Wednesday, September 30, 2015

Health Care Co-operatives, Hospital-Physician Collaboratives, Patient Communication and Other Kumbaya Pipe Dreams

ObamaCare was based on these promises : one, it would lower premium costs by $2500 per family by 2016, it would allow you to keep your health plan and your doctor, it would achieve a Kumbaya environment by getting government, hospitals, physicians, patients, and others to cooperate, collaborate, and communicate to improve care.

Kumbaya is a spiritual camp fire song. People with differences join hands and sing the verses of the Kumbaya song to cover up deep-seated disagreements and to pretend to agree for the sake of appearances and social expediency to patch up differences to act in unison.

The problem is Kumbaya doesn’t work very well.

Take health care cooperatives. In 2010, the Obama administration doled out $2.5 billion to form 23 health care cooperatives as alternatives to those evil big insurers. The co-ops were barred from advertising or marketing , supposedly used to excess by insurers at the expense of patient care. Today 21 of the 23 have either collapsed or on the verge of going out of business.
Or take hospital physician collaborative, which go by the names of Accountable Care Organizations and Medical Homes.
These organizations, the government reasoned. By doing away with the greed inherent in fee-for-service care and by offering bundled services covering the continuum of care, would save Medicare money and cause hospitals. primary care doctors, and specialists to work together in a Kumbaya fashion. Physicians would be rewarded with cash incentives for agreeing to be judged for performance, for engaging in improvement activities, and for using meaningful electronic health records.

So far, Kumbaya hasn’t worked out too well. About half the orginal pioneer ACOs have dropped out, and the record of those joining ACOs have a mixed savings record. Never mind. Hospital groups, universities, health departments, doctor associations clinics and others will now receive $685 million to promote collaboration among doctors and other health professionals.

Finally take patient-doctor communication, such as enabling patients to email providers, more physician assistants and nurse practitioners, and medical coaches and aides to help people with chronic disease cope with their illnesses.
Critics complain singing Kumbaya, which sounds noble in theory , hasn’t accumulated enough evidence to prove that how physicians are paid will achieve savings, that more data will improve that elusive concept called quality , that doctors will participate in more time-consuming email communications with patients, without reimbursement, or that American spending on health care, which grew 5.4% in 2014 or a projected 5.3% in 2015 will be reduced.

With ObamaCare, I’m afraid bipartisan or multiparticipants, Kumbaya is a pipe dream, originally defined as a vain hope induced by an opium pipem, but now perhaps by marijuana.

Why Is the President Unteachable?

The professor president who loves to talk about teachable moments is himself unteachable.

Bret Stephens, “An Unteachable President,” Wall Street Journal

Why is President Obama so unteachable?
Is it because he thinks he is unimpeachable?

Does he believe others are always to blame?
Is it because of his good intentions and fame?

Does he distrust steadfast men of action?
Does he trust only wishful men of caution?

Is it because as a former law professor,
He prefers to be a lecturer rather than a listener?

Is it because he denies existence of defeats,
Through his many Mid East strategic retreats?

Is it because he thinks solely of nation-building at home,
And shuns foreign distractions far from the capitol dome?

Is it because of his bias against intervention,
His bent towards inaction and accommodation?

Is it because he believes his enemies are evil.
That he’s an angel and they represent the devil?

Is it because he doesn’t realize he left a vacuum,
That others rushed into to fill like pond scum?

Is it because of obsession with no boots on the ground,
Left abundant ground for ISIS terrorists to abound?

Why is the President so reluctant to admit that power,
Has a place in the United States’command tower?

Whatever happened to the Russian reset?
Why was that such a bad disastrous bet?

So much for nettlesome foreign affairs,
What about domestic political nightmares?

ObamaCare, immigration reform, planned parenthood,
And other issues widely and deeply misunderstood.

On these he remains in his ideological bubble,
Far above and removed from the common rubble.

Tuesday, September 29, 2015

Bubble-Up Economics

I have a dear friend who keeps telling me, “Trickle-down economics doesn’t work.”

By this, he means you can’t trust the rich to share their wealth with the poor or working stiffs. Put another way, a rising tide may elevate the top 1% to 10%, but the rich can’t be counted upon to let their wealth “trickle-down” to benefit the poor or alleviate social or economic inequities. You have to tax the rich bastards and redistribute the wealth to grow the middle and lower class and blue collar workers.

Trickle-down economics has its flaws. I’m a bubble-up man myself. I believe true wealth and benefits for the poor and middle class comes from a growing economy, created by lifting tax burdens and regulations from individuals and small businesses, by encouraging innovation among the young and have-nots, by providing equal opportunities for all to think and grow rich, by forming start-up companies to grow in number and to flourish.

If you allow these things to occur, the economy will bubble up from the bottom.

This is precisely what President Obama’s policies have not achieved. Take health care. Regulations and taxes have increased for individuals and small businesses, with such things as $2000 penalties for employers with 50 or more employees who did not cover health benefits for workers, and mandated higher costs for health plans because every plan must offer ten essential benefits. Starting in 2016, every individual will pay $695 if they do not have a health plan.

Consequently, for these and other reasons, business start-ups are at an all time low. Why work and start a business if you receive welfare and unemployment benefits anyway? Why start a business if regulations take your profits away?

Trickle-down rules, more regulations, and higher taxes from above are not likely to cause those at the bottom and the middle to bubble-up.

Sunday, September 27, 2015

New Physician Payment Models: Judge Not, Health Policy Makers, That You Be Judged

Let us judge not, that we be judged.

Abraham Lincoln, Second Inaugural Address

I have just finished reading 2 articles in the September 25 NEJM – “Leap of Faith – Medicare’s New Physician Payment System,” and “Physician Payment after the SGR – The New Meritocracy,” by health policy academics from North Carolina, New York, and Boston.

