking people what book most influenced their lives. The Bible ranked number one and Ayn Rand’s Atlas Shrugged number two. In 1998, the Modern Library did another survey was based on more than 200,000 votes cast online by anyone who wanted to vote. The top two on that list were Atlas Shrugged (1957) and The Fountainhead (1943).

The two novels have had six-figure annual sales for decades, running at a combined 300,000 copies annually during the past ten years. In 2009, Atlas Shrugged alone sold a record 500,000 copies and Rand’s four novels combined sold more than 1,000,000 copies.

Among the intellectual cognoscenti, Ayn Rand is best known for philosophical theory of Objectivism. It states that the proper moral purpose of life is the pursuit of rational self-interest. She maintained the only social system worth considering is the full respect for individual rights as embodied in laissez faire capitalism, and objective reality is the only true measure of success.

The worlds of academia and progressive politics reject Objectivism as inhumane and socially unjust. But capitalists and conservative thinkers believe Objectivism explains why America is the most affluent and innovative nation on Earth, and why it has a certain “magic” that makes it such a magnet for immigration and risk-taking entrepreneurs ( Charles Murray, The Magic of America: How Ayn Rand Captured the Magic of America ( Federalist, October 16, 2014).

One can argue the merits of Ayn Rand’s philosophy whether capitalism is the most successful social system or whether it has a certain entrepreneurial magic. One can debate whether Adam Smith of the 1776 Wealth of Nations fame holds the key to social progress and can improve your life (Russ Roberts, How Adam Smith Can Change Your Life, Portfolio, 2014). One can even postulate that capitalism, with its doctrines of economic empowerment and entrepreneurship, is the capitalistic cure for poverty, terrorism, and epidemics (Hernando De Soto, ” WSJ, October 11-12, 2014). But one cannot deny that Ayn Rand is a inspirational novelist that has captured the imagination of millions of people.

One of these people is Josh Umbrecht, MD, a concierge physician in Wichita, Kansas. Umbrech named his three person medical group, the Atlas Medical Group because he admires Ayn Rand. Here is an excerpt of the interview I conducted with Doctor Umbrecht.

Q: “ I read you came to this model, because one or all of you had read Ayn Rand’s 1957 book, Atlas Shrugged, and you adopted her philosophy as your philosophy. Indeed, so much so, that you named your practice “Atlas MD.”

A: Yes, we all have read her book. I have read it 11 times. Her philosophy is “Objectivism,” that the science of economics has objective answers that you can be logical and thoughtful about. Her book is a justification of capitalism that brings the most protection to the individual. Money is the root of all this is good. It a a voluntary exchange of goods for all parties involved. The love of money is to love what is good.”

When voters go to the polls on November 4, they will be voting, among other things, on whether they agree with President Obama’s philosophy of big government with its makeover of American capitalism and its health system or whether they approve of Ayn Rand’s philosophy of laissez faire capitalism with individual choice. President Obama has said repeatedly that his policies are on the ballot. So are Ayn Rand’s.

(Doctor Reece, author of over 3600 Medinnovation blogs over the last 7 years, with over 2.1 million readership view, is available for speaking engagements on the future of health reform. For more information, call 1-860-395-1501 or write doctor.reece@gmail.com)

Election Indignation

I would rather remain with my unavenged suffering and unsatisfied indignation, even if I were wrong.

Dostoevski (1821-1881), Brothers Karamazov

Even if I am wrong, I believe indignation will drive midterm election results. Voter indignation is strong displeasure at political and economic results deemed unworthy, unjust or base. The elections will reflect righteous indignation at what’s happening to the world and to themselves.

In the U.S. results will signify indignation of the middle class, who will express their displeasure at the collapse of their incomes, at the redistribution of their wealth and health benefits, at their inability to find good jobs, at the rising income inequality between the middle and upper classes, at the perceived favoring of the non-white minorities over the white majorities, and at governmental incompetence.

It will be indignation that accounts for white men and married women voting Republican. It is indignation that drives the Tea Party. It is indignation for the white middle class being called bigots for defending the police, for being offended for calling for voter ID, for being accused of conducting a war on women, for calling the IRS targeting of conservatives scandalous, for questioning the handling of Benghazi, the Iraq withdrawal, the ISIS victories, the lack of an Ebola travel ban.

In health care, it is indignation about health plan cancellations, broken promises about keeping your doctor and health plan, rising premiums, soaring deductibles, and omnipresent co-pays, the botched federal health exchange website, the negative affect of ObamaCare on full-time hiring, difficulties in finding doctors that will accept you or your health plans.

The list goes on. It is not fun being called prejudiced when you are down and out and concerned about providing for yourself and your family because of your social class or the color of your skin.

Right now the tunnel is dark. But there is light at the end of it. With the election and events beyond, illumination will come. Economic growth will resume, the Keystone Pipeline will flow, gas prices and heating costs will drop, tax reform will occur, Ebola will be contained, ISIS will be slowed, politicians are both sides of aisle will learn lessons, civil wrongs will be righted, and the magic of the American brand of capitalism will continue to attract the huddled masses and lighten their health and economic burdens.

I may be wrong , but as an optimist I see the doughnut, not the hole. I predict the bright lights of imagination and innovation will put indignation in the shade, where it belongs.

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Why Doctors Need Stories: In An Era of Systematic Clinical Research, Medicine Still Requires the Vignette

Title of New York Times Sunday Review essay, by Peter Kramer, Clinical Professor of Psychiatry, Brown University, October 19, 2014

Doctors practice in an era of Big Data, where anything and almost everything can be reduced to a data set, as expressed in an algorithm, protocol, arithmetic trend, and meta-analysis.

