Saturday, October 31, 2015

A Place for Smallness in Health Care

Small Is Beautiful: Economics As If People Matter

Ernest Friedrich Schumacher (1911-1977), Title of His Book (1973)

In most last blog, “Bigness Begets Bigness in Health Care”, I wrote how health care businesses are caught in the grips of massive consolidation, triggered by the rise of big government.

In this post, I wish to stress small can be beautiful too. Smallness in health care is occurring simultaneousily with Bigness in health care.

It is useful to compare things great and small. Each has its virtues. In his 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, Robert Wachter, MD, described this binary problem well, “Medicine is at once an enormous business and an exquisitely human endeavor.”

A human endeavor health care is indeed. Health care is about our health, from birth to death. It’s about sickness and wellness. It’s about patients-doctor interaction. It's about economics - spending your money and other people’s money. It’s about fairness and waste, and the blend of the two when spending other people’s money in government health programs. With centralized care, more people are covered but anything goes, and humanity get lost in the regulatory blizzard. It’s about the need for more efficiency, which Big Business and Big Government, never seem to deliver.

But in the end, it’s also about privacy, confidentially, and hand holding. People are seeking kindness, listening skills, and bedside manners among physicians. And in these realms, smallness not bigness matters.

Physicians are beginning to buck the trend towards bigness by retreating into something called direct primary care, or its off-shoot concierge medicine.
By doing so, they are trying to preserve their autonomy and patient and doctor relationships.

Physicians are paring down, the number of patients they see each year, from 2000 to 3000 or more to 500 to 1000, in order to cut through the bureaucracies and regulations that have engulfed medicine and to what they are trained to do, engage with patients.

Physicians are cutting their practice overheads and costs to patients by not accepting patients covered by third parties, by not being slaves to time consumed by data and coding entry and documentation for insurers and government.

They are delivering bundled prices for a variety of services in their offices, including routine tests and minor surgical procedures.

They are telling patients precisely what to expect for their money by posting prices in advance in their offices and on the web.

They are offering same day scheduling.

They are giving out their cell phone numbers. and they are answering patient emails.

They are spending more time with patients, addressing their concerns, listening carefully to their complaints, explaining what it takes to stay healthy, and unraveling the intricacies of treatment and payment and government policies.

They are being more personal, for medicine is a very personal business.

Health care is a big business, but it’s a small business too

Friday, October 30, 2015

Bigness Begets Bigness in Health Care

Business is business!
And business must grow

Doctor Seuss, The Lorax>

To survive in today’s health care’s business climate, you have to get bigger, so bigger you get.

To grow bigger faster, you merge or acquire other health care businesses, so health care mergers and acquisitions are at an all time high, comprising 24% of total U.S. merger and acquisition deals.

Drug stores – Walgreens has agreed to buy Rite Aid for $9.4 billion to create a chain of 12,700 stores. That leaves 2 huge drug store rivals - Walgreens-Rite Aid with 12,700 stores, 459,000 employees, 46.5% market share: CVS with 7,800 stores, 217,800 employees, and 30.8% market share.

Health insurers- The proposed Aetna-Humana and Anthem-Cigna deals . along with UnitedHealth would leave three insurance giants in its wake, each with more than $100 billion in revenues.

Pharma and Biotech - Valeant Pharmaceuticals and others have struck more than $240 billion in merger and acquisition deals in the last year. Pzizer may grow even bigger by moving to Ireland to form its headquarters to escape U.S corporate taxes, the highest in the world.

Hospitals - Hospitals are acquiring and merging with other hospitals at an accelerating rate, converting themselves into large integrated systems with multiple hospitals, multiple outlets, and dominant state and regional integrated systems.

What is the cause of this massive trend toward bigness of these segments of the health care industry?

Response to big government is one answer. Under Obama and Obamacare, health care has grown into a centrally controlled massive business enterprise. Medicare, Medicaid, ObamaCare, and the VA now cover 150 million Americans, nearly half the population, and CMS (Medicare and Medicaid) set the fees and the codes and regulate the activities of the private sector.

Health care has become a $3 trillion yearly business. To protect themselves against government and contract with huge government agencies, health care participants must become big themselves - to cope with regulations, to remain profitable, to install costly information technologies, to hire expert managers, to mobilize specialists with their expertise in creating profitable hospital lines of business, and to cushion against loss.

Government bigness begets health system bigness. Bigness begets bigness, money begets money, and organizations beget counter-organizations.

Not that bigness begets efficiency or effectiveness. The VA is a prime example of the badness of bigness. The VA is the biggest health system in the United States, with 9.1 million enrollees, 20,000 physicians, 1600 facilities, 288,000 employees, and an annual budget of $59 billion.

“Yet everybody – veterans, the government, the public at large, and physicians – agree the VA is one big mess. An independent blue ribbon panel of experts, conducted by the Institute of Medicine, concluded “ VHA systems for patient scheduling, staff hiring, supply-chain management, billing, and claims management are stagnant and have more limited capabilities than their private sector equivalents.”

Bigness begets higher costs. Premiums are rising under ObamaCare health exchange plans. Thirty percent of 30% of Medicare recipients’ costs are set to rise 52%. Fees for hospital-acquired practices may double. Fees for common procedures in regions with a high concentration of large group practices are higher than those of small or single practices.

Where does this leave private physicians? In a lurch, frankly. Physicians as a whole as yet have no cohesive national organization representing their business interests. Only 15% belong to the AMA. Their numbers are fractured into 300,000 primary care and 600,000 specialists, each with its own set of priorities.

Movement towards a large physician organization is growing among physician organizations- such as the United Physicians and Surgeons Association, Physicians4patientcare, SERMO, and the Physicians Foundation- to unify physicians, but the movement is still young. Meanwhile, in response to organizational bigness, physicians are retiring early, going to work for hospitals, serving as temporary locum tenens practitioners, entering concierge practices, forming big physician groups, and creating specialty, disease, and urgicare, and other focused centers, to ease the pain of bigness and to cope with its consequences.

Health care is big deal, and it’s begetting even bigger deals.

Wednesday, October 28, 2015

Hillary’s Wars

Hillary Clinton is conducting multifront wars – on the GOP right wing conspiracy, in GOP wars on women, blacks, ObamaCare opponents, in those who support big businesses, big insurers, and those who would drag down the middle class.

She takes no prisoners of war, and she proclaims “the economy does better when you have a Democrat in the White House.”

