Wednesday, April 29, 2015

Wearable and Implantable Apps

With the European Union’s move to limit Google’s monopoly of the European search market and the U.S. government's proposed takeover of the Internet, we may be reaching the end of the unlimited expansion of the Internet.

This slowing expansion may include limiting or regulating the use of Internet apps to monitor and improve health – including the Apple Watch, Intarcia Therapeutics implantable matchstick –sized insulin pump for type 2 diabetes, Scanudu’s simple-to-used devices – a forehead scanner that measures your vital signs, Theranos technologies that allows one to measure scores of blood constitutes on a single drop of blood obtained by a finger prick, , and, of course, those saliva swabs that permit analysis of one’s complete DNA with subsequent genetic social engineering. I believe it is even possible to make accurate diagnoses given demographic, vital sign, body measurements, and patient-provided historic algorithms (see Richard Reece, Innovation-Driven Care ( Jones and Bartlett, 2007).

The idea behind all of these developments is empowering consumers with diagnostic information through mobile Iphones and over the Internet by providing them with cuff-less, pain-less, and less-invasive gadgets that may ultimately offer full blood, DNA, and vital sign information. This can be done on the fly with mobile Iphone clicks.

It will take time to slow the venture-capital, Silicon Valley –driven. mobile-phone, social media, and Internet app juggernauts. Apple is world’s most profitable company, with a market cap of over $18 trillion, and Facebook, Twitter, and Amazon are growing fast . Internet evangelists gleefully tell us Internet app people - including Silicon Valley billionaires, social media marketers, and network idealists will tell us their apps and gadgets will bring "value" to society and users. But government regulators, businesses and the unemployed left dead by the side of the road by use of these devices, those who worry about the security of our personal information in the wake of hackers, those concerned about universal surveillance of the patterns of our lives, and the humanists among us who believe there’s more to life and health than manipulation of data, aren’t so sure that we can leave our destiny and culture to clicks of buttons.
U.S. Citizen Medical School Graduates of Caribbean Medical Schools

I serve on the advisory board of Charlemagne University, a Caribbean medical school, about to be built.

Little is known about Caribbean offshore medical schools.

Yet U.S. citizens who are International Medical School Graduates (IMGs) are educated at medical schools in the Caribbean account for 27% in U.S. residency programs.

An article in the April 30 New England Journal of Medicine goes a long way towards filling the knowledge gap on IMGs. W. Lynn Eckhert, MD, and Marta van Zanten, Ph.D., of Partners HealthCare International in Boston and the Foundation for Advancement of International Medical Education and Research in Philadelphia, respectively, wrote the article "U.S.-Citizen International Medical Graduates – A Boon for the Workforce?” saying we should should pay attention to offshore medical schools. They can help alleviate U.S. physician shortages.

Here are facts presented in their article.

U.S. citizens represent 38,5% of IMG applicants and 13.7% of all residency applicants.

Caribbean schools are private and for-profit.

More than half of Caribbean medical school graduates enter primary care practice.

Most of their clinical education occurs in the United States.

U.S. IMGs have a 53% success rate in 2014 Residency matches compares to 94% in U.S.traditional medical schools and 78% for U.S. osteopathic schools.

39 offshore medical schools exist in the Caribbean.

Each year more U.S.residency positions are filled by graduates of St. George’s University School of Medicine (Grenada) or Ross University School of Medicine(Dominica) than any single U.S. Medical School.

The average total cost for four years at an offshore medical school is $97,683 compared to an average of $198, 804 at a private U.S. medical school.

The article calls for more information on IMG's exposure to qualified faculty, to research, student advising, and an integrated curriculum, the blending of pre-clinical and clinical studies. Accountability and accreditation oversight, is necessary if offshore medical schools are to continue to supply a substantial number of U.S. physicians, particularly in primary are.

Tuesday, April 28, 2015

My Letter to the Editor in April 28 Wall Street Journal

Today, April 28, the WSJ published a letter of mine among 4 letters under the umbrella title of “The Government Is Big on Antitrust, Except in Medicine."

My letter read: “Because of ObamaCare’s onerous regulations, reimbursement cuts and expenses and time spent on electronic health records and ICD-10 coding, physicians are being propelled into hospital employment. Hospitals, in turn, to protect themselves against ObamaCare penalties, are consolidating into dominant entities. These entities are often the only game in town."

"When you are a monopoly, you tend to charge what the traffic will bear. Hospital executives arene’t evil. They are simply reacting to save their skins and grow their businesses. I favor freeing up the regulations on physicians so they can compete with hospitals."

The other 3 letters were from,

Brian Kent, MD, of Tulsa, Okla said, “As large hospitals digest other hospitals and physician practices, I don’t see anything positive for patients an doctors."

Robert Geist, MD, of St. Paul, Minn. commented, “ The question is: Ehich cartel partners will control the other” The price to the nation of a state-corporate cartel system has not been calculated; it may be very high.”

Rich Umdenstock, President and CEO, American Hospital Association, noted, “ We all want hospitals to continue the good work of coordinating care , and integration across facilities is a particularly good way for hospitals to organize themselves to do so. Coordination requires the kind of teamwork that often works best when everyone is under the same ownership umbrella.”

As I observed in a recent blog, hospitals tend to be King of the Health Care Mountain with physicians as their serfs in any given community. Most often hospitals are Kings because of their organizational structure, access to capital, time that can be devoted to organizational matters, their political clout as the largest employer in town and the their central role as a health care center.

There is nothing wrong with this. It is the role of the hospital executive to make profits and to advance of their institution and their careers. Unfortunately, the result may be higher health costs because of higher overhead costs in acquiring and maintaining medical practices, less productivity of employed physicians, the ability of the hospital to charge high hospital “facilities fees” and to negotiate higher fees from 3rd parties as the only game in town. Having hospitals, physicians, and sometimes health plans under one corporate roof has advantages in marketing, pricing, and market dominance.

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Can Government Assure Access and Quality Through Penalties?

Under ObamaCare, patients must pay penalties for not having a health plan, and doctors must pay penalties for not reporting quality data. Is this any way to run a government health care railroad? Do penalties work?

In the case of access,it might. Over 16 million uninsured Americans became insured last year, 8 million via health exchanges and 8 million via Medicaid. A goodly proportion of those insured gain came secondary to the realization you had to pay a fine, $95 for not having a plan in 2014, $395 in 2015, and higher amounts thereafter.

With doctors, the story may be different. This year 460,000 of eligible doctors, 40% of 1.25 million providers, will have their Medicare payments docked by 1.5% for failing to submit data. In the other hand, 642,000 complied with the federal reporting quality program, which was launched.

What kind of data? Percent of patients checked for blood pressure, percent asking for smoking cessation counseling, percent ask for what medication they were taking, and so onl.

The 1.5% penalties don’t stop with not reporting quality data. Penalties include 1% more for not having electronic health record in 2013, 0.5% to 1% for not complying with a complicated cost and quality adjustment, The Value-based Payment modifier. Penalties may grow to 9% by 2017 for the three programs combined. And the three penalties are scheduled to morph into one program under the law just passed last month to replace the annual Sustainable Growth Formula.

Most doctors will probably comply by 2017, as 51% already have. Most don’t have mmch choice, since more than 90% of doctors treat Medicare patients, or patients under other federal programs. Another federal program creating more paperwork for doctors will be conversion from the ICD-9 to ICD-10 coding system on October 1. 2015.