The last 20 years has been an era, according to Dr. Kramer of Brown University Medical School, in which “clinical vignettes have lost their standing. For a variety of reasons, including a heightened awareness of medical error and a focus on cost cutting, we have entered an era in which a narrow, demanding version of data-based medicine prevails.”

This is unfortunate, says Dr. Kramer, “ The vignette, unlike data, retains the texture of the individual life.” That is why Kramer assigns only case vignettes for psychiatric residents in training. Vignettes, or case studies, have long been the mainstay for teaching in academic medicine, as indicated by the enduring popularity of a Case Study in the New England Journal of Medicine.

According to NEJM, “Data are important, of course, but numbers sometime an order to what is happeing that can be misleading. Stories are better at capturing a different type of ‘big picture.’”

Narratives and anecdotes have a story-telling power that data sets can never duplicate. I became acutely aware of this power two years ago when I visited an ophthalmologist. He was resisting the implementation of an electronic medical record system in his office.

He groused, with words to this effect, “ I get these data summaries from other doctors, and I can’t make heads or tails of why they sent the patient. The EMRs don’t tell a story. They are a mumbo jumbo of numbers and leave me cold. I’ll be damned if I’ll waste my time entering data or investing in staff to enter that data.”

I share with you this personal vignette , even though the story is anecdotal, and therefore suspect in the modern era of Big Data and Data Sets. The vignette illustrates the graphic reasons why in a physician survey, 40% of 20,000 clinicians, 85% of whom had EMRs, thought EMRs decreased efficiency while only 24% felt EMRs enhanced efficiency (“ Physician Foundation Poll of 20,000 Physicians," Medinnovation Blog, September 24, 2014).

Clinical judgment requires narrative, as well as data.

Evidence-based medicine, while essential, is only half a patient’s story.

A clinical data set, after all is said and done, is nothing but a collection of related information composed of separate elements that can be collected by a computer, but must be interpreted by a doctor.

Health Exchanges: No Free Lunch

There is no such thing as a free lunch.

Milton Friedman (1912-2006), Conservative economist

I recently did 12 interviews with participants in direct pay independent practices for my book Direct Pay Independent Practice – Medicine and Surgery (Kindle, Amazon.com).

Two things surprised me about the interviews:

One, the repetitive claim by direct pay practitioners that health exchange-inspired plans,now held by 7.3 million Americans, 80% of whom have received subsidies, were the best salesman for direct pay care without 3rd party involvement.

Two, the customers for these plans were a mix of patients – the insured, the uninsured, the rich, the poor, the young, the old, those covered by employers, those covered by government.

How could this be?

ObamaCare, with its exchanges offering subsidized federal care, was purported by some policy makers and big government enthusiasts to be a free lunch- a free ride on the federal dollar for those who could not afford health care.

Well, as it turns out, the health exchanges have a catch. The cheapest plans, the Bronze and the Silver, have a hook. The hook is high out-of-pocket costs in the form of high deductibles and co-pays.

For those of you not in the know, out-of-pocket costs are costs paid with your own money rather than money from another source (the company you work for, the insurance company, or government.)

And co-pays, short for co-payments, are paid for by you, the beneficiary, of the health service, in addition to payment made by the insurer.

In the U.S., co-payments for health exchange plans are defined by the insurer policy, of which there are many, by the person for a medical service or policy. Co-pay amounts vary from $20 to $50 for a doctor visit, $50 to $150 for an emergency room visit, $20 to $50 for a prescription, depending on whether the prescription is for a generic or brand name drug.

The big stick in the federal ointment, however, are rising deductibles. For Bronze plans, deductibles average $5,081 for individuals and $10,386 for families. For Silver plans, deductibles are $2907 for individuals and $6078 for families.

The federal government “protects” individuals from soaring deductibles by placing a limit on deductibles of $6350 for individuals and $12,700 for families. And the government has a maximum of out-of-pocket costs of $6500 for individuals and $13,200 for families.

To many consumers, who often must pay co-pays and deductibles before receiving the service, these federal ceilings are un unpleasant surprise , even when subsidies cover much of the cost and even when employers soften the cost by partially covering the deductible and co-pay. The high deductibles and ubiquitous co-pays smack of an shell-game.

Consumers are beginning to understand new rules of the health exchange game, as set forth in detail in “Unable To Meet the Deductibles and Out-of-Pocket, “, Abby Goodnough and Robert Pear, New York Times, October 18, 2014). This understanding may be why many of these consumers are turning to direct cash-only care as a less expensive, less complicated, and more convenient alternative.

Who Shall Benefit from All That Health Care Spending?

All that is and shall be.

Sophocles (495-BC 404 BC) , Antigone

I have a weakness for the word “shall.” To me, “shall” implies command and determination as to what should be, rather than what will be.

“Shall” has moral weight. That may be why I entitled a 1988 book And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota (Media Medicus).

I was concerned then, as I am now, that physicians were losing control of health care to managed care organizations. My concern now is how much control government should or shall have.

I was concerned too that patients were losing control, a question that Victor R. Fuchs, PhD, a Stanford economist raised in his 1974 classic Who Shall Live? Health Economics and Social Choice (Basic Books). I remember a Harvard Business School professor telling me, “ What a title. I would kill to come up with a title like that.”

Which brings me to the title of today’s blog “Who Shall Benefit from Health Care Spending ?” Perhaps the title should be “Who Should Benefit from Health Care Spending?”