Both articles ruminate on the new physician payment systems. Both say the “merit” of future physician payment will be based on 4 domains – quality of care, resource use, meaningful use of electronic health records, and participation in clinical practice improvement activities.

Both comment on the commonly held notion among policy wonks that cost-containment will success if we move away from fee-for-service notion.

Although it is not explicitly stated, new payment models – primarily Accountable Care Organizations and Medical Homes, are based on the premise that physicians do an excessive number of unnecessary tests and procedures because doing so lines their already overfilled pocketbooks.

Of the two articles, I find the first, The "Leap of Faith" piece, the more honest and forthcoming. Its two authors, Jonathon Oberlander of the University of North Carolina and Miriam Laughesen of Columbia University, say the move towards new payment models and away from fee-for-service has five fundamental problems.
One, other countries who spend far less than the U.S. has fee-for-service systems.

Two, under the new system, cost will still depend on volume and mix of procedures do, not on how physicians are paid..

Three, the new systems, primarily ACOs and Medical Homes, are unproven and may fail, and are therefore a “leap in faith.”

Four, the switch to value-based systems, or a “meritocracy,” are front-loaded with bonuses and extra physician payments through 2024, and will fail if too many or not enough physicians jump on the incentive bandwagon.

Five, these incentives, bonuses, or bribes, whatever you wish to call them, may cost the government more rather than less, and may not keep pace with increases in medical expenses required to comply with them, leading physicians to demand more in fees.

If the conversion to new payment models falters, as it may indeed be the case if other payment schemes like the Sustainable Growth Rate (SGR) formula is an example, government policy makers, not physicians, may be judged to be a fault.

“Value,” or “Merit,” or “Quality,” based on data and technical formulas , is an elusive concept. In the words of authors of the Leap of Faith article, “It’s unclear that we have the appropriate measures to accurately, meaningfully, or comprehensively evaluate the quality of physicians’ care, let alone to render such a judgment in a single score.”

Saturday, September 26, 2015

Where Do You Go When You’re Sick?

There are some things you can’t legislate – like where do you go when you’re sick.

In the first place, you don’t know how sick you really are or whether you need medical treatment.

Second, chances are, you can’t get in touch with a doctor. This may be because you don’t have a doctor. It may be because you got sick in off-hours, and your doctor’s office is closed. If may be when you call your doctor’s office, you get an answering machine, which tells you the office is closed and to go to the emergency room, if you’re really sick.

Third, you may not know the alternatives, such a retail clinic, likely closed in off-hours or holidays. Or an urgent care center, the existence of which you are probably not even aware.

Four, if you call 911, they are likely to direct you to the nearest ER.

So what do you do? You go to the ER. You know it’s always open. You know doctors are there. You may even know ERs are legally obligated to see you regardless if you’re able to pay.

Paul Auerbach, MD, professor of emergency medicine, and an ER physician for 35 years, discusses your dilemma in today’s WSJ. “Why ER Visits For Non-Emergencies Aren’t Going Away.”

He makes 4 important points:

1) “You can’t teach patients economic lesions when they don’t feel well.”

2) “ It would be wonderful if patients could self-diagnose and always seek the appropriate level of care, but they can’t. It would be amazing if there were a system that promptly supported patients after work, and on nights, weekends and holidays, but there isn’t. There are so many patients for whom I need to do what I can, or they’ll fall through the cracks. They need a doctor, a social worker and a case manager. The nation would benefit if there were round-the-clock high-quality telemedicine specialists.”

3) “So let’s provide the resources to make emergency departments more efficient. Most of the time, the emergency department is a good entry point for health care, as long as the patient is then connected with other support. Emergency physicians know how to sort patients and offer treatment in an cost-effective manner, with the decency and compassion patients deserve.”

4) “ The most urgent needs are to build primary-care and specialist capacity that will effectively and appropriately assist patients who otherwise must rely on the emergency department, develop telephone and video-assisted care, promote wellness, harness the power of digital health, and finally, educate and convince patients that the system will serve them. Until these problems are addressed, the emergency room will continue to be the main event, not a safety net.”

Emergency or non-emergency? It is not for the person who is sick to decide. Only an experienced health professional can distinguish between the two.

Friday, September 25, 2015

Organizations and Size Matters

In my 45 years of writing about health reform, I have learned organizations and their size matters. As I wrote in my 1988 book, And Who Shall Care for the Sick? The Corporate Transformation of Medicine, “Let’s concede that this is the age of management in which major social tasks – from education, to economic services, to health care – are entrusted to large organizations, let’s not say: “Down with health care organizations!” Let’s study management techniques and methods, and let’s apply them to our own situation in a responsible way that increases our leverage, maximizes our effectiveness, and brings medical knowledge to society in the most efficient ways…The biggest danger of corporations is that they are treating health care as a commodity…a product to be controlled, priced, limited, and parceled out. People do not like to be thought of as a product, or piece of meat, moving through an assembly line. It is up to us to define the boundaries of quality in evaluating and treating humanity.”

The size of health care organizations matters,
Without organizations physician practices lie in tatters.

Physicians can no longer be individual practitioners,
They must be organizational and societal parishioners.

As Aetna-Humana, Cigna-Anthem, and UnitedHealth know,
size gives heft, leverage, and power to keep others in tow,

As hospitals as centers of their communities recognize,
Hospitals are the biggest game in town in scale and size.

As centralized government is knowingly aware.
Its massive spending pervades all health care.

As the huge medical-industrial complex can appreciate,
Its organizations’ size helps better contracts to negotiate.