What are doctors are other providers to do rather than bow to the Medicare and ObamaCare programs? One choic some 5% to 10% are exercising is converting to so-called Free Market Medicine, which appeals to mann doctors because eliminating coding and quality reporting by cutting out the government/insurer middlemen by foregoing insurance paying directly in cash. This is one option being adopted by growing numbers of self-funded corporations, which effectively eliminate state and federal mandates and Medicare patients. How much this option will progress and what patient market share it will gain is unknown, but doctors are interested in the concept because it eliminates coding, quality reporting, federally-approved electronic records, and reduces overhead, often by 50% or more.

Sunday, April 26, 2015

Purported Medical Wizard of Oz

This month, 10 “Distinguished Physicians, “ fired off a letter to the Dean of Columbia Medical School, asking him to oust Mehmet Oz, M.D., a 54 year old Turkish-American cardiovascular surgeon, author, and principal of the Dr. Oz television show from the Columbia faculty.

The physicians portrayed Dr. Oz as a modern day Wizard of Oz, a quack and a fraud, a deserter from the medical scientific ranks.

But as an Op-Ed New York Times piece of April 26, 2015, says in a headline, “Dr. Oz Is No Wizard, But No Quack, Either”.

Oz is a tenured professor and co-chairman of Columbia University’s department of surgery and director of Columbia’s Cardiovascular Institute and Integrative Medical Program.

In his TV show, since 2004, he has spoken openly, often, and sometimes inaccurately aboutnon-scientific controversial subjects such as homeopathy, faith healing, naturopathy, acupuncture, vaccines and autism, genetically modified foods, and a host of health and wellness products – health foods, dietary supplements, low testosterone therapies, probiotics, fruits and vegetables in pill form, antioxidants, herbs, home remedies , and sensitive sensitive things bowel movements, menopause, and body fat.

This dual role has landed him in scientific hot water. The British Medical Journal has reported that only 33% of 80 of his recommendations stand up under scientific scrutiny and are “believable.” This kind of negative publicity prompted the leaeder among 10 well-known physicians to write the following public letter to the dean of Columbia medical school.

“I am writing to you on behalf of myself and the undersigned colleagues below, all of whom are distinguished physicians.”

“We are surprised and dismayed that Columbia University’s College of Physicians and Surgeons would permit Dr. Mehmet Oz to occupy a faculty appointment, let alone a senior administrative position in the Department of Surgery.”

“As described here and here, as well as in other publications, Dr. Oz has repeatedly shown disdain for science and for evidence-based medicine, as well as baseless and relentless opposition to the genetic engineering of food crops. Worst of all, he has manifested an egregious lack of integrity by promoting quack treatments and cures in the interest of personal financial gain.”

“Thus, Dr. Oz is guilty of either outrageous conflicts of interest or flawed judgments about what constitutes appropriate medical treatments, or both. Whatever the nature of his pathology, members of the public are being misled and endangered, which makes Dr. Oz’s presence on the faculty of a prestigious medical institution unacceptable.”

Dropping Doctor Oz from the faculty will be had to do.

1. According to the first amendment, he has the right of free speech.

2. He says he has never received any reimbursement for endorsing or promoting a product.

3. He is the best known physician in America because of his syndicated television program.

4. He is a tenured professor of surgery , which means he would be difficult to fire.

5. While a resident at Columbia , he was the four-time winner of the prestigious Blakemore research prize, which went to the most outstanding surgery resident. He has 11 patents for inventing methods and devices involved in heart surgeries and transplants. This includes helping to research and develop the left ventricular assist device, or LVAD, which helps keep people alive while they’re awaiting a heart transplant. Oz had a hand in turning the hospital’s LVAD program into one of the biggest and most active in the world.

6. More than 50% of Americans use products or treatments of CAM (Complimentary and Alternative Medicine), which is $34 billion dollar industry. Many prestigious organizations like the Mayo Clinic deem CAM worthy of serious scientific discussion, and many University medial centers have established “Integrative" medical centers , e.g. using acupuncture and meditation techniques to supplement scientific medicine.

Given these facts and factors, it is hard to dismiss Dr. Oz as a “”quack,”defined as a fraudulent or ignorant pretender to medical skill. He may be injudicious and should strive to be more guarded in promoting or evaluating products that have not gone through double-blind and controlled scientific trials, but with the vast array of products available that would be impractical. Perhaps he should cut back on his free-wheeling and engaging personal style, but that is what appeals to millions of TV watchers.

Dr. Oz is not ignorant, nor is he a fraud. He received an undergraduate degree from Harvard and his MD and MBA from the University of Pennsylvania. His views may not pass the scientific "smell test", but he knows what the public wants to know about alternative, complementary, and integrative products, approaches, and techniques. Oz claims discussing the boundaries of conventional vs. alternative care are better coming from a physician than elsewhere. During the 10 years of his TV program, he has made a fortune, but by doing so has "suffered the slings and arrows of outrageous fortune"(Hamlet) from the physician establishment.

One hundred and fifteen years after Frank Baum published his epic book The Wizard of Os in 1900 about a charlatan hiding behind a curtain. According to some physicians, Oz is supposedly a modeern Wizard of Oz who has emerged to lead people down another yellow brick road. This road may turn into a blind alley. There is room beyond peer reviewed journals and scientific proof to discuss alternative health issues that are not scientifically proven but widely used and sought after among Americans.

Saturday, April 25, 2015

Single Payer – The Dream Never Dies

At some point, perhaps 5 to 10 years from now, as the size and scope of Medicare, Medicaid and the ACA subsidy structure balloon far beyond today’s larger-than-life levels, our political leaders may discover the inanity of running multiple complex systems to insure different classes of Americans. If advanced by the right leaders at the right time, the logic of consolidation may become glaringly evident and launch us on a new path. If such consolidation is to occur, like it or not, I believe it will happen federally and not in the states – and no time soon.

John E. McDonough, Dr. P,H, M.P.A, Democrat activist and professor at the Harvard School of Public Health, “The Demise of Vermont’s Single-Payer Plan, New England Journal of Medicine, April 23, 2015. In 2011, McDonough was author of Inside National Health Reform, University of California Press, the inside story of how ObamaCare came to be

Friday, April 24, 2015

Health Care Transformation: The Big Ideas:

Hint: It’s All About Data, IT Disruption, and Consolidation

In God we trust, all others use data.

W. Edwards Deming (1900-1993) , Management Consultant

This morning I ran across “Special Report: The Transformation of Health Care Delivery.” The report appeared in and was sponsored by PriceWaterHouseCooper, the consulting powerhouse.

In essence, the report is about using IT technologies to:

Do away with “archaic “ clinical paper files.

Go digital, collect data from electronic health records.

Use data to disrupt current physician and hospital arrangements.

Transform that data into digital from to measure outcomes, improve quality, lower costs, capture more market share, increase efficiencies, raise revenues.

Consolidate health systems and physicians into larger “congruent” integrated organizations capable of increasing individual and population health and enhancing outcomes.

Transforming health delivery from individual physician and hospital practices to corporations has been going on for at least 45 years as I reported in my 1988 book And Who Shall Care for the Sick; The Corporate Transformation of Medicine in Minnesota.

What has changed is the speed of change, as facilitated by the Internet, the formation of companies like Microsoft and Google, spread of the social media through Facebook and Twitter, and the widespread adoption of electronic health records.

Almost overnight, in historical perspective, we are up to our hips, armpits, and brains with data, and the need for larger organizations to harness and deploy masses of data for achieve useful goals.

The Special Report , through an 11 member panel of editors, versed in organizational transformational matters, including 5 MDs, reaches certain conclusions, which they present in revealing bar graphs with these percentages

What’s important in carrying out the health delivery transformation are: data provided by clinical information technologies 26%, EHRs 26%, and data analytics 21%.

Types of data needed are EHRs 95%, patient demographics 91%, and 85% aggregated EHR and patient data.

The best use of the data is to improve quality 90%, to identify gaps in quality 84%, to lower costs 83%.