According to the Centers for Medicare and Medicaid Services, the projected spending on health care in 2014 will be $3.06 trillion. The government will spend over $1 trillion of that amount for 50 million Medicare recipients and 110 million Medicaid beneficiaries, or $6250 per person. If you divide $3.06 trillion by 320 million, the U.S. population, that comes to about $9,565.50 per individual. The national debt now runs about $58,000 for every man, woman, and child in the U.S. The fastest growing part of that debt is health care entitlements for Medicare and Medicaid.

Who should benefit from these vast present and future expenditures?

• Should it be government, with the number of people it employs to administer health programs and the political power it conveys upon the governing party? Is government capable of protecting and providing “affordable health care” for all, as implied by the title of the current health law “The Patient Protection and Affordable Care Act?” Evidence to date, nearly five years after ACA enactment, with the law is running roughly 15%-20% over budget, and the Congressional Budget Office giving up estimating what it will cost over the next 10 years, creates doubt about government’s ability to contain costs and benefit those who need care.

• Should it be those agencies and health plans who administer the law? It is estimated that administrative costs eat up one-third of health costs. Chief cost consumers in the administrative realm include government itself and those ubiquitous health plans, including giants UnitedHealth, which has just announced it will invest heavily in health exchanges by introducing two dozen new plans into federal exchange markets, and WellPoint, Inc, which holds monopoly positions in more a dozen major metropolitan markets.

• Should it be participants in “medical-industrial complex” – that vast array of health care product distributors, such as pharmaceutical companies, device manufacturers, big data providers, or companies like General Electric. GE has just announced it earns $3.7 billion producing biologically specific medicines and high-tech diagnostics to screen for disease and health indicators.

• Should it be hospitals and doctors, who together account for about 50% of health spending? There is little doubt that hospitals are benefiting from Medicaid expansion, driving by health exchanges, which now give them predictable sources of revenue. But at the same time more than half of hospitals are being heavily penalized for hospital readmissions and for meeting federal regulations, which make up 25% of their costs. As for doctors, their earnings have been flat for the last 10 years, and they say public and private regulations account for 50% if their overhead.

• Or should it be health care consumers themselves? Nearly 150 million Americans get their health insurance through their employer. But most employers are changing their plans to comply with new expenses from the Affordable Care Act and new demands they cover full-time employees working over 30 hours by shifting costs to workers, cutting benefits, and introducing health savings accounts and new health care arrangements with tax-deductible spending and high deductiables. These plans may be called “consumer-directed”, “account-based plans,” “flexible-health savings accounts ,” or as one cynical observer noted, “ OWAs (Other Weird Arrangements )”. Some employers are even offering employees compensation for not enrolling in their health plans. It’s all a little weird and bewildering.

• This bewilderment has resulted in a growing number of consumers, approaching 5-10%, saying, in essence, “To hell with it, I will take a chance and pay for my health care directly without insurance coverage.” Most workers are studying the options, doing the math, weighing the incentives, and considering other alternatives before considering buying a policy through public exchanges.

To conclude:

It’s all more than a little mind-boggling,

All of this health cost tugging and toggling.

One answer may be universal tax credits,

To minimize those overall health cost debits.

Ebola, Government, the Health System, and Unrealistic Expectations

Oft expectation fails, and most oft there

Where most it promises.

Shakespeare (1564-1616), All’s Well That Ends Well

We must scrunch or be scrunched.

Charles Dickens )1812-1870), Great Expectations

It may seem a strange thing to say. But I believe the U.S. suffers from unrealistic expectations. We expect government, health, and hospital officials to get things right the first time around. This is unrealistic. People, and believe it or not, including politicians, are never perfectly competent in things they are never experienced before. Disease prevention, diagnosis, and treatment are learning curves.

When the story of Ebola is the U.S. is written, it will be about how the center for disease and prevention, hospitals, and health care professionals made mistakes . It will be about what occurred when the virus first surfaced in a Dallas hospital, how the hospital ER personell were caught off guard, why the hospital was unprepared to deal with the virus, why it infected two nurses on the wards, why the CDC faltered in not forbidding an infected nurse to take a flight from Dallas to Cleveland, how government officials made false reassurances and misleading statements, and what the impacts were when these miscues rippled across the land.

It will also be about political finger pointing, about casting blame. It will be about blaming President Obama, Doctor Friedman and the Centers for Disease Control and Prevention, airline companies, hospital executives, emergency room personnel, faulty disease prevention protocols. Unfortunately, as a WallStreet Journal"editorial says, “Life does not obey protocols. Failure, uncertainty, and error are inevitable in human affairs. And institutions learn from mistakes.”

Whomsoever we blame, do not blame the nurses. They are on the frontlines, the bear the brunt of exposure to infectious disease, and they do what they have to do, even without proper training and protective personal gear. The nurses are the ones most likely to be exposed to infected blood and body fluids and to direct skin contact.

Do not blame the nurses. Do not blame hapless government bureaucrats, do not blame the CDC, do not blame the hospitals, do not blame the doctors, do not blame the public health system. Blame the Ebola virus. The little SOB has a mind and mutations of its own.

Our job is to collaborate across government, private, and health care sectors to contain and kill the virus. Our job is to cooperate to find a vaccine to prevent it and a drug to treat it. Our job is to spot Ebola outbreaks more quickly. Our job is to develop a fast finger-prick blood test for Ebola. Our job at the point of care is to diagnose the disease on the spot and to hydrate and isolate the patient. Our job is to prevent the victim or exposed person from entering or leaving an Ebola victim’s home, to prevent he or she from travelling, and to monitor every person with whom the infected person came in contact for as long as necessary. Our job is to develop computer systems to facilitate this tracking. And lastly, our job is to work together to prevent his hybrid of Ebola and fear from spreading. We can do it. We have done it or are doing it with measles, polio, smallpox, HIV/Aids and we can do it with Ebola.