As social media’s incredible reach and impact grows,
Everyone knows they can’t do without its cons and pros.

But size by itself is rarely, if ever, enough.
Instead the right size is needed to do the right stuff.

The VA is biggest U.S. health system by any analysis
But its rigid structure causes bureaucratic paralysis.

Medicare-Medicaid has $100 trillion in unfunded liabilities,
As the third rail of politics it has outlived its capabilities.

ObamaCare says all health plans must be the same size.
With ten essential equal benefits as the progressive prize.

Alas the price of equal benefits and outcomes for all.
Is too high, for the middleclass it is beyond the pall.

Big size alone will not satisfy desires of individual persons,
Who crave freedom, choice, access, and privacy as humans.

For them health care has become outsized and oversized,
Physicians’ roles are to downsize to simplify and personalize.

As a member of an organization, to treat every person as a human entity,
And to give that person their undivided attention and individual identity.

Wednesday, September 23, 2015

Explaining Pope Visit and This ObamaCare Week

I hope Pope’s visit will be inspiring, conciliatory, uplifting, and healing. But, as our forefathers knew, religion and politics don’t always mix , and are often best kept separate, esp. in the current environment when it comes to climate change, immigration, abortion, and same-sex marriage, and conservative and liberal political philosophies. Every side has contrasting points of view, as John Saxe reminded us in his famous poem of six blind men feeling an elephants.

And so these six men of Nirvanastan,

Disputed long and loud

Each in own opinion

stiff and strong

Though each was partly in the right,

And all were in the wrong!

The Pope and the President will be quiet and dignified in their responses, agreeing upon what they agree and being quiet but firm where they disagree. But their followers will point out their differences. Im his quiet and humble way, The Pope has not been hesitant in diving into U.S. politics and matters of church reform.

Which brings me to health care reform. As Garrison Keillor would say, “It’s been a quiet week in Lake Woebegon.” But the woe is not gone. Hillary Clinton has spoke and tweeted the pharmacy companies need to reined in, the government shutdown over Planned Parenthood still looms, a study shows ObamaCare health exchange eligibility is deeply flawed, the GOP says it plans to sue over Obama’s illegal executive action in providing health exchange subsidies, the HHS secretary says it’s going to be “tough” to sign up new health exchange members in spite of the 2016 $695 penalty for not having a plan, and the ObamaCare is going to make a renewed effort to the explain the health law.

Why is ObamaCare so complicated and hard to explain. The best explanation I have read is that of Jonathan Oberlander, University of North Carolina health analysis and an ObamaCare supporter.

“The ACA is not so much a program but a series of programs- regulations, subsidies, and mandates that fill gaps in our current patchwork insurance system. It treats different groups of Americans in different ways , in different ways, at different times, which complicates efforts to explain the law, enroll eligible populations into benefits, and mobilize public support.”

Tuesday, September 22, 2015

How Big and How Consolidated Is Health Care Going to Get?

In a book I’m not writing, The ObamaCare Legacy, I assert the principal hallmark of ObamaCare will be that it provided the spark leading to massive consolidation of the health care industry.

In today’s September 22 WSJ an article appears, “ Health Law Speeds Merger Frenzy” that affirms my assertion. The lead paragraph reads, “Five years after the Affordable Care Act set off a health-care merger frenzy, the pace of consolidation is accelerating, transforming the medical marketplace into a land of giants.”

And giants the insurers are becoming. The proposed mergers of Aetna-Humana, Anthem-Cigna, and the presence of UnitedHealth Group would signify the existence of 3 massive companies, each with revenues of over $100 billion.

the hospital front, in 2015, 71 mergers have occurred before the end of August. Last year there were 100. Hospitals claim they must merge to gain the scale and heft to compete, to constrain costs, and to meet quality and efficiency goals imposed by ObamaCare. They must add other hospitals to their systems, acquire doctor practices, and add a wider range of services to stay in the game, and to meet the demands of growing doctor groups, who are says, “Take my rates or you’ll have no network.”

The buzzwords are you have to be "horizontally and vertically integrated" to survive and thrive. They claim they have to get bigger to squeeze out costs, end duplicative services , and end waste so they can “coordinate care across the entire continuum and partner with providers to provide proven value.” Never mind that in the short run costs for physician services have gone up to offset the costs of acquisition, management, and adding new outpatient facilities.

As Doctor Suess said in Lorax,

Business is business!

And business must grow

regardless of crummies in tummies, you know.

I meant no harm. I most truly did not.

But I had to grow bigger. So bigger I got.

I biggered my factory. I biggered my roads.

I biggered my wagons. I biggered the loads.

And I’m figuring

On biggering,

And biggering,

And biggering.

Add to these figures the facts that health care is already a $3 trillion industry, that Medicare’s unfunded liabilities are now in the $100 trillion range, and that it would cost $15 trillion to offer Medicare-for-all, and you begin to wonder how much bigger and biggering health care can get.

What is to become ObamaCare’s legacy,

Is it first and foremost a progressive fantasy,

Can our children afford its projected destiny,

Is massive consolidation the only remedy?

Monday, September 21, 2015

In Health Care A Little Imagination Can Go A Long Way. Three Why Not Solutions.

You see things and say, "Why?" But I dream things that never were; and I say, "Why not?"

George Bernard Shaw (1856-1950)

In writing my Medinnovation and Health Reform blog, I am always on the lookout for imaginative ways to cut costs and circumvent obstacles.