Types of organizations desired to gain physician buy-in through mergers, acquisitions, or partnerships 50%, to merge with other hospitals 36%, to establish new physician arrangement with health systems, 26%.

Merger objectives are to improve position in population health management 70%, to improve efficiency 65%, to improve clinical integration 61%.

To improve finances by expanding outside of hospitals, 63% , by enhancing strategic marketing 43%, by developing Accountable Care Organization or other sharing entities, and by merging services with with physicians 36%.

None of this will be easy. It will require disruptive technologies, creative destruction of existing hospital and physician organizations, and harnessing the data for useful clinical use. It will also demand a blind trust in data to provide “ evidence-based” clinical value and the partial sacrifice of one-on-one clinical autonomy
For Health Care Transformation: EHR Data and Physician Practice Acquisition

To achieve health care delivery potential.

maximal use of clinical data is essential.

Say health leaders and management sages.

Data can’t come from archaic print pages.

It must come from the electronic health record,

It must come from doctors on their own accord,

Working together or for a health system,

to provide value, to avoid data mayhem.

Only through more digital information,

can we attain health care transformation,

can we provide evidence-based facts,

which the current systems so sadly lacks

“Special Report: The Transformation of Health Care Delivery, “, April 22, 2015

Wednesday, April 22, 2015

Health Reform Metaphors

The greatest thing in style is have command of the metaphor.


I am a sucker for metaphors that crystallize what is happening to the U.S. economy related to health reform.

I was reminded of my weakness by this concluding paragraph in yeterday's WSJ Op-Ed piece by Phil Gramm, former Republican Senator from Texas:

“With better economic policies America was like the fabled farmer with the goose that laid golden eggs. He kept the pond clean and full, threw out corn for the goose and every day the goose laid a golden egg. Mr. Obama has drained the pond, burned down the coop and let the dogs loose to chase the goose around the barnyard. Now that the goose has stopped laying golden eggs – the administration’s apologist – arguing that we are now in ‘secular stagnation’ – add insult to injury by suggesting that something is wrong with he goose.’

Mr. Gramm is suggesting that if we would simply lower taxes and lift regulations, economic growth would renew and American exceptionalism would reassert itself. Gramm asserts under Obama, “Compared with average postwar recovery, the economy in the past six years has created 12.1 million fewer jobs and $6,175 less income for average for every man, woman and child in the country.’ He goes on to say income tax rates are up 24%, capital gains and and dividends up 59%, estate-taxes up 14%, and the U.S. corporate tax rate is the highest in the world. And, he adds, “With ObamaCare, the government now effectively controls the health-care market.”

I don’t know about his figures, but Gramm certainly is a master of the metaphor. Speaking of the metaphor, in yesterday’s blog, I said in yesterday’s blog that hospital monopolies were “Kings of the Health Care Mountain” in most major markets because of their organizational structure and physicians were “Stray Cats,” difficult to herd because of their lack of structure. I could have added the golden goose of private practice has stopped laying golden eggs, and the employer mandate was killing the golden goose of small business growth, but I did not. But my liberal readers might have objected that what is sauce for the goose is sauce for the gander and that the goose is a greedy bird.

Tuesday, April 21, 2015

Hospitals as Kings of Health Care Mountain

In my reading today, I ran across Doctor Marty Markay’s April 19 WSJ article “The ObamaCare Effect: Hospital Monopolies.” with a subtitle of “Last year saw 95 hospital mergers and acquisitions, a frenzy encouraged by the Affordable Care Act.”

Marty Markay, MD, is a surgeon at Johns Hopkins Hospital and professor of health policy at the Johns Hopkins Bloomberg School of Public Health. He is the author of Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care“(Bloomsbury Press, 2013).

Dr. Markay argues that when you are a hospital monopoly and the only game in town, you can charge whatever you want because every town has to have a hospital, and you can negotiate the price that suits you.

“Today’s frenzy of hospital mergers and physician practice acquisitions is giving hospital systems even greater leverage to inflate opaque “charge-master” medical bills that even hospitals are sometimes unable to itemize sensibly. With no mechanism to allow free-market forces to keep prices in check, this translates into higher health-insurance deductibles and copays for insured Americans, and in the case of Medicare and Medicaid, higher taxes. “

This is not new news. Avik Roy, of the American Enterprise Institute, made be same case back in 2011 in Forbes Magazine in “Hospital Monopolies: The Biggest Drive of Hospital Costs That Nobody Talks About.” And before that, Regina Herzlinger of Harvard Business School in Who Killed Health Care (MaGraw-Hill 2007). More recently, in 2012, Steven Brill, complained bitterly and acidly about how hospitals were soaking the public with his epic book, America’s Bitter Pill: Money, Politics, Back Room Deals, and the Fight to Fix Our Broken Health System.

And even me, yours truly, has been engaged in portraying hospitals as kings of the community health care mountain. In the 1990s, seized by the naive notion that hospitals and doctors could work together harmoniously as equal partners, I formed a national organization The National Association of Physician Hospital Organizations, later renamed the National Association of Integrated Health Organizations. Both floundered because of lack of interest by hospitals and physicians and lack of capital. I even served at chairman of a community PHO, and with James Hawkins. a hospital administrator, wrote a book on Hospital-Physician Relationships, Sailing the Seven “Cs” of Hospital-Physician Relationships: Competence, Convenience, Clarity Continuity, Competition, Control Cash, Finally, I written a series of Medinnovation and Health Reform blogs on the subject : February 22, 2013, “Why the Medical-Industrial Complex Is Killing Us, March 26, 2013, “Hospital Malfeasance: Fees for Services, Fees for Items, Fees for Facilities, and Fees for Physicians” and January 8, 2015, “Quotes from America’s Bitter Pill”.

All to no avail. Hospitals are going their merry monetary way, dominating 80% of metropolitan markets, hiring tens of thousands of physician employees, charging high opaque chargemaster fees, doubling physician fees in practices they own, squashing competition, negotiating higher fees from health plans. Not that I blame them. Obamacare is forcing them to form Accountable Care Organization, paying lower fees for government plans; and penalizing them for re-admissions.

But never mind. Hospitals are the visible beating heart of most communities, have the organizational structure and capital to centralize high technologies, maintain 24 hour emergency rooms, equip their facilities with high-tech wonders, are reaching out with free standing facilities and owned physicians into the communities, are the largest employers in those communities, and have the political clout to block or neutralized competing physician-owned facilities.

Hospitals are kings of the health care mountain, or if you prefer the 800 pound gorillas, in most communities and larger cities, while physicians are stray cats looking for homes in which they can feel secure.

Monday, April 20, 2015

Facts, Big Question, and Unanswerables

According to the Obama administration, these are indisputable facts:

Since its inception, the health law has added 16.4 million to the insured rolls, and the rate of national health spending has declined to a historic low.

The administration is correct, the facts are correct. No one disputes them. But they are misleading.

If you pass a law penalizing people for not being insured, subsidize those who are not insured, spend $2 billion on to promote the law, and engage in national campaign to sell the law, the number of uninsured will go up.

If the rate of national spending was going down even before you passed the law, and the rate of spending continued to follow the rate of decline after you passed the law and was coupled with a recession and a slow rebound from recession, it is problematic to attribute slower growth to the law alone.

The big question is: Has the law bettered the quality of care and improved the health of the American people?

After five years of the law, these questions and other questions remain unanswerable . Has it decreased premiums and other costs for the typical American taxpayer? Has it made health care more accessible for middle class Americans? Have Americans accepted its various mandates – that they must have a plan or pay a penalty, that employers must cover workers or pay the federal piper, that you must have a plan containing 10 essential benefits whether they apply to you or not? Why is the plan more costly than estimated? Has it slowed economic growth, and largely replaced full-time workers with part-time workers?