Really? To buy this line of attack, you would have to ignore reality. From 2008 to 2012, when she was Secretary of State, 92% of jobs lost were among women, and poverty among women was 16.1%, the highest in 20 years. In recent years, incomes of black families fell 33%. The rich, the top 1%, made 95% of income gains. Under ObamaCare, in 2016, premiums will rise an average of 7.5% in government-sponsored plans, and Medicare premiums will spike by 52% for 30% of recipients. Big businesses are doing fine, if you take the stock market as your guide, and thousands of small businesses and startups are declaring bankruptcies, failing, or not launching . The middle class has lost an average of $1300 of income, are living from paycheck to paycheck, and average less than $100 in savings.

Meanwhile, the big are getting bigger. In health care, insurers, hospitals, pharmaceutical firms, and drug store chains are merging and growing bigger at record rates. Government itself is growing bigger. The national deficit now nears $19 trillion. Big government works best for big business, the powerful, the wealthy, and the well-connected, not for thee or me.

It may be true, as Margaret Thatcher said, “In politics, if you something said, ask a man. If you want something done , ask a women.” But that depends, on what politics you embrace, what you want done, and what woman you ask. Ask Carly Florina, and you will get a different answer (“Hillary Clinton Flunks Economics,” WSJ, October 27, 2015).

Questions to Ask When Watching Tonight’s GOP Debate on the Economy

1. Are you better off economically after 7 years of the Obama Presidency?

2. Is your income higher or lower than 7 years ago?

3. Are President Obama’s present policies or President Bush’s past policies or GOP opposition responsible for the slowest economic growth since World War 2?

4. Does the economy do better under Democrats or Republicans?

5. Does big government with higher taxes and more regulations produce better results than small government with lower taxes and fewer regulations?

6. Which political party cares more or does more for the middle class?

7. Has ObamaCare improved the affordability or status of your personal health care?

8. Do you trust government controls or market freedoms to do the right thing for you economically?

9. Is an “insider” traditional politician or an “outsider” results-oriented candidate more likely to change the direction of the country for the better?

10. Which candidate makes you most optimistic about your future or the future of the country?

11. Do you think American voters and the “wisdom of the masses” can be trusted to make the right decisions for the country?

Tuesday, October 27, 2015

Death of Print Books

On the occasion of our 53rd wedding anniversary, my wife and I were ruminating over our collection of 6000 books – old books, new books, books on literature, books on medicine, books on writing, books of biographies and autobiographies, books on gardening, cooking and the fine arts, books on the present and the future.

We are moving to smaller quarters. We recently decided to downsize our collection. We called in a well-known book dealer to buy books we didn’t read anymore.

The dealer, after looking over our collection, said, “ I can’t give you any money. These books won’t sell.” We were stunned. The books represented the cream of our culture. “People, “ he explained, “ don’t buy old books, only books by current best-selling authors, only books featuring current celebrities or the latest fads.”

We were astonished. Where have readers of good books gone? Was there no interest in the books that shaped our culture, told of our past, predicted our future?

Sadly, we concluded we are members of a past generation – buyers and readers of physical books with embedded printed pages. In our place and in the place of books had come a new generation who receive their information on what to read from Kindle, tweets, Facebook, streaming videos, blogs, apps, iphones, and books promoted on TV.
New books can be parked in the Internet Cloud, taking no room, and just a click away. Old books are space-occupying dinosaurs, housed and treasured by an older generation.

It is a sad new world for others like us. We are people of another generation who like the tactile pleasures of sitting before a crackling fireplace, of cozying up propped by a pillow in a warm bed, with a good book in hand; of fondling well-made, well-designed , well-composed books, or simply admiring shelves of well-ordered handsome books, and sorting through them with our mind’s eye, or a fond hand that appreciate the feel of good books.

We live in a disruptive digital age that has displaced books to the electronic cloud and the dustbin of history. I recognize the demands of immediacy and instantaneity in our fast-paced society, but the death of print books is a sad chapter in our culture.

Richard L. Reece, MD, Old Saybrook, Connecticut

Monday, October 26, 2015

Theranos CEO: Elizabeth Holmes, 31, Pushes “Pause” Button

Not so fast, McDuff

William Shakespeare

Due to a series of October 14-23 WSJ articles questioning the validity and deliverability of Theranos testing methods, a Food and Drug decision that Theranos “nanocontainer” is an unapproved medical device , and WalGreen’s halt in their testing using Theranos tests, Elizabeth Holmes has announced a “pause period” as it seeks FDA approval of its propriety Edison technology.

The WSJ and Elizabeth Holmes are exchanging conflicting statements about the accuracy of Theranos tests.

This is the third blog I have written about Theranos. The titles of the first two speak for themselves.

One, April 17, 2015, “Theranos, Disruptive Innovation, and Creative Destruction of Clinical Laboratory Industry”

October 16, 2015, “ 240 Tests on a Single Drop of Blood, Too Good to be True”

These latest developments are a setback for Theranos and for Silicon Valley’s golden girl, Elizabeth Holmes, whose company has attracted $9 billion in venture capital value.

California is the land of the information technology gold rush, a land where young entrepreneurs are making billions, seemingly on the blink of an eye.

Until now, Theranos was the hottest IT game in town.

She is a heroine to IT geeks for style and imagination.
As explained in The New Times Style Magazine (October 25),
“Theranos, a complete blood count and electrolyte tests, taken by a single finger prick, costs $10.17. Her goal? To democratize health care. Turning a blood test into an inexpensive, essential and even (almost) pleasant experience rather than an expensive, dreaded, and time-consuming procedure – makes people more likely to get testes. As a result, medical problems can be identified earlier, enabling the prevention and effective treatment of disease ranging from diabetes and health aliments to cancer.”

Suddenly, as the result of the WSJ articles and a Food and Drug Administration investigation into the validity of Theranos claims about the accuracy of its proprietary Edison testing methods and unapproved medical device “nanocontainers" used to collect finger-pricked blood, Ms. Holmes’ dream of revolutionizing the clinical laboratory industry is on hold.

As a clinical pathologist who has been writing about screening laboratory tests since 1974 (“The Screening Laboratory of 1980,” Perspectives in Biology and Medicine, Winter, 1974), Theranos may have other challenges as well.

1) Many states do not allow patients to order clinical tests directly, nor do they allow laboratories to report results directly to the patients.

2) Patients may not have the requisite knowledge to interpret the clinical significance of tests.

3) When many tests are performed at once, it is inevitable many tests will fall just outside the normal range but be clinically insignificant.