As Doctor Larry Brilliant, previously part of the WHO team that eradicated smallpox, has remarked, “The Ebola outbreak in West Africa is a humanitarian and public health crisis, and we must do more to help the victims while avoiding our own ‘panic fever.’”

Ebola - Uncharted Waters and Seas of Speculation

If you’re in uncharted waters, you are in a situation unfamiliar to you, in which you have no experience and don’t know what might happen, leading to endless speculation.

American Idiom

With the spread of the Ebola virus to America, with the cropping up of three documented cases and fear of dozens more to come, we are in midst of a sea of speculation of how the West African Ebola epidemic will affect the U.S. people.

These events and possible chain of future events, have created a political crisis for the Obama administration, It responded by holding an emergency cabinet meeting on Ebola and appointing a political czar, Ron Klain, a Washington insider, who is long on politics and short on health care, and who served as chief of staff for Vice-Presidents Gore and Biden, to orchestrate the federal response, which I will predict will eventuate in a travel ban from West Africa.

What is at stake here may be a political disaster for Democrats based on lack of competence in handling events protecting the public’s health care prior to the midterm elections. This criticism may be unfair because this looming pandemic, which will probably never develop, is unprecedented, human mistakes will be made, lessons are being rapidly learned, and new protocols are being put in place.

Predicting the future of the Ebola epidemic has become an exercise in predicting the future through mathematical models.
Two of these models are frequently cited.

One is the Center for Disease Control and Prevention mode, which explains what may happen in this article , “Estimating the Future Number of Cases in the Ebola Epidemic - Liberia and Sierra Leone, “by nine authors in the CDC’s Morbidity and Mortality Report , September 26, 2014.

The report predicts the number of cases will double every 20 days from September 23 for the next 30 days, reaching 14, 000 cases (37,000 when corrected for under-reporting, and by January afflicting 550,000 people (1.4 million when corrected for under-reporting).

Two is the World Health Organization (WHO ) report, “Ebola Virus Disease in West Africa – The First Nine Months of Epidemic and Forward Projections, “ which is reported in the October 16, 2014 New England Journal of Medicine, The WHO numb ers are much more conservative and estimate 20,000 cases by early November.
Both reports assume the Ebola epidemics will proceed unchecked , which is unlikely .

An October 1 report in Vox by Suzanne Locke “The 6 Myths About Ebola” sets forth these myths about Ebola,

1) Ebola outbreaks are unstoppable. Ebola outbreaks since 1976 have been stopped in rural West Africa.

2) Ebola is a death sentence – the survival rate is closer to 50% than 70%.

3) Ebola patients always have hemorhagic disease, generally dying from internal hemorrhage.

4) Ebola is an airborne disease - Not true so far. It is usually transmitted by touch and exposure to body fluids.


5) Ebola is easy to catch – Not so. You have to have contact with a victim with fever and other symptoms.

6) Ebola is the most serious disease in West Africa – HIV/Aids, respiratory diseases, diarrhea, malaria, and strokes are much more common causes of death.

Predicted U.S. Ebola Cases

There may be as many as two dozen people in the U.S. infected with Ebola by the end of the month, according to researchers tracking the virus with a computer model.

The actual number will probably be far smaller and limited to a couple of airline passengers who enter the country already infected without showing symptoms, and the health workers who care for them, said Alessandro Vespignani, a Northeastern University professor who runs computer simulations of infectious disease outbreaks. The two newly infected nurses in Dallas don’t change the numbers because they were identified quickly and it’s unlikely they infected other people, he said.

The problem with mathematical models if that they offer nothing but estimatec guesses, but their guesses are the best science can offer in stormy political seas.

Ebola and the Sum of All Fears

It’s the single greatest fear I’ve had in my forty year public health career. I can’t imagine anything – and that includes HIV – that would be more devastating to the world than respiratory transmission of Ebola virus. This is the sum of all fears.

Michael T. Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

I have been asked by one of my blog readers, now approaching 10,000 each day, to comment on Ebola fears, on whether this festering viral epidemic will engulf the world.

This request reminds me to two things.

One is President Franklin Delano Roosevelt’s comment after Pearl Harbor, “ The only thing we have to fear is fear itself.”

Two is my nurse wife’s comment, “Dick, they say Ebola is only spread through contact with body fluids. What happens when people cough viral droplets. Those are body fluids.”

My wife has a point. Sputum and respiratory droplets are body fluids. What would happen if unsuspected infected Ebola victims coughed or even breathed aboard trains, plans, or in public places, or in crowds of people, spewing viral-laden respiratory body fluids.

We have more to fear than fear itself . We have respiratory-spread body fluids to fear. We have ignorance of how this deadly virus is transmitted, killing 70 % of its victims.

Here are a few comments by Michael Osterholm on the problem in a New York Times artricle. “What We’re Afraid to Say About Ebola," September 12, 2014).

Osterholm's comments were made before Dallas, Ebola's spread to Spain, the Ebola panic in Washington, D.C., the flight of an infected nurse from Dallas to Cleveland, the closure of schools in Dallas and Cleveland, the political finger pointing at the Obama administration, and demands for a travel ban from West African nations of Liberia, Sierra Leone, Guinea, and Nigeria and for the ouster of the Head of the CDC.