And, in the words of Cliff Asness, a managing and founding principal of AOR Capital Management, “Will government intrusion into the health-care market raise or lower the long-germ qualty of of care? What will it do to innovation? Is the Rube-Goldberg structure of ObamaCare the right – or even the reasonable way to go about this? Should we pass laws first, read them second, and force the courts and agencies to find the problems?” (“In Praising ObamaCare, They Bury It,” Wall Street Journal, April 16, 2015)

The real issues, which are unanswerable, are: What are the long-term effects and consequences of ObamaCare.

Sunday, April 19, 2015

Why Has “Balance of Power” Shifted from Physician Autonomy to Corporate/Government Control?

As editor of Minnesota Medicine Dr. Richard Reece pointed out the risks of HMO medicine in the 1970’s warning of the medical profession. Let’s ask Dr. Reece about the notion of “balance” between physician autonomy and corporate/government control.

Lee Beecher, M.D., psychiatrist,

Thank you, Lee, for posing the question. You ask. Why the shift of balance of power for control of health care from autonomous physicians to managed organizations?

As you observe in your email, physicians and their societies may appear to have “sold out” to government and corporate interests. Consequently , physicians have given up much of their autonomy. They now move to the beat of corporate and government drummers.

And as you further indicate, I warned of this shift of balance of power in my editorials and my book And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota (Medica Medicus, 1988), which is still available on Amazon.

To your question, I would add another question: Why Minnesota? To that I would say, Minnesota is bedrock of the cultural phenomena known as “Group Think.” In Minnesota Group Think, which may reflect a gathering together to combat the cold, organizations become more powerful than individuals in promoting the social good. This may be why Minnesota is home of large HMOs and their variants, the Mayo Clinic, Group Health, Partners Health Plan, United Healthcare, and 34 multinational corporations.

To me the balance of power shift in Minnesota and elsewhere is not a question of “selling out” but of succumbing to larger societal and market forces.

Compared to organizations like HMOs, PPOs, health insurers, other members of the medical-industrial complex, and government, we physicians as individuals in our quest for “autonomy” are pygmies in terms of the balance of power shift.

Organizations have the powers of:

Scale - The typical physician has an audience of 2000 patients, United Health has 100 million customers, Obama has 315 million mandated followers, hospitals dominate 80% of U.S. metropolitan markets, the social media, especially Facebook and Twitter, and Twii have billions of connectors, worshippers, listeners, and broadcasters.

Access to capital
– Corporations have stakeholders and venture capital, government has taxpayers .

Leverage - Organizations can mobilize teams of specialists under one umbrella to finance , deliver, and market high tech care . To take one example, Kaiser health care owns hospitals, employs physicians, and controls its health plans.

Information technologies - Organizations can deploy IT to collect data to manage input and output, to measure improvement, to standardize care, and to spread word of their products.

Individual physicians and even their organizations have few of these corporate/government advantages or the business skills to deliver mass services to massive audiences across the social spectrum.

Throw in the reality that the public entrusts socially responsible large organizations to manage and deliver social tasks, and you will realize why the private independent practice of medicine is in decline and why the balance of power for physicians is out of kilter.

Individually or in larger organizations, physicians can empower their smaller constituencies, and they can opt out of the government and corporate power structures by delivering a more direct higher quality, lower cost, more personal brand of care, but they are unlikely to have the advantages of scale, capital, range of technologies, and IT digital social media.

On the horizon, I see an evolving two-tier system – one mandated by government, the other directed by physicians.

Friday, April 17, 2015

Theranos, Disruptive Innovation, and Creative Destruction of Clinical Laboratory Industry

When I read that Elizabeth Holmes, a 31 year old Stanford University dropout, has become the first billion dollar woman entrepreneur by creating and leading Theranos, a laboratory company capable of measuring in minutes more than 70 tests on a single drop of drop for a fraction of current costs, I immediately thought: this may be the beginning of the end for the clinical laboratory industry.

Multiple tests on a single drop of blood. What a simple and powerful concept. Blood tests performed at the site of care, with no venipuncture,on a virtually painless finger prick, no more blood vials, no more searching for a vein, no more waiting for days for results.

And, arguably, no more clinical laboratories.

Theranos has signed a deal with Walgreens to have tests performed at their outlets. These tests are scheduled to be performed at 8200 Walgreen outlets in the near future.

In the U.S. clinical laboratories are a $76 billion industry that performs more than 7 billion tests each year. These laboratories tend to be free-standing, although hospital laboratories own many of them and perform tests in-house. There are thousands of blood drawing stations scattered across the country, and they hire hundreds of thousands of phlebotomists and laboratory professionals. Doctors with their own blood drawing teams, refer tests to these laboratories, who generally perform the tests and report results the next day.

When I read of Theranos, I thought of Joseph Schumpeter (1883-1950), an Austrian economist who served as a professor at Harvard from 1932-1950, and who coined the term “creative destruction” as a hallmark of capitalism.

I thought of Eric Topol (born 1954), MD, of Scripps Health in California, who wrote the book The Creative Destruction of Medicine in 2012.

I thought of Clayton Christensen (born 1952), a Harvard Business School professor, who came up with the term “disruptive innovation” to describe any innovation that replaced an existing service or product because it was cheaper, quicker, better, and more convenient. Christensen dubbed disruptive innovation as the “technology mudslide hypothesis.”

I thought of the whole field of theranostics, a word created to denote a combination of therapeutics and diagnostics and to describe a more individualized and personalized approach to medicine as a single stroke.

I thought of how Internet apps and Iphones have either disrupted or are in the process of destroying or marginalizing newspapers, Encyclopedia Brittanic, book publishers, bookstores, main street businesses, musical record shops.

And I thought of how disruptive innovation and creative destruction go hand in hand of my own experience. Starting in the mid-1960s through the 1970s and mid-1980s, I was one of the co-owners of a clinical diagnostic laboratory At the dawn of the Internet age in the 1970s, I foresaw the Internet would marginalize clinical pathology testing.

To make the clinical laboratory more clinically relevant, with the help of physicist, Russell Hobbie, at the University of Minnesota, using the Internet, I developed a differential diagnostic computer program. Based on the patient’s age and gender and an array of laboratory tests, we were able to pinpoint the correct diagnosis 80% of the time. The differential diagnosis accompanied the laboratory report on an attached separate sheet of paper. We sent out over 6 million of these reports without any pushback. When a national laboratory chain bought out our laboratory in 1985, the chain discontinued the program because of its expense and its potential medical legal problems. I described what happened in my 2007 book Innovation-Driven Health Care.

As things have turned out, national clinical laboratories and technology advances have largely destroyed clinical pathology as a source of pathologist revenue, and are an example of how innovation technological innovation has resulted in creative destruction of one branch of medicine.

Thursday, April 16, 2015

Patient-Centered Care: Generalities and Realities

In 2009, my book Obama, Doctors, and Health Reform (IUniverse, inc) was published. Its subtitle was A Doctor Assesses The Odds for Success, The Health System from the Top-Down to the Bottom-up, As Seen Through the Lenses of Complexity. I said odds for success were slim but wished Obama and its administration the best of luck and even gave a toast for their efforts.


The book’s unifying theme was reform-based improvement would be based on patient-centered care that was affordable, effective, and patient-friendly. Its success, I commented, would depend on patient responsibility and involvement.
That was 6 years ago, one year before ObamaCare passed.

How is ObamaCare doing so far?

Very well, in one sense. These days talk of a patient-centered health system is the rage , particularly in Republican circles, where the idea of a patient-centered, market-based with freedom of choice alternative to ObamaCare holds sway.