4) Large scale testing my compromise the privacy of test information.

These considerations aside, I applaud her efforts to break down barriers to tests and to provide lower-costs, less invasive testing.

Saturday, October 24, 2015

Richard Armstrong, M.D., Interview

Question: Share with me your background and why you became so intensely interested in health reform and what you think physicians can do to make a difference.

Answer:I am a general surgeon currently working in a multi-specialty group based at a critical access hospital in the upper peninsula of Michigan. I have been in my current position for 13 years.
I graduated from The Ohio State University College of Medicine in 1976. Medical school was paid for by a United States Navy Scholarship. As a condition of the scholarship, I did a 5 year general surgery residency at the Naval Regional Medical Center in Portsmouth, VA

Following completion of this program in 1981 I received orders to the USS Nimitz and served one year as the Ship’s Surgeon on deployment in the Mediterranean Sea.

In 1982 I was assigned to the United States Naval Hospital, Great Lakes, Illinois and became the acting Chief of Surgery. I could not assume the full title as I was still a junior officer…LCDR. I spent two years at Great Lakes during which time I also had the title of Assistant Professor of Surgery at The Chicago Medical School. We trained students and residents at the Naval Hospital in conjunction with the North Chicago Veterans Administration Hospital.

I received the Navy Achievement Medal for my service at Great Lakes and was promoted to Commander, but I would have been required to spend two more years in the Navy to accept the promotion and I had decided that I wanted to become a “real” general surgeon in rural private practice. I moved to the upper peninsula of Michigan in 1984 and formed “Superior Surgical P.C.” with a partner.
During 18 years in private practice my partner and I built a new $1.6 million office building and as a hospital board member for 17 years I assisted with doubling the size of the hospital and increasing the volume of our practice so that it was possible to hire a third full time general surgeon. I represented my hospital on the Michigan Hospital Association and the American Hospital Association.

I became a Fellow of the American College of Surgeons in 1987 and eventually chaired the regional Committee on Fellowship for the Upper Peninsula for the College. I also became an ATLS instructor and actively taught trauma care for over a decade in upper Michigan and northern Minnesota.

In 2002 at the request of my family I sold my interest in my private practice and designed a new practice at my current location in conjunction with the hospital’s CEO who had been a friend of mine since 1984.
I am also a Clinical Assistant Professor of Surgery with the Michigan State University College of Medicine and teach medical students from both Michigan and the University of Minnesota.

Question: When did your interest in health care policy intensify?

I have had an intense interest in United States health care policy since I began medical school but was able to follow things much more closely after I left private practice for my position at Helen Newberry Joy Hospital.
In September of 2009 I listened to President Obama speak to a joint session of Congress about health care, and I was horrified. He was describing building a larger federal health care bureaucracy which from the point of view of a practicing physician was the last thing we needed.

This was the continuation of an ideologically driven agenda which began early in the 20th century. I felt that practicing doctors needed to act. I couldn’t sleep, so at 4 am the following morning I wrote to the President and explained that he needed to speak with the working physicians in America, those who care for patients day and night, rather than relying on “policy experts” within the beltway and academia.

Question: What is your connection to SERMO?

I posted my letter on SERMO, which is now the world’s largest social media site for physicians. I immediately began to get calls and was invited to read my letter as well as explain my views at a rally in Washington, DC on October 1st, 2009. I had to go because I was very tired of hearing doctors complain while doing nothing positive about it.

In Washington I met Dr. Hal Scherz who had formed the 527 political action group, Docs 4 Patient Care in Atlanta, Georgia earlier that year. Hal and I become friends.
We began communicating with each other and Dr. Lee Gross through SERMO. At the request of many physicians nationwide Docs 4 Patient Care was transitioned to a 501c6 membership organization in January of 2010 with the intent to stop the passage of the Affordable Care Act and to give American doctors a voice in the debate.

This was a daunting task . We managed to increase our national membership to over 1000 physicians and develop chapters in 17 states, the ACA passed in March of 2010. Subsequently, we spent a tremendous amount of time working on the political front. We actively helped elect a general surgeon to Michigan District 1, Bart Stupak’s former seat in the fall elections of 2010, We supported many other candidates nationwide who agreed that the ACA was not the solution for American health care.

We traveled to Washington at our own expense over 14 times and held many sessions with legislators directly which we called “House Calls on Congress”. We worked closely with The Heritage Foundation, The Galen Institute and the Pacific Research Institute in these efforts.
In 2012 we filed an Amicus Brief to the United States Supreme Court in support of the 26 states and NFIB lawsuit against the Secretary of HHS, Kathleen Sebelius. You know the outcome. I also testified about the effects of the ACA that year before the House of Representatives Committee on Oversight and Government Reform.

We supported Governor Mitt Romney in 2012 and worked diligently for his campaign. You are aware of how that worked out. As a candidate, reforms which had been passed in Massachusetts hampered his campaign.

These setbacks, as well as a mood of hopelessness among physicians caused the efforts of the 501c6 organization to wane. We were also finding it increasingly difficult to manage the organization as we are all practicing medicine and surgery full time.

In 2013, Dr. Scherz was approached by a major philanthropist who recommended that we form a non-partisan 501c3 educational project specifically to educate the American public, our physician colleagues, leaders of business and legislators about health care from the point of view of practicing physicians with experience in policy and media. We took the advice and founded the Docs 4 Patient Care Foundation in 2014 which we are actively building now…

We feel strongly physicians can make a difference by becoming educated about the complex policy issues which affect our ability to practice daily and by working with us to preserve the sanctity of the physician-patient relationship.


You recently spoke before the Physicians Board, a non-profit organization dedicated to advanced the cause of private practice. What was your message?

Yes, I am currently the Treasurer of the Docs 4 Patient Care Foundation, which as mentioned above is the outgrowth of efforts to unite physicians over the past 6 years.

SERMO is the world’s largest physician only social media site. I have been a member since 2007 and have been an active medical advisor for the site for the past 3 years.
Our recent interaction with the Physicians Foundation addressed two main issues. The first was a proposal to collaborate to become actively engaged with the physician community by sponsoring national conferences designed to educate physicians about positive reform efforts, These efforts are possible even under the current laws.

We also wanted to become agents of innovation and change by removing barriers to physician entrepreneurship to strengthen the ability of private practice to remain viable.

To grow this effort, increased funding from many sources will be required. We have approached the Physicians Foundation for financial support as well as many other sources through our association with the professional organization, American Philanthropic.