I believe three serious mistakes have been made by the Obama administration: 1) not instituting a travel ban from afflicted African nations; 2) not forbidding an infected nurse from Dallas to Cleveland even after she asked permission from the CDC to fly; 3) falsely reassuring the nation that no problem of a pandemic exists.

Otherwise, as an uninvolved bystander, I am in no position to comment.

But I do think it is worth reprinting some of Dr. Osterhholm’s comments from a September 11 New York Times article.

“THE Ebola epidemic in West Africa has the potential to alter history as much as any plague has ever done.”

“There have been more than 4,300 cases and 2,300 deaths over the past six months. Last week, the World Health Organization warned that, by early October, there may be thousands of new cases per week in Liberia, Sierra Leone, Guinea and Nigeria. What is not getting said publicly, despite briefings and discussions in the inner circles of the world’s public health agencies, is that we are in totally uncharted waters and that Mother Nature is the only force in charge of the crisis at this time.”

“There are two possible future chapters to this story that should keep us up at night."

“The first possibility is that the Ebola virus spreads from West Africa to megacities in other regions of the developing world. This outbreak is very different from the 19 that have occurred in Africa over the past 40 years. It is much easier to control Ebola infections in isolated villages. But there has been a 300 percent increase in Africa’s population over the last four decades, much of it in large city slums. What happens when an infected person yet to become ill travels by plane to Lagos, Nairobi, Kinshasa or Mogadishu — or even Karachi, Jakarta, Mexico City or Dhaka?”

“The second possibility is one that virologists are loath to discuss openly but are definitely considering in private: that an Ebola virus could mutate to become transmissible through the air. You can now get Ebola only through direct contact with bodily fluids. But viruses like Ebola are notoriously sloppy in replicating, meaning the virus entering one person may be genetically different from the virus entering the next. The current Ebola virus’s hyper-evolution is unprecedented; there has been more human-to-human transmission in the past four months than most likely occurred in the last 500 to 1,000 years. Each new infection represents trillions of throws of the genetic dice.”

“If certain mutations occurred, it would mean that just breathing would put one at risk of contracting Ebola. Infections could spread quickly to every part of the globe, as the H1N1 influenza virus”

“This is about humanitarianism and self-interest. If we wait for vaccines and new drugs to arrive to end the Ebola epidemic, instead of taking major action now, we risk the disease’s reaching from West Africa to our own backyards.”

Health Care Limbo

Into a limbo large and small since called

The Paradise of Fools, to few unknown.

John Milton 1608-1674), Paradise Lost

ObamaCare will remain in limbo,

As voters, standing with arms akimbo,

Wait until November fourth to go forth,

From all directions – West, East, South, and North,

To vote for Machos, Bimbos, or Dumbos.

President Obama as Scarecrow and Beacon of Wisdom

Logical consequences are the scarecrows of fools and the beacons of wisdom.

Thomas Henry Huxley (1825-1895), Science and Culture

When you write a blog each day, sometimes you turn to a quote for inspiration and explorations of words, phrases, or sentiments contained in the quote.

These explorations can serve as a metaphorical jumping off place.

Scarecrows – An object, traditionally a thin man, with a straw hat and ragged clothes, set up to frighten crows and other birds away from the crops. Here President Obama is that thin man. His problem, at the moment, is that he no longer frightens crows, those domestic black birds of prey. Nor does he frighten foreign crows from other fields, who no longer fear him or expect him to protect their crops. To crow has come to mean to retract an emphatic statement and to admit one is wrong, which this scarecrow is loathe to admit. But this scarecrow is no fool and he will permit no humiliation, even though black villains, known as Republicans, Putin, and ISIS are eating his crops. The metaphor is deeply flawed, of course, Obama is no slouch, and he seldom wear anything but a golf cap, and he is dressed to the nines either in an immaculate fund raising suit or golf togs.

Beacons of wisdom - It is hard to serve as a beacon of warning or light from on high, when your status has dropped to its lowest level. You may not even be visible to marauding crows. Obama’s public approval has dropped to 39% in polls, and to 31% on matters of foreign affairs. Furthermore, his reputation for protective wisdom is at its nadir, as everything seems to going wrong domestically and in foreign affairs at the same time and the wrong time, just before the midterm elections. The public does not seem to think wisdom is the President’s strong suit and even question your competence, the antithesis of wisdom. As Chris Cilliazi of the Washington Post explained, “You can understand President Obama's current political problems -- and how those problems could make things very tough for his party in this fall's midterm election -- in a single word. And that word is "competence."

One of Obama’s big problem are the logical consequences of his most cherished achievement , the Patient Protection and Affordable Care Act - high premiums and deductibles, unaffordable care for the middle class, pervasive part-time employment rather than full-time jobs, and the Ebola virus on the loose. These consequences seem to be outweighing the health law’s benefits in the public’s mind, which are considerable, reducing the uninsured rate from 16% to 13%, increasing the number of uninsured by 10 million.and offering subsidies to the poor. Now that is something to crow about.

Oh well, President Obama, you’re only out there in the field protecting the Patient Protection and Affordable Care Act and scaring crows away for three more years. From 2016 on, you will be out to another pasture, which will surely be fertile, rich, and green because of your prolific fundraising.

The Obvious Power of Price and Transparency in Slashing Hospital and Physician Administrative Costs

It takes a very unusual mind to undertake the analysis of the obvious.