Here are examples:

One, Health Leads, a Boston-based nonprofit, founded by Rebecca Onie, a Harvard-trained lawyer, after working alongside physicians in Boston, spotted a problem. Physicians could prescribe precisely what poor patients needed, but they could not prescribe what poor patients needed once they left the office - heat, food, jobs, transportation, and home care. It dawned on Onie what patients needed was a connection with community resources that could supply these needs. Why not, she imagined, recruit idealist , computer –savvy, college student volunteers bent on health care careers , have them set up a desk at medical clinics and physician offices, and have these volunteers use their skills to help them poor gain access to community resources. And why not make it possible for physicians to prescribe these community resources? Onie has recruited hundreds of college volunteers; set up volunteer desks in scores of clinics, physician practices, and hospitals in multiple cities; and raised $30 million from organizations like the Physicians Foundation, the Commonwealth Fund, Robert Wood Johnson Foundation, and the Skoll Foundation to expand to multiple cities. Finally, Onie asked, why not make access to community resources a standard part of health care? Health coverage and subsidies can only go so far. Patients also need information on where to find help for basic needs like food, heat, work, and basic home care medical advice.

Two, although it is seldom mentioned, health care middlemen – like government and insurers and hospitals - add a great deal of cost for medical services. These middlemen offer essential services but they are not needed for all health care transactions. Consider such routine ambulatory surgical procedures – like biopsies, endoscopic gallbladder removal, cataracts, or a host of minor orthopedic, GI, cosmetic repairs. These procedures can be performed safely on an outpatient ambulatory basis without an overnight stay. The Surgical Center of Oklahoma, in Oklahoma City, using the services of 52 surgeons, has performed thousands of these procedures, the cost of which is announced online and includes bundled costs of nurses, anesthesiologists, and post-op care. Costs are as low as ½ to 1/6 those charged by hospitals and can be done with short waiting times at surgeons’ and patients’ convenience. The transactions are not covered by insurance but their low cost and convenience make them ideal for self-funded corporations seeking to lower costs and for patients who desire no-frill convenient ambulatory surgeries with documented results comparable to hospital procedures.

Three, here I shall be brief. The VA health system is notorious for its long waits. Many of these long waits are due to a VA prescription policy that says a VA physician must OK any prescription written by a private physician. Why not, simply fill the prescription automatically rather than have patients sit for hours or days in waiting rooms waiting for an overly busy VA physician to OK the prescription?

Wednesday, September 16, 2015

Anger, Anxiety, and Legislative Legerdemain

Skill in or practice of feats of magic, jugglery, sleight of hand, trickery.


As tonight’s second GOP debate approaches, I ask- Will it be about Trump’s boastful message of making America great again or Obama’s legerdemain?

Trump is a master at tapping into public anger over the political class and their inability to break the political deadlock over how to stimulate the economy, unshackle innovation, provide health care relief for the middle class, and tackle the chaos of the Middle East.

But the majority of the public has yet to show anger at Trump’s policy contradictions or his lack of specific proposals. Unlike Bill O’Reilly, who says the public is deeply angry at politicians and their lack of performance, Charles Krauthammer defines the public mood as “anxiety” over the direction of the country.

Is the public angry over Obama as a leader? Hard to tell. 50% disapprove of his performance, approve. The are angrier at Congress, which earns a 75% disapproval rating, or the direction of the country a 61% disapproval ranking, according to Real Clear Politics polls.

But one thing is for sure. Obama is a master of political legerdemain. He insists his health plan is a success because his health exchange subsidies have benefited 10 million uninsured people, 3% of the population, while 33 million, 10% of the populace remain uninsured and national polls continue to show disfavor-over-favor the health plan by 10% margins.

The legerdemain is more evident with the Iran deal, which about two-thirds of the public disapprove. Somehow by calling the deal an executive agreement rather than a treaty, Obama was able to get it passed with only a 1/3 approval of Congress.

Obama, it seems, can “do deals” without compromise and without Congressional approval through executive fiat. Whether this legerdemain is necessary because of his lack of experience, his inability to relate to Congress, or his ideology is open to question, but it has left an opening for Trump, who boasts he can “do deals” and overcome political incompetence.

In my case, I would point out the public and political anger is not new, as I indicate in this October 2013 blog.
Looking Back in Anger over ObamaCare

Look Back in Anger.

John Osborne (1929-1994), title of play (1956)

Everybody, especially the American public, is angry about ObamaCare and its baleful effect on the debt ceiling debate.

I am interested in the impasse because I have a book at Westbow Press, a branch of Thomas Nelson publishers, due out before Christmas, entitled Understanding ObamaCare.

It’s About Anger

ObamaCare is about anger- anger over 50 million uninsured, anger over high health costs, anger over the nature of the health law passage, anger over its mounting expense, anger over its broken promises, anger over its unanticipated consequences, anger over its effect on the full-time economy, anger over misinformation and lack of information, anger over failure of political parties to compromise and reach a consensus.

Source of Anger

This anger dates back to the parliamentary chicanery surrounding its passage without a single GOP vote and without consulting Republicans. Anger over the health law was responsible for the Tea Party rise and Democratic loss of the House of Representatives. Anger boiled over into the 2012 Presidential campaign. Anger fueled use of words like “anarchists,” “terrorists,” “extremists, ” and “right wing nuts” to describe the Tea Party. Anger culminated in the House-Senate-Presidential-Red State standoff, partial government shutdown. and threat of government default.

Momentary Insanity

Anger is momentary insanity. What begun as anger has ended in hurt for Veterans and government employees and shame of both political parties. In the case of ObamaCare the greatest remedy may be delay with negotiation.

Anger has fueled debate over ObamaCare and led to partial government shutdown and the threat of government

Tuesday, September 15, 2015

Oh, Well, A Few Trillion Dollars Here and a Few Billion Dollars There, and Pretty Soon, We’ll Be Talking About Real Money

Socialist Bernie Sanders proposal to expand government largesse over the next decade include:

• $15 trillion for Medicare for all.