Not so well, if you consider the state of political controversy whirling around ObamaCare. It remains deeply unpopular with the American public. The GOP used ObamaCare as its main cudgel for capturing the House in 2012 and the Senate in 2014. And ObamaCare's continued existence may depend on a Supreme Court decision in June 2015.

And what about the patient-centered theme in the real world? How ‘s that going?

Again, not so well. In my book, I laid out 10 simple guides for patient-centered care, as set forth by the Institute of Medicine in its book Crossing the Quality Chasm, A New Health System for the 21st Century, (National Academy Press, 2001).

1. Care will be based on continuous healing relationships rather than on office visits. Sounds great, but health care continues to be based on episodic visits to different doctors in different settings rather than guidance from one primary care doctor.

2. Care is customized according to the patient needs and values rather than physician autonomy. This is slowly changing as patients gain more information from the Internet, but in most circumstances, doctors are still determining what patients need. “Values” remains a nebulous term based on the views of the beholder.

3. The patient is the source of control rather than the professional. This remains mostly pie in the sky because in a complex technological world only doctors have the information required to direct care, and patients for the most part still trust the doctor’s judgment.

4. Knowledge is shared and information flows freely rather than information remaining strictly in the record. This is beginning to change with the “open notes” movement, but patients still have trouble getting their records, and doctors are concerned patients may be unable to interpret information, and there are time constraints and privacy concerns in sharing information.

5. Decision making is evidence-based rather than on training and experience of the physician. In other words, decisions are based on data rather than on clinical intuition. Doctors are dubious about this proposition, because it takes experience to cut through the data clutter. Data may be an essential tool, but it is not the end game.

6. Safety is a system property rather than the individual responsibility of doctors even if doctors are dedicated to doing no harm. The idea that the “system” will take care of you and ensure your safety has a nice ring to collectivists, but I have doubts any “system” can effectively “protect “ patients against professional “harm.”

7. Transparency rather than secrecy is necessary. Of course, but there’s a thin line between transparency and confidentially and privacy.

8. Needs are anticipated rather than a reaction to needs. This is about maintaining health and preventing disease, which everybody agrees is needed, but it also about the reach of medicine. Medicine cannot control the culture or society or patient’s behavior once they leave the office, or the hospital or a health organization’s system. Only 15% of a nation’s health outcomes depend on medicine. The rest depends on the culture and patients’ life styles.

9. Waste is continually decreased and cost reduction is sought. This is obvious, but it isn’t always achieved by government regulations or not paying for care based on outcomes research. Too often, one person’s waste is another person’s hope for cure or life style betterment.

10. Cooperation among clinicians is a priority rather than preference being given to professional roles in the system. In short, two or more minds, acting cooperatively and collaboratively, are better than one. Or, to put it another way, organizational or team care decision-making , is preferable to individual care and individual decision-making.
In my book, I predicted health reform would have a mixed success and would not end with ObamaCare. The success of reform depends on patient freedom and choice and patient centered are and on American innovation and market experimentation, not on government regulation and guarantees of patient protection and affordability, which hve failed to date. Sometimes it is difficult to translate glittering generalities into the nitty-gritty realities .

Wednesday, April 15, 2015

Converting from ICD-9 to ICD-10 Coding Systems Isn’t So Hard If You’re 23 , and You’re Determined To Save Your Father’s Solo Practice

Yesterday Parth Desai, a 1st year medical student at Mercer University School of Medicine in Macon, Georgia, gave me a call. He had been reading my book Innovation-Driven Health Care (Jones and Bartlett, 2007) and my blog, Medinnovation and Health Reform. He had an idea he wanted to speak to me about.

It was a blockbuster of an idea. Over the last 2 years, he and his best friend, Will Pattiz, had developed a website,, that had just gone digital. The site allowed medical practices to convert from the current ICD-9 coding system to the ICD-10 coding system, all completely free. This idea is powerful because America’s physicians have been looking forward with dread to the mandatory use of the ICD-10 system.

The new system, which will be mandated and will go into use on October 1, 2015, contains 68,000 compared to 14,000 in the ICD-9 system. To set up an ICD-10 system will take anywhere from $5,000 to $10,000 to install for a solo practice, up to $30,000 for a ten person group, and over $100,000 large hospitals. For most practices, it will require hiring a coding person, and it will slow the pace of a practice, often dramatically at first. You will have to master its complexities if you want to get paid by CMS and insurers. For many anticipating physicians, its use poses a logistical nightmare.

According to Wikipedia: "The International version of ICD-10 should not be confused with national Clinical Modifications (CM) of ICD that frequently include much more detail, and sometimes have separate sections for procedures. The US ICD-10 Clinical Modification (ICD-10-CM), for instance, has some 68,000 codes. The US also has the ICD-10 Procedure Coding System (ICD-10 PCS), a coding system that contains 76,000 codes not used by other countries."

Work on ICD-10 began in 1983 and was completed in 1992 has been modified for clinical use in other countries.

ICD-10 use in the U.S. has been delayed three times in the last seven years, the last time in because of its relationship with the Sustainable Growth Rate(SGR) fix. This delay has occurred because of the unique complicated features of U.S. health care and the objections of many special interests. Many of its features do not lend themselves to doctor and hospital ease of use.

But mandated use of the clinical U.S. version of ICD-10 is coming, on October 1 2015, CMS will mandate its use on that date, whether practices are ready or not, and whether it drives physicians or small independent practices into retirement or into the arms of larger practices or hospital employment or not.

For Parth Desai, the son of Nitrin Desai, Md, a 59 year old Internist of India descent who practices in Columbus, Georgia, , solving the ICD-10 dilemma was a challenge, a labor of love, and a means of saving the family business. His 26 year brother is also medical student, and his mother, a respiratory therapist in India, was the practice manager of her husband’s practice. His friend Will Pazzi,the grandson of a family physician in Southern California, had spent his life mastering computer programming. A fellow humanitarian and innovator, Will was spending his life creating artistic films to raise conservation and awareness for America’s National Parks through his non-profit project, "More Than Just Parks", thus Parth’s idea resonated with his very core.

Here is Parth’s story as told by him:

“My father is a physician, my brother is a physician and one day I will be a physician. Medicine is all we’ve ever known, but medicine as we know it is changing. In the past 5 years, I’ve seen my dad’s practice lose roughly 40% in reimbursements and over double in management costs due to government regulations. All the while, he is spending more time on paperwork and documentation, and less time on actual patient-care than ever before. With ICD-10 coming, there has been so much fear-mongering about projected costs for implementation and potential losses in reimbursements, that physicians are legitimately scared about what this change will do to their practice. The other ICD-10 Software vendors are taking advantage of this fear to squeeze as much money as they can from physicians like my dad. “

“Which is sad because ICD-10 by its very nature is meant to improve our healthcare system, not to burden our good doctors. But the truth I want to share with everyone is that ICD-10 should not be as difficult as they are telling us, and it certainly shouldn’t be as expensive. It should be free. I see a day in medicine when technological innovation’s are made for the betterment of our field, instead of purely for personal gain at the expense of the great physicians of our country, and that’s what ICD-10 Charts is really all about, so that maybe one day when I’m practicing alongside my father and my brother, we can look to the future of medical technology, and see it as a blessing, instead of a curse.”

The two young men. Parth Desai and Will Pattiz, were prepared for the challenge. He and Will had been coding since a young age. When Parth was 21, his mother developed carpal tunnel syndrome, and could no longer manage his father’s practice for a time. Parth stepped into the void at age 21 and served as the practice manager for 2 years. He quickly realized something had to be done, if his father’s practice and others like it were to survive and thrive. He knew the problems of the new coding system were daunting, for example, the number of codes for back pain went from 1 to 80. The problem was increased specificity. You had to search out the proper code to get paid, and that search took time, which translated into less time with the patient and less revenue.