Alfred North Whitehead (1861-1947), Dialogues of Alfred North Whitehead

I shall begin with the obvious. U.S. health costs are too high, and administrative costs account for much of these costs in hospital and physician practice settings, to wit, complying with regulations make up 25% of hospital costs, doctors spend over 20% of their time in nonclinical administrative tasks, and administration gobbles up about one third of all health care dollars.

I shall now proceed with three selected quotes:

The first is my own making in a March 26 2013 med innovation blog “Hospital Malfeesance – Fees for Services, Fees for Items, Fees for Facilities, and Fees for Physicians.”

The blog began:

“Steven Brill made quite a splash when, in a 2400 word article in the February 20, 2013 issue of Time, the most lengthy in the history of the magazine. Brill accused hospital executives of ripping off Americans.”

“How? By using a billing mechanism known as chargemaster accounts to charge exorbitant fees for everything from use of hospital rooms, to operating rooms, to recovery rooms, to ICU rooms to Tylenol to cotton balls to band aids. The problem? Chargemaster accounts are so complex, convoluted, and arcane that nobody seems capable of figuring them out or unraveling them.”

• The second quote is from Peter F. Drucker (1909-2006), the father of modern management and a social philosopher, whom I quote in my book The Health Reform Maze; A Blueprint for Physician Practices (Greenbranch Publishing, 2011).

“Government is a poor manager. It is, of necessity, concerned with procedure, for it is also, of necessity, large and cumbersome. It must administer public funds and account for every penny. It has no choice but to become ‘bureaucratic’. Every government is, by definition, a ‘government of forms,’ This means high costs. For control of the last 10 percent of phenomena always costs more than the first 90 percent.”

1. The third quote is from the November 25, 2012, New England Journal of Medicine, “Reducing Administrative Costs and Improving The Health Care System,” by David Cutler, PhD and two colleagues from Harvard.

“The average U.S. physician spends 43 minutes a day interacting with health plans about payment, dealing with formularies, and obtaining authorizations for procedures. In addition, physicians' offices must hire coders, who spend their days translating clinical records into billing forms and submitting and monitoring reimbursements. The amount of time and money spent on administrative tasks is one of the most frustrating aspects of modern medicine.”

“Indeed, for the system as a whole, administrative tasks are extremely costly. According to the Institute of Medicine (IOM), the United States spends $361 billion annually on health care administration — more than twice our total spending on heart disease and three times our spending on cancer. Also according to the IOM, fully half of these expenditures are unnecessary.”

Cutler et al conclude the only means of bringing these costs under control is more government with standardization of billing codes and more clinical coordination. This conclusion is predictable, given the fact that Dr. Cutler was one of President Obama’s major health care advisers.

I shall end with this obvious observation: anybody in his right mind knows that the U.S. government will not lower costs, even as it promises to do so. It raises costs, as it has done with ObamaCare, with premium costs rising more than $5000 per family per year instead of falling $2500 a year as promised.

So what are the answers? One answer, say the left, is universal government-run health care, as in Canada, England, and Europe, with their lower health costs. Another answer is more direct private care with less administration and lower costs.

Two examples of the second solution, with which I have some experience, are:

One, upfront bundling of hospital and physician charges for episodes of hospital care with back-up reinsurance should complications occur. In the early 90s, as chairman of a hospital PHO in Oklahoma City, we did this for more than 100 hospital procedures. How? Doctors, primary care and specialists alike, submitted their desired fees; the hospital gave us their usual expenses for treating patients with a given disease and procedure; we created backup reinsurance contingencies should costs go awry; we consolidated the costs and made them available to health plans in advance. The idea crashed because the state’s major health plan said it preferred to deal with hospitals and doctors separately and bundling of hospital-physician services would be too much turmoil in its billing system.

Two, upfront transparency and competition by hospitals and doctors by publishing fees and posting them in physician offices, surgical suites, and hospital marketing documents . I suppose this would be too radical for vested administrative interests in the present system, but it is doable, and it is being done by some hospitals, some physicians, and some diagnostic and surgical centers as they compete for the business of American health care consumers, who have grown leery, weary, and wary of the secrecy and delays surrounding health care charges which they only learn about weeks or months after the health care event occurred.

Ryan Visniski, in an October 13 Letter to the Editor in the Wall Street Journal, summed up my point of view;

“Price transparency is the key to significant, meaningful cost reduction. Transparency leads to competition, competition reduces price discrepancies and lowers overall prices. As an added bonus, which allows providers to arrange payment up front, rather than chasing delinquent accounts for months. Price transparency would reduce premiums and out-of-pocket expenses, creating a massive economic stimulus that benefits every individual, corporation and level of government.”

What Happens if Senate Flips

Things which you don’t want to happen happen more frequently than things you do hope happen.

Plautus (254 BC – 184 BC)

What happens if GOP wins the Senate?

The short answer is: we don’t know. The long answer is: we know what GOP hopes to happen.

The GOP hopes ObamaCare is repealed.

And to that end, Republicans will hold one or more symbolic votes to repeal. But those repeals will be vetoed, and the GOP will not have the 60 votes to overturn a veto.

The GOP then hopes to offer an alternative plan which will contain these elements.

• Allowing shopping across state lines.

• Allowing small businesses to band together to reduce premiums.

• Strengthening Health Savings Accounts and Patient-Centered Health Advantage Plans.

• Leveling the tax-reform field by allowing individuals and small groups health spending deductions, in other words, making tax credits universal.

• Enacting legal and malpractice reforms to discourage defensive medicine.

• Allowing more free market and state-based decision making, particularly for Medicaid.

The Republicans will then to try to passing bills they think have a decent chance of passing.

These bills will include.