Question: How large an audience do these and similar organizations, like United Physicians and Surgeons Association, have? I have heard the figure of 460,000 bandied about.

UPSA is an interesting project launched in 2014 by Drs. Michael Strickland, Gina Melink, Dan Craviotto and Judy Thompson. Dr. Strickland is the driving force behind this 501c3 project. The purpose of the group was to organize a national meeting which would bring together like minded groups of physicians to begin a conversation called “Let My Doctor Practice”. This statement summarizes in a short phrase the frustrations many American physicians feel deeply as third parties, mostly related to payment, have intruded on our autonomy and ability to practice what we trained long years to do…medicine and surgery. The meeting was held in July in Keystone, Colorado. The Docs 4 Patient Care Foundation played an integral part in the conversations leading up to the meeting and in the meeting proper. This is summarized on their website…

Dr. Mike Koriwchak, Dr. Hal Scherz and I participated in the web and in the live events in Keystone.
I cannot say how many followers the Let My Doctor Practice site has to this day, but that information should be available from Dr. Strickland.

SERMO currently has over 460,000 members internationally. I communicate daily on the SERMO site.
4: What is the role of the AMA in organizing doctors? As you may know only 15% of practicing doctors belong to the AMA,. Why the high non-participation rate?


Prior to the passage of Medicare in 1965, the AMA represented over 70% of practicing physicians. In fact, in 1962 Dr. Ed Annis, a general surgeon from Florida who would become the President of the AMA, spoke to the empty Madison Square Garden in protest, the night after President Kennedy went to the stage to promote the King-Anderson Bill which was the original Medicare legislation. His speech is prophetic…]

As we all know, after JFK was assassinated and LBJ won a landslide in 1964, Medicare passed, The AMA attempted to limit federal influence in health care by including language in the original bill which said that the government would never interfere in the practice of medicine. How has that worked out for all of us?
Most critically, the AMA was instrumental in developing the Current Procedural Terminology(CPT) system for coding and billing third parties. This copyright has been lucrative for the AMA. In 1983 the AMA signed a contract with HCFA(now HHS) to be the monopoly provider of the coding system for the government. This was rapidly adopted by virtually all third party payers. The AMA also essentially controls the Relative Value Update Committee.

This committee assigns relative values under the RBRVS to CPT codes and is essentially the government’s price fixing committee under Medicare. The AMA is estimated to generate between 80 and 100 million dollars per year from licensing fees and the sale of CPT coding manuals.
What was once a membership organization for physicians and an advocacy group for independent private practice has become a partner with the federal government. It is this conflict of interest and support for government programs that has resulted in the significant drop in membership for the AMA. While they will debate this, the facts are apparent and are troubling to a majority of American physicians.

Question: What common problems and complaints do physicians share? From my point of view, these problems center around loss of autonomy, interference in the doctor-patient relationship, pay based strictly on data, on outcomes and performance, credentialing hurdles, and the time squandered on electronic health records and documentation. The latest documentation nightmare is how to comply precisely with 70,000 ICD-10 codes to get paid or risk being audited.

Answer:The short answer is all of the above and more. Physician autonomy has been gradually eroding for decades, however the acceleration in metric reporting, RAC audits and much more is directly related to the fact that our federal medical programs are running out of money…rapidly.

Medicare was never a fiscally sound program from the outset. President Johnson knew this and intentionally hid the facts from his own party. Medicare was projected to cost the nation $10 billion by 1990; however the actual figure was $110 billion. Since the passage of Medicare the program has run up a total of $3.2 trillion in deficit spending…. $305 billion in 2014 alone. Currently Medicare is running an estimated $35 trillion in future unfunded obligations…care promised which cannot be paid for.

About 10,000 people become eligible for Medicare daily and on average each one of those recipients will consume $3 of spending for every $1 they deposited in the program during their working years. This is unsustainable. The Medicare Actuary estimates that Part A(the hospital portion) will be depleted in about 2028.

Still, program reforms have had no significant effect on slowing spending. Everyone in Washington knows this, but few politicians have had the courage to address it.
The HITECH Act of 2009 is a classic example of the disaster that can be created when the federal government mandates something which should have been allowed to develop organically in a free market.

In 2007 a small study of early IT adopters, about 3500 tech geek doctors, were interviewed by the RAND Corporation. When asked if they like their systems, 95% of them answered “yes” which should be no surprise as they designed and built custom systems for their own use. However, the NEJM published this as an editorial which stated “95% of doctors like their electronic medical record systems”.

Viola! The politicians and the IT industry pounced. It was stated to the general public, with no evidence, that EMR systems would reduce the cost of medical care, reduce medical errors, make doctors more efficient, and allow more seamless communication among health care providers.
None of this has occurred to any extent. This is not because EMRs are a poor idea; rather it is because the EMR vendors are not working for the users.

The “customer” is the government and the private insurance industry who have forced medical documentation into the CPT coding and billing system. Thank you once again AMA! Is this becoming a bit clearer?

ICD-10 is yet another nightmare story, especially for doctors in private practice. The United States is one of only a few countries using this system for medical coding and billing. In Canada and Europe the ICD-10 system is utilized for research, frankly…where it belongs.

And this would not be complete without mentioning the American Board of Medical Specialties Recertification and Maintenance of Certification conundrum which is driving physicians nationwide to retire early or opt out of all areas where these onerous requirements must be met.

Kurt Eichenwald of Newsweek has published three recent articles about that which are linked here

So, the bottom line is that doctors are being crushed from all sides…even by the leadership of their own profession and they have become sick and tired of it, which is why the Summit at the Summit was organized and why the Docs 4 Patient Care Foundation feels so passionately about reclaiming the leadership position once held by American practicing physicians.

Question: As I see it, one of two central problems that need to be addressed is the relationship between physicians and hospitals and how to get paid across the “continuum of care.” I am dubious about the proposition that can use EHRs to document every patient across the full continuum of care.

Answer:There are many layers of this issue to explore, but among the most critical related to the erosion of physician autonomy is the move toward the employed physician models…the corporatization of the profession. In subtle and not so subtle ways the authority of the independent medical staff in the hierarchy of hospital management is disappearing, and this is dangerous.
In most hospitals the Medical Staff is an independent body responsible through its bylaws to set policies, do peer review, do credentialing and appoint committees among other duties. It is a separate entity which reports to administration and ultimately to the Board of Trustees of the hospital.

As more and more physicians become employed by for-profit hospital corporations the Medical Staff is losing independence and is often unduly influenced not by the medical needs of the patients, rather by the bottom line of the corporation.