So Parth and Will went to work and came up with a simple way to convert existing ICD-9 codes to ICD-10 codes, at the push of a button.

Doctors who want to use the system can access it for free or learn about it at They can watch a video explaining its use at : If a doctor wishes to donate $10, $20, $50, or $100 for use of the system, he or she can do so through a credit card or Paypal.
Doc Fix Deal

One of many definitions of the word “deal,” is an economic or social policy pursued by a political administration. There are New Deals, Square Deals, Fair Deals, and now, Doc Fix Deals.

The Senate has just passed a Doc Fix Deal by a vote of 92-8 to replace the old Sustainable Growth Rate (SGR) Deal, which has existed since 1997 but has been changed 18 times to prevent deep doctor cuts. This year, today, April 15, the cut was to be 21% for Medicare payments to doctors. This was unacceptable to doctors, who were likely to stop or reduce seeing Medicare patients, and besides, the cut might cause doctor shortages, which would alienate seniors,an important voting bloc, how entering Medicare at the rate of 10,000 a day..

Here is the essence of thedoc fix deal.

Medicare payments to doctors are to increase annually 0.5% through 2019, starting in July 2015.

After 2019, doctors will be paid by alternative.methods involving bundled bills, shared savings through Accountable Care Organizations, altered fee-for-service based on performance and outcomes, or some combination thereof.

The Childrens Health Insurance Program and Community Health Centers will be funded for two more years.

High income seniors will bear more of Medicare costs through co-payments for Medigap policies.

This is a bipartisan solution. Both sides tout the Doc Fix as a sensible solution to a complex problem. Republicans says it shows they can govern. Democrats say they got what they wanted- help for children and for the uninsured and poor who frequent Community Health Centers.

In the political health care arena, the next big deal will come with the Supreme Court decision in late June, If the Court rules in favor of federal health exchange subsidies, ObamaCare will go forward unimpeded. If the court rules negatively and Republicans are not ready with a simple, workable health care plan, it will be a make-or-break ObamaCare moment. Obama will ask Congress to pass a one-sentence bill allowing subsidies to flow through federal exchanges. He will mobilize his political operation and give heart-rending examples of subsidized patients who have been left high and dry without insurance.

Republicans are working on developing alternative bills which go under names like , “If You Like Your Health Care Plan, You Can Keep It Act,: and “Preserving Freedom and Choice in Healthcare,” but they have yet to unite behind a single bill. GOP Senator Ron Johnson of Wisconsin warns if Republicans wait until the ruling on King v. Burwell is handed down, it will be too late to derail ObamaCare (Ron Johnson, “ A Make-or-Break ObamaCare Moment,” Wall Street Journal, April 14, 201

Tuesday, April 14, 2015

Health Reform "Should Be" Game

If you give the matter any thought at all, you will realize health reform in general and ObamaCare in particular is a should be game.

Who should control health care?

Should it be government based in Washington, relying on voters dependent on government subsidies and taxpayer dollars?

Should it be market-place forces, appealing to consumers with innovative and convenient services?

Should it be who pays and in what amount for health care, taxpayers, employers, or consumers themselves?

Should it be insurers, in league with government, who determines what and how and when services are to be distributed?

Should it be physicians and hospitals, who account for 54% of health care spending, who deliver the services and who know most about health and disease and who are closest to the site of delivery?

Should it be integrated health care organizations, in control of insurance, hospital, and physician functions?

Should it be consumers, spending more of their precious dollar and tied to the Internet and social media, who make informed decisions based on choice, convenience and personal needs?

Should it be employers, who currently pay a King’s ransom for covering more half the American population?

Should it be carried out with the massive data input of computer-based algorithms, dictating what it to be done and what is to be paid for?

Should it be a fight for political control since history shows that the party that controls health care sets the tone for the nation’s agenda?

Or should it be all of the above. What "should be" in the minds of various advocates, is not what "shall be".

There’s a huge gulf between what "should be" and what "shall be". And that’s the way it should to be in a democratic society seeking compromise and middle ground.
Electronic Health Records - Document Friendly But Not Doctor Friendly

You can say a lot of things about electronic health records(EHRs).

They are great at collecting and documenting data. They are the hope and dream of “data-driven” and of “evidence-based” documentarians . Congress has voted to spend $30 billion to promote their usage. They cost a passel of money - $28 billion so far in government incentives to doctors and hospitals to install them. There are a lot of them out there : they adorn 80% of physician offices and 60% of hospitals. They are the coming thing at the dawn of computer medical age. They are likely to be the basis for comparative research efforts to judge what procedures and what treatments to pay for and what groups of doctors and what hospitals to put in into what networks of caregivers to favor with government or insurer contracts. They replace vague subjectivity with specific objectivity.

And, at the same time, EHRs don’t work very well for doctors who say they interfere with personal patient interaction. Doctors claim you can’t simultaneously look for buttons to press and read patient’s face and decipher their body language and interpret what words patients use. In a 2014 Physicians Foundation survey of 20,000 physicians, 85% of doctors said they had EHRs, but 24% said EHRs detracted from quality, 46% from efficiency, and 47% from patient interaction.

And here’s the kicker, according to an Obama administration report, “Spurred by $28 billion in incentives to date, nearly 80% of doctors and 60% of hospitals have converted from paper files to electronic health records, known as EHRs since 2009. But only 20% to 30% of providers are able to share records with outside providers, according to government and industry surveys.” (“ Obama Administration Report Slams Digital Health Records:Report Criticizes Vendors for Making It Costly to Share Patient Information,”Wall Street Journal, April 10, 2015)." In other words, to use 8 syllable word, EHRs are 70% to 80% "uninteroperable," meaning they don't talk to one another, communicate, or share data, and to make matters worse, they don't transmit an understandable narrative, i.e. tell the patient's story in plain English.

All of this makes you wonder, What good are electronic health records, if they decrease quality, efficiency, and patient interaction? You can argue, of course, as the Obama administration has : that any general government program of enormous scale has inevitable glitches, that these glitches and inefficiencies, are the inevitable result of an ambitious governmental agenda, that it is somebody else’s fault - troglodyte doctors or greed-stricken EHR vendors; that transformation and reform of the giant health care industry takes time and patience; that what is needed is more government standardization and regulation.

Or, I suppose, you could argue, after 10 years of this push for a nationalinteroperative EHR program, maybe we ought to rethink this EHR thing. Maybe after the litany of complaints from doctors, there’s something fundamentally wrong with our approach. Maybe we ought to ask the doctors what kind of system would fit their needs and those of their patients Or maybe it just takes time to shake out.

Friday, April 10, 2015

Politics Isn’t Patty Cake

When Senator Ted Cruz announced for the Presidency, it was a reminder that politics isn’t patty cake. Patty cake is a children’s game in which children pat hands while reciting a nursery rhyme. Politics isn’t a nursery game. Politics is an adult game in which politicians slam each other while exchanging insults to bring down more powerful opponents.

Saul Alinsky , the patron saint of community organizers who died in 1972, set down these rules to show how the game is played( Rules for Radicals, 1971):

The rules[1]

“Power is not only what you have, but what the enemy thinks you have.” Power is derived from 2 main sources – money and people. “Have-Nots” must build power from flesh and blood.

“Never go outside the expertise of your people.” It results in confusion, fear and retreat. Feeling secure adds to the backbone of anyone.

“Whenever possible, go outside the expertise of the enemy.” Look for ways to increase insecurity, anxiety and uncertainty.