• Repealing the medical-device tax, which will have bipartisan support, even in blue states like Minnesota and Massachusetts and California.

• Taking a stab at repealing, defunding, or otherwise hobbling the individual and employer mandates, which are unpopular among the public and which have made the part-time workweek without health benefits the rule rather than the exception of full-time employment.

• Concentrating on those improper subsidies on federal health exchanges, which the law said could only be offered on state exchanges.

• Pointing out that only 67% of physicians accept Medicaid patients, the acceptance rate which could be increased by upping Medicaid pay and cutting regulations for physicians.

All of these hopes, in my opinion, will rest on the margins, if any, of the GOP Senate victory. With a small Senate margin, say 51 to 49, or a 50/50 tie partisan paralysis is likely. With a large margin, three to four or 54-46 or 55 to 45, other things are possible.

ObamaCare will be very difficult to reverse because three more health exchange signups are scheduled before Obama’s second term ends. How things pan out will depend on how many sign up, how smooth the healthcare.gov enrollment process is, how the public’s judges Obama’s competence , how steep premium increases and deductibles become, and how foreign affairs defeats or triumphs work out.

In any event, it will be difficult to reverse ObamaCare if as many as 15 to 20 million of America's 30 to 40 million uninsured receive benefits under the provisions of the health care law.

Eight Practical and Legitimate Ways to Opt-Out of ObamaCare

The term “opt out” refers to methods individuals can use to avoid an unsolicited or undesirable service, product, or government mandate.

Definition, Opt-Out

Come tax-time in April 2015, individuals will be asked to pay a $95 penalty if they do not sign up for ObamaCare’s individual mandate.

What is not generally known is that 23 million of 30 million of America's uninsured qualify for exemptions for reasons, such as religious objections, hard times, or deaths in the family and that only 4 million Americans will end up paying the penalty when the learn how to legitimately avoid the penalty.

I learned about some of these ways back in June 2013 when I interviewed Sean Parnell, author of The Self-Pay Patient: Affordable Health Care Choices in the Age of ObamaCare and a blogger at TheSelfPayPatient.com.

In an interview with Susan Berry, MD, of Breitbart News, Parnell offered these eight practical suggestions to avoid paying the penalty and getting less expensive care as part of the bargain.


1. Join a health care sharing ministry, which are voluntary, charitable membership organizations that share medical expenses among the membership.
Parnell states that Samaritan Ministries, Christian Healthcare Ministries, and Christian Care Ministry are open to practicing Christians, while Liberty HealthShare is open to those who are committed to religious liberty.

Healthcare sharing ministries “operate entirely outside of ObamaCare’s regulations, and typically offer benefits for about half the cost of similar health insurance,” says Parnell. “Members are also exempt from having to pay the tax for being uninsured.”

2. Purchase a short-term health insurance policy.

“These policies usually last between one and 11 months and are not regulated under ObamaCare, and, therefore, don’t offer the same high level of benefits that can drive up costs,” writes Parnell.

3.Buy alternative insurance plans such as fixed-benefit, critical illness, or accident insurance.

“These policies pay cash in the event you are diagnosed with cancer, spend a night in the hospital, or need some other medical treatment,”

Parnell says. “They cost a fraction of what health insurance costs under ObamaCare, and by giving you cash directly you aren’t locked in to any particular provider network.”

Parnell also recommends maxing out medical and uninsured/underinsured driver coverage amounts under an auto insurance policy, which can help pay for medical bills in the event of injury in an auto accident.

Once major medical insurance is arranged, Parnell suggests shopping around for health care providers and services.

4. Visit cash-only doctors and retail health clinics for primary care. If you usually visit a doctor more than a couple times per year, consider joining a direct primary care practice which will give you access to nearly unlimited primary care for a modest monthly fee.

5. Sign up for a telemedicine service—lower-cost options in which doctors treat relatively simple medical issues via phone calls, email, or a video connection. Telemedicine especially works well, Parnell says, for common injuries, conditions, and illnesses.

6. Use generic prescription drugs whenever possible, and compare prices between pharmacies. Less expensive options are sometimes available at large chain pharmacies such as Walmart and CVS, and online sites such as GoodRx.comand WeRx.org allow patients to view the best deals on medications.

7. For surgery, Parnell recommends going to a facility that offers up-front “package” prices for self-pay patients, such as the Surgery Center of Oklahoma and Regency Healthcare, where prices are typically much less than what is charged at most hospitals. In addition, sites such as MediBid, where doctors bid on providing your surgery or treatment, will often yield substantially less expensive costs coupled with high quality medical care. Yet another option is to become a medical tourist.

8. When a hospital visit becomes necessary, Parnell suggests working with amedical bill negotiation service to get the best price available rather than accept the wildly inflated “chargemaster” prices, usually three to five times more than what insurers pay for the same service or treatment. Patients who wish to negotiate on their own will likely need to put in a significant amount of time and effort, but can use the Healthcare Blue Book or Pricing Healthcare as a starting point to help them find out what insurers are paying for medical services.

“Many Americans say they would prefer free market healthcare, and they don't have to wait for Congress to repeal, replace, or reform Obamacare to have that,” Parnell told Breitbart News.

“Simply by opting out and doing things like visiting cash-only doctors, becoming a medical tourist, shopping around for the best prices on prescription drugs, and obtaining an alternative type of coverage they can enjoy all the benefits of free market healthcare today including access to affordable, quality care and getting government and insurance company bureaucrats out of the doctor-patient relationship.”