Sometimes the changes are subtle and gradual and at other times they are obvious and disturbing. This was a recent topic of serious discussion at a meeting convened by the President and the Executive Director of the American College of Surgeons in Chicago which I attended personally.

The bundling of payments issue is, in my view, an outgrowth of the demonization of fee-for-service which has been the result of poor federal policies, not the fact that payment for medical services by any “fee” is bad. Incentives in federal systems have been misaligned for decades where reduced reimbursement has stimulated physicians to make up for this with greater volume.
In family practice this has reduced the average office visit in America to 8 minutes. How can you have a relationship with a patient in an eight minute visit? I would be pleased to discuss this in much more depth, but this is why Direct Primary Care is on the rise and is also why places like The Surgery Center of Oklahoma are succeeding and growing.

I believe there is great potential for digital technology to improve patient care, but we need to let the market work. Doctors and patients should adopt systems which help them become better at what they do, not have a one-size fits all solution forced upon them.

Question : What is your attitude towards Accountable Care Organizations, Obamacare’s answer for assembling doctors and hospitals into common organizations responsive to government regulation and saving Medicare money.

The short answer is that, like the HMOs of the 90s, they will fail. The longer answer is that they are inherently unethical for the medical profession.

Essentially the federal government is telling the doctor…”here is a pot of money to care for these 5000 Medicare “covered lives”. If you manage the care in such a way that you come in under budget…you get a bonus. If you don’t…no bonus.

Now, aside from the obvious fact that these “assigned lives” all have behaviors which the physician cannot control…including using up some ACO money outside of the ACO, what the physician becomes is a “covert rationer” of care at the patient’s expense.

This may be subtle at first, but it could come down to a question…expensive MRI vs. more money in my pocket. This is an unethical choice which no physician should agree to participate in…my strong opinion.

Question: Recently the Sustainable Growth Rate formula was replaced by a new payment model, transitioning away from fee-for-service and towards “value” of outcomes and quality for 30% of care by 2018.
Do you think this new model is feasible?

Aanswer: My short answer is no. John Graham, my friend and a health care economist with the National Center for Policy Analysis describes it well here

What I was personally outraged about was the way Congress and our major medical societies handled this “SGR fix”. In a word…it was a scam.

The AMA wanted this very badly. They had compromised with the administration during the debate over the ACA to keep the “cost” over the first decade below $900 billion. A “Doc Fix” then would have run up the tab to about $1.2 trillion which would have killed the ACA(eerily reminiscent of 1965). So, Congress was anxious to get this done and so was organized Medicine. Our medical organizations sent out mass e-mails telling members to “Call your Congressman and tell her/him to vote yes on the SGR repeal”….stop! The SGR was repealed in the first 11 pages of a 263 page document.
The following pages set up the Alternative Payment Models and the Merit Based Incentive Payment System which officially begin in 2019. These are bureaucratic nightmares for doctors. They lock in the Meaningful Use program for EHRs and also the MOC system of the ABMS. Most doctors don’t understand this yet, but they should be uniformly outraged as they were once again sold out by the AMA and the majority of organized medicine. Yes, this one makes my blood boil.

Question: : As you know, the Physicians Foundation, founded in 2003, in response to a court settlement with HMOs, has conducted a number of large scale national physician surveys. These surveys show demoralization among physicians, dissatisfaction with ObamaCare, and a widespread unhappiness with time spent on paperwork. I believe these surveys are fundamental importance and contribute to doctor shortages and the massive wave of hospitals hiring doctors, seeking to escape the rigors and headaches of modern practice.

Answer:I agree that the surveys are extremely valuable and assist all of us in presenting data which backs up our general assertions.

Question: Do you believe direct cash practices, including concierge medicine and direct pay for ambulatory care patients, has a future?

Answer: The short answer is yes. This is one of the bright future prospects for primary care in America and is what our Foundation President, Dr. Lee Gross, is personally doing in Florida with his practice…Epiphany Direct Care

Question: I’m aware you call yourself an independent, neither Republican nor Democrat.

Given that state of mind what do you think about the GOP proposals out there? Among these proposals are universal tax credits, lids on catastrophic care, expansion of health savings accounts with high deductibles, patients shopping for routine care and paying for that care, shopping for care across state lines, and more affordable health plans with narrower choice of benefits, and retention of guaranteed access to care for chronic illnesses and coverage of care for young adults under 26 under their parents plans.

Answer:There are elements of our Physician’s Prescription For Health Care Reform in most of the announced candidates plans. Ben Carson talks about Health Savings Accounts wherever he speaks and we have placed the document in his hands personally. Marco Rubio has our document which was given to him by one of our colleagues who is close to him in Florida. Scott Walker embraced many of our ideas. Jeb Bush just released some detail today which I have not had a chance to read. However, all agree that the ACA needs to be repealed, but I think it would be a huge error to replace it with another centrally planned and administered legislative product.

America needs more market driven reforms while understanding that we can afford to provide a safety net for those who need it and in fact it is our moral obligation to do so, however, it is not compassionate to drive the federal government into fiscal insolvency over political promises which obviously cannot be kept.
I would also add that we are in the process of rewriting the linked document and would appreciate any commentary from you, Walker and Tim in that regard.

Question: Why do you think heretofore, physicians were not part of the reform conversation? How do we insert ourselves into that conversation?

Answer:Our experience is that the majority of doctors are too busy practicing or are employees and feel generally “safe”. Of course for those of us that have been studying the ACA and the financial pressures ahead, we know that employment is not safe. I would anticipate that in the coming years as new practice models spring up spontaneously there will be a shift back to private groups of physicians. What we hope and desire is that doctors will have a soft landing as the government programs begin to wane.

I think we get them into this conversation by positive engagement in meetings, conferences, media and much more. SERMO has been an excellent tool for that and we intend to continue to nurture that relationship.

Question - In general, patients and consumers have not been consulted about what they would like as the ideal solution to health reform. The Physicians Foundation is in the process of conducting such a survey? Why is this survey so overdue? After all, patients are what health care is all about.

Answer: I believe that such a survey will be quite valuable and look forward to seeing it.

Friday, October 23, 2015

Are Electronic Medical Records (EMRs) Fit for Patient and Physician Consumption?

There’s something subhuman with electronic medical records (EMRs), upon which the Obama administration has squandered $30 billion since its 2008 stimulus bill.