• $1.2 trillion for Social Security.

• $1.9 trillion to rebuild roads, bridges, and airports.

• $750 billion for tuition-fee schools and more favorable financing.

• $319 billion to allow workers paid family and medical leave.

• $29 billion to bolster private pension funds.

• $5.5 billion for jobs for disadvantaged youth.

Source: Laura Meckler, Price Rag of Sanders Proposals; $18 Trillion, Wall Street Journal, September 15, 2015

An Ode to Donald Trump on the Eve of Second GOP Debate

Why is Trump tomorrows debate's center of attention?
What accounts for his unfathomable ascension?

Donald is brash, blunt, and even bizarre.
But he has the skills of a reality TV star.

He uses TV to hog national show time,
But he never, never, uses his own dime.

He repeats simple phrases “Make America Great Again.”
He calls others stupid and vows to end the brain drain.

Only he, says, can get those foreign deals done,
Outsmart foreign leaders and put them on the run.

He claims he will bring jobs back to America,
So many as to defy belief beyond numerica.

He will build a tall impenetrable Trump wall,
for which Mexico will pay or take a monetary fall.

He will build up our defenses and our military,
And, if needed, bury enemies in the cemetery.

Be they Iranian mullas, ISIS extremists, or Putin thugs.
He and his team will wheel and deal and subdue these slugs.

He will replace and repeal ObamaCare.
But just how he spares us the detail.

Opponents claim his policies’ details are contradictory,
So what, he counters, there’s no substitute for victory.

He may prove to be a bully in the bully pulpit,
But rest assured, he will always make a profit.

The ObamaCare Experiment

ObamaCare, now nearly 6 years old, is an economic and social experiment, testing whether government can successfully run a national health system in partnership with the private sector.

America itself, like ObamaCare, according to these observers, is an experiment.

• “The preservation of the sacred fire of liberty… is an experiment entrusted to the hand of the American people.” George Washington

• “America is the most grandiose experiment the world has ever seen, but I’m afraid, it is not going to be a success.” Sigmund Freud

• “When the world looks at America, they look at us because we are the most successful political and economic experiment in history.” Condolezza Rice

Like all experiments, the time comes to declare the experiment a success or failure. President Herbert Hoover, said Prohibition, introduced in 1919, was a “noble experiment. ” But in 1933, the experiment was declared a failure and was repealed.

As Richard Feyman, an experimental physicist, declared, “It doesn’t matter how beautiful your theory is, it doesn’t matter how smart you are, if it doesn’t agree with experiment, it’s wrong.”

Has the time come to pronounce ObamaCare experiment a success or failure? Yes, say Americans in countless national polls disapproving of the health law, and in 2010 and 2014 midterms. Perhaps No, said Americans, when they re-elected the President. '

The time may come again in 2016, when ObamaCare will be a central domestic issue in the Presidential election.

These questions on the experiment will surely arise.

• Is the ObamaCare experiment a success or failure, and has the time come to give it more time, or judge it a failure and replace and repeal it?

• Has the ObamaCare experiment delivered on its promises to keep your doctor and health plan, to reduce premiums , and to improve care?

• Have elements of the ObamaCare experiment, such as data derived from ubiquitous electronic health records to improve the efficiency and quality of care, or the introduction of 463 Accountable Care Organizations to save Medicare money, succeeded?

• Is the ObamaCare experiment’s success in providing subsidies to 10 million uninsured in health exchanges and in expanding Medicaid coverage to another 5 million to make care more affordable , sufficient evidence to keep the ACA going full-tilt?

No amount of experimental evidence can prove ObamaCare to be absolutely right or wrong, but the judgment of the American people in a single election on whether the experiment is a success or failure, can prove the experiment is wrong.

Monday, September 14, 2015

Why Aren’t Physicians Asked to Help Reform Health Care?

The title poses a perplexing question. Why isn’t physician participation an integral part of health reform decision making? After all, physicians provide the care, order the tests, prescribe the drugs, and perform the procedures that form the basis of modern health care and account for the bulik of health care spending,

Yet, according to a 2012 Physicians Foundation Survey of 650,000 doctors, 82% of doctors said they felt helpless and could play no active role when it came to influencing health reform. Perhaps that’s why in a similar 2014 survey, also by the Physicians Foundation, only 3.7% gave ObamaCare an A, and 75% gave it a C, D, or F.

Why are doctors bypassed when it comes to reforming care? After all, doctor incomes make up 25% of all health costs, and their orders are said to account for 80% of costs, and they are on the frontlines of care where critical decisions are made.

Why are doctors so seldom asked for health reform input?
Do those outside the profession know more curbing costs and managing care than those inside? Do outsiders know more than insiders about patients’ problems? Do government officials, insurance executives, hospital managers, and other overseers possess the knowledge and know more than doctors about what will save money, improve outcomes, and enhance efficiencies?

Will data fed into electronic health records and transformed into algorithms replace clinical intuition ? Will giving doctors incentives to join with hospitals into Accountable Care Organizations (ACOs) actually save Medicare money? Does forcing doctors to spend 20% to 25% of their time on coding claims, solving billing problems, meeting credentialing criteria, asking for pre-authorization, and complying with regulations improve care?

I do not know the answers.

But I know a revolt is brewing among doctors about having more input into reform. In late July, an organization United Physicians and Surgeons, held a conference with 40 speakers in Colorado, designed to address the issues of restoring physician autonomy, protecting the doctor-patient relationship, and resetting relationships with overreaching government and insurer relationships.