Obama and Leadership

While Mr. Obama rarely speaks about it, the effects of race, real or imagined, on his presidency are on the minds of black and white voters, who repeatedly brought up the issue as an explanation of why he has faced such opposition.

Ashley Parker, “From Mid-Atlantic to Midwest, Voters Exude Frustration and Fatigue,” New York Times, October 12, 2014

Why is President Obama failing as a leader? Why does the Washington Post election model predict a 95% chance the GOP will win the Senate? Is the Tea Party rise due to white conservative bigots? Does this failure, as manifested by a slow economic recovery, bitter partisanship, and recent racial turmoil in Ferguson, Missouri, occur because President Obama is black?

Is Denise Carter, a black restaurant hostess in Springfield, Illinois, right when she says,” A lot of people do not like taking command from a black man. That’s all there is to it.”

I don't think so. There's more to it than Obama being black. I say this even though I was raised and educated in the South, Tennessee and North Carolina.

The U.S. voted for President Obama not once but twice, Oprah Winfrey is one of the richest women on Earth, black faces are everywhere on the visual media. Black athletes are heroes to millions of white fans. Black white couples dance the tango on Dancing with the Stars. We have a black Senator from South Carolina. A black physician from Baltimore who has announced he will run for President as a Republican. We are a tolerant, and increasingly color-blind, nation.

Obama’s leadership problems are more complicated than his being black.

I have on my desk a copy of a book On Leadership: Essential Principles for Business, Political, and Personal Success (SkyHorse Publishing, 2011).

Its author is Donald J. Palmisano. M.D. – lawyer, surgeon, and former AMA president. he is a Southerner from Louisiana, but this does not color his views.

On page 23, Palmisano lists these attributes of a leader.

A true leader:

1. does the necessary “homework.”

2. demonstrates courage.

3. is persistent.

4. fully understands both the mission and the goal.

5. has integrity; is ethical.

6. does not fail to act in absence of instructions , unexpected crisis, or desired data on which to base decisions.

7. Is a good listener and an effective communicator.

8. understand that unity leads to success and division leads to failure.

9. leads “from the front.”

10. inspires others and engages them using his or her passion and authentic behavior.

11. never asks others to take risks that he or she would not take.

12. does not get rattled in a crisis.

13. seeks opportunities to advance the mission.

14. knows how to identify those who are sincere in interpersonal relationships.

15. is trustworthy and learns quickly whom to trust.

16. is dependable , adhering to a company’s or a movement’s mission without compromising principles for personal enrichment or benefit.

17. becomes a loyal follower and supporter of other leaders once they are identified.

18. recognizes that leadership is not an ego trip.

Palmisano concludes “The cornerstones of success are homework, courage, and persistence, but leadership requires that and more: integrity, decisiveness, communication and inspiration, to name only a few.”

President Obama has failed as a leader because of his failure to fulfill many of these criteria, not because he is black. Obama’s problems stem from his failure to do his homework, to ignore critics and Congress, to renege on promises to keep your doctor and health plan, to waffling and changing ObamaCare 37 times for purely political reasons, shifting of blame to others instead of assuming personal responsibility when his policies go wrong, leadership “from the back” on foreign affairs, narcissism, and failure to learn to trust the judgment of the American people who believe the government that governs least governs best.

Or maybe, just maybe, we are expecting too much of a president, black or white. Aaron David Miller, a senior scholar at the Woodrow Wilson Center for Scholars, an adviser to several Secretaries of State, writes in "Barack Obama, Disppointer in Chief,"All presidents disappoint. It comes with the job, the unreasonable expectations Americans have for their presidents, and the inherent conflict and disconnect between campaigning (promising people all they can have) and governing (explaining to people why they won’t get it." (Washington Post, October 10, 2014)

Obama "Commander-in- Chief"Titles - Variations and Interpretations- Collected from Internet

Hail to the Chief who in Triumph advances.

Sir Walter Scott (1771-1832

1. Above-It-All in Chief

2. Academician in Chief

3. Aloofness in Chief

4. Amnesty in Chief

5. Apologist in Chief

6. Blame-Shifter in Chief

7. Budget-Deficit in Chief

8. Celebrity-Seeker in Chief

9. Climate-Changer in Chief

10. Coal-Killer in Chief

1o. Collectivist in Chief

11. Commander in Chief

12. Complainer in Chief

13. Cover- Up-Artist in Chief

14. Crony-Capitalist in Chief

15. Detached in Chief

16. Disappointment in Chief

17. Duffer in Chief

18. Economist in Chief

19. Enabler in Chief

20. Equalizer in Chief

21. Golfer in Chief

22. Health-Deliverer in Chief

23. Health-Reformer in Chief

24. Idealogue in Chief

25. Immigration in Chief

26. IRS in Chief

27. Liar in Chief

28. Liberal in Chief

29. Mandate-Maker in Chief

30. Micromanager in Chief

31. Minorities in Chief

32. OSHA (Our- Savor-Has-Arrived) in Chief

33. Partisan in Chief

34. Pipeline-Delayer in Chief

35. Professor in Chief

36. False-Promises in Chief

37. Radical in Chief

38. Republican-Enemy in Chief

39. Redistribution-o= Wealth in Chief

40. Retreat in Chief

41. Rhetorician in Chief

42. Social-Organizer in Chief

43 Social-Justice in Chief

44. Socialist in Chief

45. Solar, Wind, and Electric Car Savior in Chief

46. Speaker in Chief

47. Tax-Collector in Chief

48. Teleprompter in Chief

49. Transformer-of-Society in Chief

50. Withdrawal-from-Wars in Chief