Physicians’ chief complaint is the waste of time and needless expense spent over inoperable, clunky, and clinically unfriendly EMRs.

Jeff Goldblatt, MD, a general surgeon in Old Saybrook, Connecticut, puts the problem in context:

"The need to complete electronic medical records leaves no time to see the patient to talk to the patient, to touch them. It has compromised doctors' ability to take care of patients while at the same time requiring that more people be hired to IT and coding. Lots of doctors have left their careers early as a result." (Beck Coffey, "Jeff Goldblatt: the Healing Life," Harbor News, October 22, 2015.

I once asked my ophthalmologist what he thought about EHRs. He replied, “When I receive an EMR from a referring physician, I ignore it. It doesn’t tell me why the patient was referred. It doesn’t give me any useful information. It’s just a bolus of data. There’s no narrative, no story, there.”

As Robert Wachter, MD, concluded during the writing of in his 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age,

"I realized that my beloved profession was being turned upside down by technology…Medicine is at once an enormous business and an exquisitely human endeavor; it requires the ruthless efficiency of the modern manufacturing plan and the gentle hand-holding of the parish priest;…it is eminently quantifiable and yet stubbornly not.”

In recounting clinical EHR “House of Horror” stories, Lisa Rosenbaum, MD, national correspondent for the New England Journal of Medicine says,

“To these tales of EHR fallout, most of us could add our own. Physicians retiring early, Small practices bankrupted by up-front expenses or locked into ineffective systems by the prohibitive cost of switching. Hours consumed by onerous data entry unrelated to patient care. Work flow disruptions. And above all, massive intrusion on our patient relationships." ("Transitional Chaos or Enduring Harm? the EHR and the Disruption of Medicine, " NEJM, October 22, 2015.

In a recent interview with me, Richard Armstrong, MD, a general surgeon at a small critical access hospital in Michigan’s upper peninsula, related this sad tale,

“In 2007, a small study of early IT investors, about 3500 tech geek adopters, were interviewed by the RAND corporation. When asked if they liked their systems, 95% of them answered “yes,”. The NEJM published an editorial which stated “95% of doctors like their electronic medical records.”

“Voila! The politicians and the IT industry pounced. It was stated to the general public EMR systems would reduced the cost of medical records, reduce medical errors, make doctors more efficient, and allow more seamless communication among health care providers. None of this occurred. ”

Voila indeed. This is an example of a vast project launched with half-vast, half-baked, and half-studied ideas.

Electronic medical records personify bureaucratic overkill in pursuit of wishful thinking – that somehow electronic documentation in the cloud are more important than clinical doctoring on the ground.

It is an example of a blind trust in data rather than clinical judgment , of wishful thinking that EMRs would speed the transition from volume-based to value-based payments, of the ideology that somehow electronic monitoring would bring precision into the subjective business of medicine.

But there can be no central interoperability of systems with operability in practices , no increase in efficiency or effectiveness unless EMRs help rather than hinder patient-physician relationships, no technological advances unless the “data’ tells the stories of patients and physicians’ effort to help patients. Hope and change and wishful thinking are not enough unless they address human needs and are fit for human consumption.

Sunday, October 18, 2015

What’s Wrong with American Health Care

What ‘s wrong with American health care? It's simply this. We can’t afford the care most of us – liberals, conservatives, independents, and everybody in-between – think we need and deserve.

Health care costs too much – for government, individuals, employers, the employed and unemployed, the insured and uninsured.

If you doubt me, consider the implications of these 10 article headlines in yesterday’s Kaiser Health News. All articles concern costs and unaffordability of care.

1. Medicaid Spending Rises 14% as Health Law Expands Eligibility

2. Nearly A Third of Medicare Beneficiaries Face Steep Premium Increases

3. Remaining Uninsured Worry about Costs of Coverage

4. Medicaid Spending Soars – Mostly in Expansion States

5. Don’t Just Renew Your Medicare Plan: Shop Around

6. A Looming Tax on High-End Health Plans Draws Fire from Many Sides

7. Medical Prices High in Areas Where Large Doctor Groups Dominate

8. Chronically Ill Pay More in ObamaCare Plans Than Employer Coverage

9. Insurers Find Out-of-Network Bills As much as 1400 Percent Higher

10. Buyer Beware: A Mammogram Prices Vary by Nearly $1000.

For these cost, spend, and unaffordability dilemmas, there is plenty of blame to go around.

Some blame the interconnected world economy. Liberals blame the unfairness of market-based capitalism. Conservatives blame high taxes, onerous regulations, and misguided monetary policy.

The public blames government. In 1964, 77% of Americans trusted government to do the right thing, Today only 22% trust government to do the right thing. Between 200 and 2015, favorability ratings of Congress went down 18%, the presidency by 16%, and the Supreme Court by 17%.

Whose is to blame? According to Jay Cost, A Weekly Standard writer writing in “Politics of Distrust” (October 17-18, WSJ), the answer is none of the above. The answer lies in an anemic American economy, which has expanded at only a 1.7% rate since 2000 compared to 3.7% in the previous post World War II era. In short, it’s the economy, stupid!

The result? No wage increases for the middle class, 94 million Americans not working, 64% of Americans not participating in work force, high poverty rates, unaffordable health premiums, a record national debt, loss of faith in government and other U.S, institutions, dismissal of experts and politicians, and the sense among over 60% of Americans that the country is headed in the wrong direction.

The solution? It is neither Republican nor Democrat. It is resumption of the 3.7% economic growth rate between 1945 and 2000. It is consensus policies and leadership promoting that growth and making health care affordable again. It is a renewal in faith in the future and in the American dream of fairness and opportunity afforded by a healthy economy.

Friday, October 16, 2015

240 Tests on a Drop of Blood. Too Good to be True?

When Theranos, a Pan Alto startup, announced it could perform 240 tests on a single drop of blood with a finger prick and report results within 15 minutes, it sounded revolutionary No more painful drawing of blood from veins. No more expensive tests from national labs. No more endless waiting for results.

Well as it turns out, the single prick single drop of blood as the basis for performing 240 tests may have been too good to be true. Critics, many former Theranos employers, say the tests may not only be inaccurate but most are outsourced to commercial labs rather than being done by an Theranos revolutionary technology known as Edison.

Startup investors, who have poured millions into Theranos, raising its market capitalization value to $9 billion will be disappointed.

The Federal Drug Administration has told Theranos to stop finger tip collections of blood until further notice and further investigation.