And I know an article by leaders of the Physicians Foundation had an article in the September 1 issue of Forbes Magazine entitled “Why Aren’t Physicians Part of the Health Reform Conversation?” You won’t find the names of practicing physicians as a authors of the Patient Protection and Affordability Act or any other piece of health care legislation.

Why not? Here I leave solid ground. I suspect the reasons are that outsiders believe physicians themselves and their organizations need to be reformed.

They believe outside management is necessary to reform care.

They may not trust physicians to be compensated for what they order or do because they believe physicians act out of personal gain rather than patient benefit.

They may think many if not most tests and procedures are unnecessary and do not result in health improvement or better outcomes.

They may believe American physicians, particularly specialists, make too much money.

They nay harbor the belief that data monitoring, artificial intelligence, electronic health records, and doctors and hospitals working in tandem in Accountable Care Organizations using federal guidelines will modify physician behavior sufficiently to save Medicare money, although this has yet to be proven.

Sunday, September 13, 2015

“ Feel Good, Feel Bad” Numbers Game

Come, Watson, come? The game is afoot.

Sir Arthur Conan Doyle (1859-1930), The Return of Sherlock Holmes

A political game surrounding the ObamaCare legacy is afoot.

“Feel Good” faction, supporting ObamaCare, uses these numbers to buttress their side of the argument: 1) Gallup polls indicate the uninsured rate has dropped from 15.4% when Obama took office to 11.9% today; 2) the number of persons signing up for ObamaCare exchanges is 9.9 million, 85% of whom are subsidized and can now afford insurance, fulfilling the basic promise of ObamaCare, to protect the uninsured and make health are affordable.

The “Feel Bad” gang, those opposing ObamaCare, which include Republicans, majority of independents, and most of the business community, argue: 1) the 9.9 million number is misleading because it is down by 15.4% from the 11.7 million the Obama administration boosted about in the Spring of 2015; 2) the number of those enrolling in ObamaCare will continue to drop under the combined weight of soaring premiums (up 20% in 6 states and over 10% in 36 states) and progressively narrowing networks and steeply rising deductibles.

Whatever side prevails, ominous signs persist that the public is uneasy about our current political leadership. GOP voters at the moment heavily favor Donald Trump, who vows to abolish ObamaCare. Democratic voters are leaning towards Bernie Sanders, an avowed socialist who believes ObamaCare does too little in advancing the cause of universal coverage directed, controlled, and commanded from Washington

Strip Tease of ACO Bureaucratese

This is a strip tease act to reduce federal bureaucratese to its bare essentials.

Six Medicare professional just wrote this explanation of why physicians should participate in Accountable Care Organizations:
“Earlier this year, the Department of Health and Human Services announced the goals of tying 30% of Medicare payments to alternative payment models by the end of 2016 and 50% by the end of 2018. That move was reinforced by the Medicare Access and CHIP Reauthorization Act of 2015, which replaced the sustainable growth rate formula for calculating physician payments with a Merit-based Incentive Payment System (MIPS) that consolidates and incorporates key components of the Physician Quality Reporting System, the Physician Value-Based Payment Modifier and the Medicare Electronic Health Records Incentive program for eligible professionals. The MIPS will adjust payment rate on the basis of physicians’ performance on quality measures, resource use, clinical practice improvement activities, and meaningful use of electronic health records. Eligible professionals participating in eligible alternative payment models could receive a 5% lump-sum payment each year from 2019 to 2024. If they meet program criteria, accountable care organizations (ACOs) could thus be central to Medicare’s strategy for delivery-system reform.” (“Medicare’s Vision for Delivery-System Reform – The Role of ACOs,” New England Journal of Medicine, September 10, 2015),

Translated and stripped of its programmatic gobbledygook, this means Medicare will offer 5% bribes to physicians if they agree to participate in an ACO, 423 of which now dot the healthcare landscape. If physicians (pardon “physician practices, Independent Practice Associations (IPAs), health systems, hospital-physician partnerships , or any or all of the above act in partnership with other partnering health care facilities” agree to do so, they will become “partners” with the federal government’s Medicare program.
This presumably is a deal physicians cannot refuse. All you have to do is to give up your autonomy and freedom to practice as you’ve been trained and accustomed to doing is to serve as a serf of government. Welcome Aboard, Partner!

Tuesday, September 8, 2015

Tempus Fugit, Especially if You’re A Physician

Time flies when you’re having fun, getting old, or you’re an independent practicing physician. There’s only so much time. It’s a perishable commodity. Once it’s gone, it’s gone, never to return again.

Physicians know these truths. They know they are paid to spend time with patients or perform procedures. They know they are not paid to spend time in meetings or on paperwork, searching for the precise ICD-10 code, of which there are now thousands, or feeding data into an electronic health record (EHR) , or trying to decipher an EHR which has been sent to them.

These truths help explain why many physicians are acting the way they are.

• They are hiring nurse practitioners, physician assistants, scribes, and medical assistants for a variety of tasks - to record drug information, take histories, do physicals, and prescribe medications – to save time so they can use their time to focus on what only a physician can do.

• They are organizing and owning “focused factories” – free-standing facilities that maximize use of the physician’s time so that they concentrate on what they do best and know best, diagnosing and treating disease. In these facilities, they organizing the work flow and time flow to do quickly and efficiently what they are trained to do.

• Physicians are interested in setting up physician-owned specialty hospitals , in which specialists can make maximal uses of their time without competing with other physicians for slots in hospital operating rooms. Traditional full-service hospitals, which are obligated to take all comers, particularly Medicare and Medicaid patients and the uninsured, complain these physician-run hospitals are “cherry-picking,” selecting those patients and those procedures that pay the most and rejecting those who pay less or not at all.