“Make the enemy live up to its own book of rules.” If the rule is that every letter gets a reply, send 30,000 letters. You can kill them with this because no one can possibly obey all of their own rules.

“Ridicule is man’s most potent weapon.” There is no defense. It’s irrational. It’s infuriating. It also works as a key pressure point to force the enemy into concessions.

“A good tactic is one your people enjoy.” They’ll keep doing it without urging and come back to do more. They’re doing their thing, and will even suggest better ones.

“A tactic that drags on too long becomes a drag.” Don’t become old news.

“Keep the pressure on. Never let up.” Keep trying new things to keep the opposition off balance. As the opposition masters one approach, hit them from the flank with something new.

“The threat is usually more terrifying than the thing itself.” Imagination and ego can dream up many more consequences than any activist.

“If you push a negative hard enough, it will push through and become a positive.” Violence from the other side can win the public to your side because the public sympathizes with the underdog.

“The price of a successful attack is a constructive alternative.” Never let the enemy score points because you’re caught without a solution to the problem.

“Pick the target, freeze it, personalize it, and polarize it.” Cut off the support network and isolate the target from sympathy. Go after people and not institutions; people hurt faster than institutions.

Critics have repeatedly said President Obama, a social organizer in this own right, applied these rules to win the Presidency and to keep his political opponents off-balance while serving as President. For example, critics say he ridicules Republicans as heartless for opposing ObamaCare, his policies turn minorities into majorities by redistributing health benefits from the middle class to the poor, he uses scare tactics by saying a negative Supreme Court decision will lead to poor health or deaths of millions of innocents , he repeatedly attacks the Washington and business establishments as mean-spirited, he doubles down and shifts blame to others when his policies fail. These accusations may not be true, but if true they are not patty cake.

Wednesday, April 8, 2015

ObamaCare's Last Gasp

Fight until the last gasp.

Shakespeare (1564-1616), King Henry The Sixth

President Obama has told ABC News the June Supreme Court decision will be the health law opponents “last gasp” at defeating ObamaCare ("Obama: Health Law an ‘8 of 10’ Lawsuit a Last Gasp, “ Associated Press, April 8, 2015). Obama said that he cannot conceive of justices “would make such a bad decision” and that the biggest challenging awaiting the health system is expanding Medicaid.

Spoken like a true champion of government-controlled health care and protector of his signature domestic legacy. He may be right, but the odds are more like 5 of 10 or even less. The issues here are who shall control the health care system and who shall have the last gasp.

Shall it be government? Through ObamaCare and the Centers of Medicare and Medicaid spends over $1 trillion annually, government controls physician fees and regulates hospitals, and covers 125 million Americans? Shall it the multibillion dollar health insurers, who cover more than 150 million Americans? Shall it be the so-called Medical Industrial Complex, which includes hospitals, physicians, pharmaceutical firms, medical device makers, and other health care providers, who collectively spend over 80% of health dollars? Or shall it be health care consumers, who are spending the dollars that make the system go?

In a larger sense, shall it be government or market -driven? There is a struggle going on for control of health care – a $3 trillion dollar industry that accounts for 17% of federal spending. It is a struggle for power. Everybody denies they seek power. They want the best and most efficient care for Americans. It is also a struggle for how to apportion the money. Entitlements are the fastest growing segment of the federal budget, of business expenses, and household spending.

Is government or markets, and in what combination, best equipped to cope with a $18 trillion federal deficit, which will be over $20 trillion by the end of Obama’s term, and which will be passed on to future generations? This is not an idle question in a nation with an aging population. It will be a fight until the last gasp.

Tuesday, April 7, 2015

"Unnecessary Imaging Tests” in ER Aren’t Necessarily Unnecessary

There is no such thing as absolute certainty.

John Stuart Mill (1806-1873), On Liberty

We live in an age of great expectations of the certainty of imaging tests. This week a patient said to me, “My husband went to the emergency room with belly pain, and the doctor didn’t know what was wrong. Why didn’t the doctor just do a CT-scan to make certain nothing was wrong”?

The certainty of radiology imaging tests is an illusion. There is no such thing as absolute certainty even with advanced technologies. In a survey of 435 ER physicians 97% said imaging studies they ordered were “unnecessary “ (John Commins, “97% of ED Physicians Order Unnecessary Imaging Tests,” HealthLeaders Media, March 30, 2015).

There are various explanations for these “unnecessary” imaging tests- medical legal fears, insensitivity to costs because insurers will pay, blind beliefs in technology, doing something to save time and satisfy patients, a compulsion to leave no stone unturned, public expectations that imaging tests represent the final answer.

But it’s more fundamental than that. According to Hemal Kanzaria, MD, an emergency room physician in Los Angeles, “Overtesting is not due to physicians’ lack of knowledge or poor medical knowledge, but reflects a cultural response both within and outside of medicine to uncertainty and error… We need to address this cultural intolerance of uncertainty... this cult of blame that triggers the malpractice system. Outcomes do not take into account factors that led to a test…the widespread beliefs that are held in society, including the perception that error is the cause of any bad outcome, or that technology can cure all of our problems. Or that catching things early is always beneficial.”

As the George and Ira Gershwin’s song in Porgy and Bess “ said of the applicability, impact, and truth of Biblical stories on one’s life, “It Ain’t Necessary So, ” imaging tests in the ER aren’t necessarily unnecessary, nor are negative outcomes necessarily due to physician error or poor judgment, but to widespread cultural beliefs that if something goes wrong, someone did something wrong , that someone is to blame, that technology eliminates uncertainty, and that poor outcomes should be grist for the malpractice mill.

The uncertainty of why imaging tests were ordered, and the uncertainty expectations of what they reveal, show the limits of outcomes research, and the limits of judging physician performance by this research.

Monday, April 6, 2015

Easter Truths: An Interview

Pilate saieth into him, what is truth?

John 18:38

Q: You look confused, what’s your problem?

A: It’s Easter, the most holy of Christian holidays, commemorating the resurrection of Jesus Christ, and I’m trying to sort out the truth.

Q: What truth?

A: How to interpret news from the Holy Land. Whether Israel or Iran is our friend or enemy. Whether Iranians mean it when they shout “Death to America!” Or “ Wipe Israel form the face of the Earth!”. Whether the nuclear “framework” if a good or bad idea. Whether Israel will go to war if it passes Obama muster.

Q: Look, get serioous. Foreign affairs is not your expertise. You write mostly about ObamaCare.

A: I’m confused there too. I find something Orwellian about it.

A: Why?

A: Well, Defeat at the midterm polls is victory. Failure to keep your doctors and your health plan is success. Trust in government is distrust of your providers.Coverage is access. Denial of adverse consequences is reliable. Unaffordability among the Middle Class is strength. Minorities are majorities. Congress is the enemy. My way is the high way.Compromise is capitulation. Social justice is economic immobility.Rhetoric is reality.

Q: That’s not Orwellian. That’s politics. Start at the extremes. Treat your allies as enemies. End up at the center.

A: That may be, but it doesn’t strike me as Christian.

Q: What is truth? Where do find the truth?

A: Truth is a composite of your experiences and the news you read or watch. And that news, its objectivity and bias influences your thinking. In my case, my sources of truth, if you want to call it that, are, in this order.

First, in depth print articles: Wall Street Journal, New York Times, Washington Post, New England Journal of Medicine

Second, television: CBS, Fox News, BBC, and NPR

Third, online websites: Real Clear, Kaiser Health, Physicians, The Health Care Blog,

Four, Books on history, management and health reform

Q: And?

A: There are no whole truths, only half truths that fit your biases.