As a pathologist, I have always been skeptical of results produced on small or inadequate samples, whether these samples be on needle or aspiration biopsies or on single drops of blood. One needs an adequate sample to make an adequate diagnosis.

Blood-Testing Startup Theranos Halts Most Finger-Prick Collections After FDA Pressure

In most of its tests, the company has stopped collecting blood drawn from the finger in tiny vials, or “nanotainers,” that the Food and Drug Administration considers to be unapproved devices. Theranos says its services are "accurate and reliable."

The Wall Street Journal: Hot Startup Theranos Dials Back Lab Tests At FDA’s Behest

Under pressure from regulators, laboratory firm Theranos Inc. has stopped collecting tiny vials of blood drawn from finger pricks for all but one of its tests, according to a person familiar with the matter, backing away from a method the company has touted as it rose to become one of Silicon Valley’s hottest startups. (Carreyrou, (10/15)

Bloomberg: Theranos Disputes Report, Says Tests Are 'Accurate And Reliable'

Silicon Valley blood-testing startup Theranos Inc., responding to an article in the Wall Street Journal that questioned its technology, said its products and services are "accurate and reliable." The Journal article said that the company overstated the ability of its tests to accurately perform several dozen types of measurements and that Theranos relied on other companies’ equipment for many tests. While the newspaper was working on the story, Theranos removed language from its website that said, "Many of our tests require only a few drops of blood," according to the article. Theranos told the newspaper it made those changes for marketing accuracy. (Mittleman, 10/15)

USA Today: Bloodwork Darling Theranos Under Fire
Theranos, the secretive and revolutionary bloodwork analysis start-up valued at $9 billion, is under fire from a Wall Street Journal report that anonymously quotes former employees who question the efficacy and accuracy of the company's proprietary hardware. The heart of the allegations charge that of the 240 different tests Theranos offers consumers, only 15 are conducted on a machine called Edison while the rest are being outsourced to machines that are similar to those used by more traditional labs such as LabCorp and Quest Diagnostics. (della Cava, 10/15)

Thursday, October 15, 2015

The Unholy Alliance- Trump and the Media

An Unholy Alliance is an alliance that’s unnatural, unusual, unanticipated, detestable, and undesirable between two natural enemies and seemingly antagonistic parties.

Such is the alliance between Donald Trump and the media.
Trump dislikes the media. He says its practitioners are “unfair.” The media distrusts Trump, calling him a “bombastic clown” who is not serious about becoming president.

Yet Trump depends on the media for exposure. And the media depends on Trump for higher ratings. It’s a partnership forged in Hell or Heaven, depending on one's point of view.

In the last several weeks, Trump has been on the covers of People Magazine, Rolling Stone, The Hollywood Reporter, Time Magazine, He has been featured on prime time TV programs, including 60 Minutes. Saturday Night Live will devote a full hour to him this weekend. He has been the subject of 18.6 million tweets compared to 5.67 tweets for Hillary.

Trump’s says, “Think of it. I’ve spent the least, and I’m in first place a lot.” “Nobody’s bigger than me. Nobody’s better than me. I’m a rating machine.” “I’m everywhere, all of the time.” He's a legend in his mind, and the minds of everybody else. Think of it. He might just be on the path for the Presidency.

Matt Viser writing in the October 15 Boston Globe, capture the essence of what’s happening with the title of his article “Trump has found his running mate: the Media.” The media can’t help itself. It loves a good story and high ratings more than it detests Trump. And Trump loves exposure more than he distrusts his detractors and philosophical opponents, when they are saving him money and advancing his campaign. An ego is a terrible thing to waste.

Democratic Debate – Ka-ching, Ka-Ching, Ka-Ching

In other words, every time somebody gave something away, whatever it may have been -- free health care, free education -- the other one would stand up and, 'We'll give you at home, this -- and we'll give you' -- I'm saying to myself, ka-ching, ka-ching, ka-ching, because that means the money is just going out the door, and you know, we're a country that owes, we have a debt right now of $19 trillion.

Donald Trump, Morning Joe, October 14, 2015

The returns are on last night’s Democrat debate are in - Hillary Clinton had a big night and did what she had to do to stay number one; Joe Biden suffered a setback and may not enter race; Bernie Sanders gave Hillary a gift by downplaying those “damn emails,”; and critics are asking: how on earth are we going to pay for all that “free stuff” – Social Security, Medicare-for-all, free college educations, and other entitlements.

The answer, ala Hillary Clinton, is being a “progressive” with a purpose, the nature of which she did not specify. Her response translates into moving to the left - raising taxes on the rich, expanding the social safety net, erasing income differences between the top 1% and the rest of us, redistributing income from individuals to the collective population, and saving money by avoiding foreign entanglements .

Bernie Sanders said we ought to be more like Denmark, Norway, and Sweden. The total taxes of these countries compared to the GDP are: Denmark 49.0%, Norway, 43.6%, Sweden 25.8%, and United States 26.0%.

Hillary responded that we are not Denmark. Indeed, we are not, if you compare our tax rates to Denmark
Corporate tax rate - Denmark 23.5%, U.S. 35.0%
Pay roll tax rate – Denmark 8.0%, U.S, 15.3%
VAT Tax – Denmark 25.0%, U.S. 0%
Income Tax Rates, Denmark, minimum 29.7%, maximum 47.8%
U.S. 59.9% , Federal and state, with no federal income tax on the bottom 50% of population.

I suppose we could go the way of Denmark by imposing a 25% VAT on every citizen. We could also raise our maximum tax on the top 1% to 50% or 60%, whatever it takes to expand ObamaCare to Medicare-for –all, free college and to expand that social safety net to more “free stuff” for more people.

But Ka-ching, Ka-Ching, Ka-Ching. Given our $18.5 trillion national debt and our runaway entitlement programs, the main contributors to the debt, how are we going to pay for it all? There simply aren’t enough rich people to go around. The middleclass will have to shoulder most of the burden.

Maybe we could start by reducing our corporate tax rate, the highest in the world, to stimulate our economy and to bring jobs and $2 trillion back to America. And maybe we ought to just slap a 25% VAT onto everybody, so we can mimic socialized countries.

Tuesday, October 13, 2015

ObamaCare Bushwacked, Well, Sort Of

Jeb Bush is presenting his plan to New Hampshire voters to repeal and replace ObamaCare while keeping 2 of its provisions - guaranteeing coverage for those with pre-existing conditions and allowing young adults under 26 to stay on their parents’ plans.