As a result of this perception, Congress in 2010 banned new physician-owned hospitals from opening. An independent study published in the British Medical Journal, just released, with Daniel Blumenthal, MD, of Massachusetts General Hospital, concluded that overall, physician-owned hospitals do not cherry-picking.

Blumenthal says, ““By and large, physician-owned hospitals have virtually identical proportions of Medicaid patients and racial minorities and perform very similar to other hospitals in terms of quality of care.”

The 2010 federal health care law not only banned new doctor-owned hospitals but also limited growth of existing ones. Legislation introduced in May 2015 in Congress that proposes to lift these restrictions is opposed by the main industry group, the American Hospital Association (AHA). The 2010 federal health care law not only banned new doctor-owned hospitals but also limited growth of existing ones. The new legislation introduced in May in Congress proposes to lift these restrictions is opposed by the main industry group, the American Hospital Association (AHA).

A bill was introduced in May 2015 in the House to lift the ban on physician-owned hospitals, but there is no companion bill in the Senate. As things stand now, it seems unlikely Congress will lift the ban on physician-owned hospitals. The American Hospital Association has a more powerful lobby, and full-service hospitals employ millions of workers, and are often the single biggest employer in many communities. There seems to be little interest in making specialists more efficient or in saving them time.

Monday, September 7, 2015

Labor Day Thoughts – After Obama

In January 2017, 16 months from now, President Obama leaves office. What will his legacy be?

Who knows, it’s a long. long way from September 2015 to January 2017?

But here are a few educated guesses.

One, the U.S. will have a national debt of roughly $21 trillion, and from now until then, President Obama will be spending billions more on programs - free community colleges, across the board minimal wages, guaranteed sick and pregnancy leaves, solar and wind projects, EPA control of carbon emissions - to support his progressive agenda.

Two, the refugee crisis in Europe will continue to metastasize and spread. Germany will accept up to 2 million refugees (800,000 in 2015 alone) because its economy needs workers. Other European nations , Britain, and Sweden and the U.S. will partially fill the refugee gap by agreeing to take in a modicum of Middle Eastern and North Africans. But the rich Gulf Middle Eastern nations, such as Saudi Arabia and Qatar, will likely sit on their hands and accept no refugees.

Three, the dispute over the wisdom and consequences of the Iran deal will boil over, as two-thirds majorities in the U.S. House and Senate vote against the deal and 60% of the American people oppose it. Nevertheless, the deal will be implemented, largely unread by those in Congress who voted for it. President Obama and Secretary Kerry will argue no alternative to war exists , and opposing Middle Eastern states, Israel and others, will begin to prepare for war, or to build nuclear weapons, if they do not have them already, because of their belief the deal will expedite development in an Iran nuclear bomb.

There are no easy options here, as Richard Fontaine, 40, president of the Center for New American Security in Washington explained, “In Iraq we toppled the government and did an occupation and everything went to hell. In Libya, we didn’t topple the government and didn’t do an occupation and everything went to hell. In Syria, we didn’t topple the government and didn’t do an occupation and everything went to hell. This is the Middle East. Things go to hell.”

Four, a contentious U.S. Presidential campaign may result in a conservative Republican President, or left-wing Democrat. On the GOP side, victory will hinge on turn-out of the conservative base or of the “great silent majority,” a term coined by President Richard Nixon. Many in this majority have not voted before. But this time around they may. They say they are mad as hell, and they are not going to take it anymore. They are convinced straight talk, action, built-up of the military, and destruction of ISIS are needed. On the Democratic side, victory will depend on turn-out of the millenials, the minorities (black and Hispanics), and the literal elites in the media and academia. On both sides, the state of the economy will be decisive – if it booms, Democrats win; if it withers, Republicans triumph.

Five, the path to a more prosperous and productive economy may reside in the progress of data-driven innovators who believe algorithms and artificial intelligence will triumph over all and somehow the solutions lie in metrics and computer multi- angulation . Some believe there are limits to data-analysis of outcomes, and personal anecdotes and narrative storytelling are more humane and revealing.

Six, which brings me to health care. What lies beyond the Obama horizon? I believe ObamaCare will survive, but in a more limited form. The individual and employer mandates may go because of public and business opposition, but the provision prohibiting exclusion of people with chronic disease from health plans will survive. Republicans, if elected in overwhelming numbers, may repeal or replace ObamaCare but only if they provide coverage for those now subsidized by the ACA. Premiums and deductibles will rise significantly, and access to doctors and hospital networks and medical procedures and diagnostic tests, will shrink dramactically. More doctors will refuse to accept Medicare, Medicaid, and health exchange patients, and more doctors will enter concierge and direct –cash ambulatory practices, and will form doctor-owned and directed surgical, diagnostic, and urgent care centers focusing on convenience and patient satisfaction. The VA crisis, triggered by such news that 300,000 veterans have died while waiting, will intensify. A multi-headed fragmented health system, one private and governmental, one emphasizing guaranteed access the other choice, one stressing metric measurement of outcomes as the condition for entry the other confidentially and privacy as equally desirable, will emerge.

Saturday, September 5, 2015

Obama: A Lot To Be Modest About

Mr. Attlee is a very modest man. Indeed, he has a lot to be modest about.

Winston Churchill, on his predecessor at Prime Minister of Great Britain

As millions of refugees swarm into Europe from the Middle East, the greatest refugee crisis since World War II, President Obama has a lot to be modest about.

It was President Obama who declared before the United Nations, “It is not the job of the President of the United States to solve every problem in the Middle East. We must be modest in our belief that we cannot remedy every evil.”

And we cannot, it follows, be responsible for the 200,000 dead in Syria, 4 million fleeing refugees, and 7.6 million Middle Eastern and North African people seeking refuge from terror and economic deprivation.