Thursday, April 2, 2015

Obama, Doctors, and Health Reform

In 2009, my book Obama, Doctors, and Health Reform (IUniverse, Inc) appeared. It bore the subtitle “ A Doctor Assesses the Odds for Success, The Health System, from Top-Down to Bottom-Up, As Seen Through the Lens of Cultural Complexity.”

The odds for success, I believed then, as I do now, were not great.

I foresaw four major obstacles, which I called the four “Cs.”

-- Culture , American style, abhors the word “rationing.” Our health care culture cherishes unlimited choice, quick access to the latest and best in medical “cures,: and proven lifestyle restroing technologies. These traits conflict with a centralized, command-and-control, federal expansion of health care.

-- Complexities, American health care is a whirling Rubik’s cube, with millions of interrelated moving parts, institutions, and people, each with agendas, axes to grind, and oxe to gore.

-- Costs, Obama says prevention, electronic medical records, and paying only for what works, as established through comparative research, will save billions of dollars, yet scant evidence exists that these measures work. Proposed savings remain hypothetical.

-- Consequences , of curtailing health costs, may be worse than the cure, because health care constitutions and private practices in many communities are the fastest growing employer in town. Collectively, health care profoundly impacts most communities’ economies. Health care’s building blocks can’t be downsized quickly and dramatically.

To achieve reform goals, President Obama and his administration proposed four Medicare strategies.

One, initially investing heavily in ($44,000 to $64,000 per doctors) in Electronic Medical Recrods (EMRs) for doctors and hospitals.

Two, within five years, restricting or reducing Medicare payments to those doctors and hospitals that did not have EMRs.

Three, using Medicare-acquired data to pay doctors and hospitals, at the prevailing rates in the least expensive parts of the U.S., e.g. The same in urban New Jersey as rural Mississippi.

Four, stopping or reducing Medicare payments for expensive treatments that didn’t work, as determined by a federal Comparative Effectiveness Research Institute using EMR-generated Medicare data and implemented by an Independent Payment Advisory Board.

There you had it, a Medicare EMR-data-driven solution to America’s health care woes. I will leave it to the reader to judge how these obstacles and these strategies have worked out in the real world.

In the minds of the Obama administration the problems of the health system resided with the doctors and the medical-industrial complex. As economist David Leonardt explained in a Februar 2009 New York Times article (“The Big Fix: What Can Obama Do to Transform an Economy That Can No Longer Count on Wall Street or Silicon Valley.”)

“Doctors, drug makers and other medical companies persuaded the federal government to pay for expensive treatments that have scant evidence of being effective. These treatments are the primary reason the country spends s much more than any other on medicine. In these cases, and in others, interest groups successfully lobbied for actions that benefited them and hurt the larger economy.”

My response was: This is typical reform talk – those greedy doctors and their avaricious allies, drive overuse of unnecessary and expensive procedures. In reality, many patients expect these procedures to be done, since their health plans pay, and many procedures may restore a fuller lifestyle. In addition, patients and their families understandably want everything possible to be done, even though odds for success may be statistically slim.”

Fast forward to 2015. How have things worked out for those greedy doctors? Many are retiring early, not accepting or seeing fewer Medicare (24%), Medicaid (38%), and health plan exchange patients (25%), and nearly half (46%) give ObamaCare a “D”or “F” grade. This state of affairs could change , of course. Younger doctors are more accepting of ObamaCare than their older peers. The Supreme Court could drive a stake into the heart of ObamaCare in June. And the public may feel the drop in the number of uninsured justifies the costs, complexities, and consequences of ObamaCare.

Wednesday, April 1, 2015

ObamaCare Replacement: You Don’t Beat Something with Nothing

I have a friend, David Coombes, a former hospital administrator and health care innovator, who helped me organize a series of bundled bills for a community hospital to supplement traditional fee-for-service care. Our plan was actually a blend of discounts for F.F.S. hospital and doctor fees backed by re- insurance should the bundled bill be exceeded. When anyone objected to the process, David would say, “You don’t beat something with nothing.”

Such is the case with ObamaCare. You can’t replace ObamaCare with nothing. There is no going back to the old ways of doing something.

You need a replacement program that lowers costs, expands choice, fosters competition, increases quality, provides a safety net, and protects consumers.

It must be a national program that makes sense , is understandable, and makes sense to the majority of voters in the upcoming 2016 presidential and Congressional elections.

And somehow the replacement must address current adverse physician trends. Among these are: decline in private practice with physician shortages, rise in patient costs in hospital-acquired practices, narrowing of physician networks, non-acceptance of health-exchange patients by 25% of physicians, growing numbers of physicians not accepting Medicare or Medicaid recipients.

As a result of federal mandates to meet information technology demands, ICD-coding requirements, and utilization regulations, more and more physicians are switching to direct care and cash practices, further exacerbating physician shortage problems.

The America people are restless with various elements of the current system – complexities of the health exchanges, mounting premiums and deductibles, scarcity of physicians, shifts of costs from employers to employees, and so forth. These elements are driving out-of-hospital care, urgent care clinics, retail clinics, telemedicine, innovative business models , and concierge medicine and ambulatory surgical practices.

In response to all of this, Republican candidates for president are presenting a mix of substitutes for ObamaCare - shopping across state lines, more health savings accounts, refundable tax credits for all, repeal of all mandates, state block grants for Medicaid, setting up high risk pools for individuals and small groups, creating more catastrophic coverage, dropping bail out programs for insurers. (Michael Tanner, “Replacing ObamaCare: Repeal Isn’t Enough. Republicans Need to be Ready with Alternative Plans, National Review, April 1, 2015).
Bigger Is Not Necessarily Better: Hospitals v. Innovative Innovation Market Entries

The only power much care for the powerful is more power. The prize for the general is not a bigger tent, but command.

O.W. Holmes, Jr, (1841-1935), The Law and the Court

We believe it is not enough to stop dominant hospital systems from acquiring more power (Regina Herzlinger, Barak Richamman, and Kevin Schulman, “ Market-Based Solutions to Antitrust Threats – The Rejection of the Partners Settlement,” New England Journal of Medicine, April 2, 2015).

Regina Herzlinger , a tenured professor of business at the Harvard Business School, wrote in front of her book, which she sent to me, Consumer- Driven Health Care, (2004), “In admiration of all you do,”.

What I do is preach innovation, as in my book, Innovation-Driven Health Care (2007), and so does she in a series of books, including Who Killed Health Care (2007).

Regina’s consistent message is: Non-profit charitable hospitals are too big and fat and stifle competition. In the current New England Journal article, she and her two co-authors say, “ Hospital markets in more than 80% of U.S. metropolitan areas are ‘highly concentrated’, according to federal guidelines , and dominate hospitals continue to expand rapidly.”

On Boston, due to a 1994 merger between Massachusetts General and Brigham and Women’s Hospitals, the Partners system often charges two to three times as equal quality systems treating patients with equally complex conditions.” And Massachusetts has the highest per capital costs among U.S. states and the longest patient waiting times.

But unfortunately, big systems tend to quash competition, from for-example, innovative telemedicine providers and community-based urgent care centers. To contain the dominance of Partners, a Superior Court Judge in Boston blocked a settlement what would have allowed Partnrs Health to acquire three additional health systems in eastern Massachusetts. This was a good thing, according to Regina. The judge’s reasoning was the acquisition “would cement Partners’ already strong position in the health care market and give it the ability, beause of this market muscle to exact higher prices from insurers for the services its providers render.”

Too often settlements between dominant hospitals and policy makers entrench hospital dominance and stimulate its expansion. Instead we need policies that encourage innovation-oriented policies that promote lower prices, greater accessibility, and increased quality of care. Regina et all conclude, “We believe it is not enough to stop dominant hospital systems from acquiring more power. Policies must encourage innovative entrants.