But we can be held responsible for not punishing President Assad after crossing the Red Line by exterminating his citizens with sarin and chlorine gas, for prematurely withdrawing from a then stable Iraq, for not arming our allies in the fight against ISIS, for dismissing ISIS as the junior varsity for the Taliban, and for withdrawing as leaders of the Free World and our Sunni allies, when they are begging for our support.

Nature abhors a vacuum, and Obama, ii his modesty, has created.

Thursday, September 3, 2015

Skinning the ObamaCare Cat with High Deductibles, HSAs, and Self-Insurance

There's more than one way to skin a cat.

English Proverb, of uncertain origin

Employers, faced with increased health costs, secondary to the ObamaCare employer mandate, are seeking ways to empower workers by lowering their health premiums, introducing health savings accounts, and self-insuring. Despite ObamaCare restrictions, high deductible, HSAs, and employer self-insurance plans are growing and are reducing employer health costs by 15% or so.

As many as 100 million Americans are now covered by self-insuring companies, who pay health claims directly and can contract directly with providers. And HSAs, generally paired with high deductibles, increased by 29% in 2014, reaching a record high of 14.5 million. Nearly one third (31%) employers now offer HSAs, up from 4% in 2005.

These new approaches reduce employer spending by 15% or more, and empower consumers by lowering their premiums by as much as 25% to 50% and allow individuals to set aside tax-free money for out-of-pocket expenses and encourages them to set aside money for retirement. Individuals own their HSAs and do not depend on their place of employment. HSAs encourage workers to shop for care since they are using their own money to pay for services up to the level of the deductible. Self-insured employers can contract directly with providers without going through the trouble and expense of going through insurers, often dramatically decreasing employer expenses in the process. Some concierge practices and direct-cash ambulatory care surgery centers now hire middleman to directly contract with employers.

These new approaches are not a panacea for lowering health costs by according to Scott Atlas, MD, and John Cogan, senior fellows at Stanford University’s Hoover Institution, and Mike Ferguson, CEO of the Self-Insurance Institute of America, these approaches lower costs while empowering employers and their workers (“Two Essential Tools for Repairing the ObamaCare Damage,” Sept.2, WSJ, and “Remaking Companies of ObamaCare, “ Sept. 3, WSJ).

I have written 20 blogs on High Deductibles, HSAs, and self-funding or self-insurance. You may read them by going to Medinnovation and Health Reform and typing in High Deductibles, HSAs, and self-insurance into the search box. These concepts are not new, but they are not popular with ObamaCare advocates of employer mandates and ObamaCare health exchange plans.

One hundred million Americans work for companies that self-insure. ObamaCare fans are unhappy about it. It places control in hands of employers and workers.

Wednesday, September 2, 2015

The New Math

In mathematics two plus two makes four.
But in politics two plus two means much more.

In our so-called checks and balances system,
Balance was supposed to prevent mayhem,

Congress was to advise and consent.
too much Presidential power to prevent.

As a backup people could always vote,
Should either side try to jump the moat.

To keep things honest and on an even keel,
A president veto could bring Congress to heel.

But that was before Obama’s presidency,
And his unilateral actions without precedency.

Voters and Congress he has learned to circumvent
With executive action, he has avoided the malcontents.

has learned to create the new political math,
To get his way without taking a political bath.

Only 40% of voters approve the Affordable Care Act,
Yet it passed without a single GOP vote, that’s a fact.

Only 34 of 100 Senators approve the Iran Deal,
Yet even without his veto, the deal will become real.

His disregard for voters and their representatives,
Is astonishing: no one has come up with preventatives.

Since when does two-thirds disapproval,
become equal to two-thirds approval/

It must come down to executive unilateralism,
and the power of presidential supernaturalism.

The mathematician may say two and two makes four.
But in politics sum are calculated at the back door.
Ben Carson, MD, Transcends Black Lives Matter Debate

A debate is raging over the Black Lives Matter (BLM) organization. Does BLM foster hate over police tactics in suppressing black crime? Does BLM rhetoric result in more police killings, such as the “assassination” of a Houston deputy or the murder of a policeman in suburban Chicago. Should President Obama condemn the Black Lives Matter rhetoric of “Pigs in a Blanket” or “ Let the Bacon Fry,” the language used after the killing of two New York City policeman in their car.

No one can say for sure. Of course, as a matter of simple humanity, all lives matter, and no one has said this more eloquently than Ben Carson, the retired John Hopkins neurosurgeon who has risen to second or third in many polls.

How has Ben Carson, a black doctor born into poverty in Detroit accomplished this feat?

By personal example.

graduated from Yale in 1971, married a black Yale fellow student, received his MD at the University of Michigan medical school, rose to the top of his profession at John Hopkins, raised three successful sons, and with his wife, wrote a book praising America, America the Beautiful. He and his wife created the Carson Scholars Fund, which has given 6,700 scholarships for student s in grades 4-11, towards their college education.

Along the way, he has spoken in a calm, reasoned, non-racist voice. He has taken generally conservative views and humbly admitted he has a lot to learn about foreign policy. All intelligent leaders, trained to make decisions based on facts and empirical data, he says, are capable of learning.

He has opposed ObamaCare, but said he would preserve its policy of prohibiting health coverage to those with pre-existing conditions. He dislikes the concept of for-profit insurers and would give every citizen catastrophic coverage, medical record, and a health care savings account. He had said the Affordable Care Act is “the worst thing that has happened in country since slavery because it makes all of us subservient to government.” Although this may sound harsh, Carson has expressed his views quietly without rancor. Among Iowa voters, he has an unprecedented 81 % likability or favorability rating, which may mean it’s not what you say but how you say it and whether you think all lives matter.