The Buag plan “promotes innovation,” “lowers cost,” and “returns power to states,” by, among other things, by giving more tax credits, putting a catastrophic lid on health costs, expanding Health Saving Accounts limits to $6550 for individuals, allowing small businesses to contribute more tax-free benefits to workers, permitting workers to choose lower priced plans with fewer benefits rather than maintaining the present laws which calls for 10 essential benefits for all plans.

Bush would leave states in charge of overseeing a “transition plan” for covering 17 million people who now get coverage under the health law. States would also be responsible for crafting plans to cover those with pre-existing conditions . He would give states the option of adopting more flexible plans to cover those in their states on Medicaid. Finally, he would cap benefits that employers get for providing health insurance for workers.

the Bush plan will play well with voters is unknown. Bush tends to be more thoughtful than most candidates in presenting details for reforming and replacing ObamaCare. Most voters say they want ObamaCare improved but not repealed. Hillary Clinton supports health plans with high deductibles tha consumers must pay before benefits kick in. Bernie Sanders favors a Medicare-for-all plan, the costs of which would run up to $15 trillion over the next decade.

To date, Jeb Bush has lagged badly in the polls. His health care proposals, while thoughtful and credible, so far have not galvanized voters, even those 175 million Americans enrolled in employer-sponsored health plans.

One problem, according to J Bush, is that “you can’t fix everything that was broken in the first place

A second problem is that health plan details get lost in the technical and jargon underbrush, and you can’t cut through the underbrush in one whack, when 17 million people are protected by the underbrush.

A third problem, such as what to do about the 40% levee on “Cadillac “ health plans whose value exceeds $12,500 for individual and $27,500 for families doesn’t kick in until 2018, an infinity in politics, and the 2016 election could change everything, and is unlikely to raise Bush in the polls in Republican primary state elections.

Monday, October 12, 2015

Political Wordplay: Sander’s “Lamebrain” and Obama’s “Blamebrain”

I enjoy word play. For God’s and fun’s sake, we need a little comic relief from this world of half-brains. In the first GOP debate, Doctor Ben Carson remarked that he was the only candidate to take out half a brain. No longer, half brains are at work.

Media Lamebrains

In the October 11 Politico Magazine, Jack Shafer came up with this inspired article title: “Bernie Sanders vs. the Lamebrain Media.” Shafer describes Sander’s criticism of the media for failure to comment on or question his cherished Socialistic agenda for the people, by the people, and for the people.

Sanders take umbrage and expresses outrage at the lamebrain’s media failure to focus on these views.

• Pro-big government

• Pro-labor and pro-union

• Anti-Wallstreet and big banks and hedge funds managers

• Anti-business and anti-corporate profit

• Anti- income differentials

• Anti-poverty

• Anti- 1%

• Pro-free education and welfare benefits

• Pro-Medicare for all

• Pro-high taxes on rich

• Pro-women’s rights

• Pro-free abortion

• Pro-foreign policy withdrawal

• Anti-middle class woes.

Ergo, ipsi-facto, therefore, consequently, inevitably, and axiomatically, the media are lamebrains. Sanders has now extended his lamebrain list to include the “corporate media,” which, he says, “ trivializes “ the major issues that beset humankind” in favor of “underarm spray deodorants, automobiles, beer, cat food, politics, and whatever,” to make a profit to stay in business and grow rather than tending to what and for what humankind needs and bleeds.

Obama “Blamebrain” Game

Then there is the “Blamebrain game,” are practiced and perfected by President Obama. This game was on full display on the October interview on 60 minute in a Steve Kroft interview. In the interview, he shows his disdain for critis and shifts the blame to any one who downplays his quest for high-minded moral high ground, as if critics had half a brain and not an ounce of compassion. Everybody, it seems, ought to know the issues facing the world are not the 250,000 killed in Syria and the 4 million fleeing that embattled country, but climate change and world united against a nuclear Iran. Obama says “my definition of leadership would leading on climate change and mobilizing the entire world community to make sure Iran doesn’t have a nuclear weapon.” Never mind that Israel, our Mideast allies, and the majority of the U.S. Congress disagree by believing that lifting sanctions will speed the race to a nuclear weapon. It is “they’, not he, who are to blame. “They,” mostly Republicans, Obama says without evidence to the contrary, want to send another 100,000 to 200,000 boots on the ground into Syria and back into Iraq, and “somehow we are going to be not just the police, but the governors of the region.” This is Obama’s familiar strawman argument, that his critics have no alternative but war and troops on the ground. To be lamebrained and blamebrained require only half a brain . To be constructive and serious takes whole brain thinking.

Sunday, October 11, 2015

The Money-Go Round and the Upcoming Democratic Debate

When they say it’s the principle, and not the money, it’s the money.


This week Democrats will go toe-to-toe and face-to-face in the first Democratic presidential debate. Most eyes and ears will be on Hillary Clinton and Bernie.

Will their debate be a love fest on Democratic values attacking big money as personified by the GOP? Will it be a contest on how far left each other will go away from capitalism and towards socialism? Will it be about how much bigger a role government should play in improving the health system? Will it be irrelevant because Joe Biden has not entered the race?

Most polls show Bernie Sanders is gaining ground on Hillary Clinton. Sander’s message resonates around money. In his stump speech, he repeatedly traces the ills and injustices of America to greedy hedge fund managers, corrupt corporate energy and financial titans, and establishment politicians in bed with big money interests and the avaricious 1%.

Among other things, Sander's says we need a revolution – to take America back for the people, by the people, and of the people by spending $15 trillion for Medicare-for-all.

For the health system, Sanders and Clinton solution will be that bigger government is the answer.

In weighing debate proposals, keep three things in mind.
One, Americans increasingly distrust government.

In their minds and in the words of Ronald Reagan, “Government is not the answer, it is the problem.”

Two, easing America’s health problems, including shorter life expectancies and higher infant mortality rates, compared to other nation’s are not due to not enough money being spent on health care(we spend twice what any other nation spends) but to our culture.
On the second point, a nation’s health system accounts for only about 15% of a nation’s health status, life style makes for 30% and other factors – poverty, inferior education, income differences, and lack of social cohesion make up the other 55%(Satcher, D., and Pamies, R. (2006), Multicultural Medicine and Health Differences, McGraw Hill). Therefore, any reform of our system is unlikely to increase the nation’s overall health status. In other words, a nation’s culture and its life style habits determines its health .

Take the problem of obesity. The U.S. leads the world in adult obesity rates at 35.3%. The rate among 34 advanced countries is 18%, and in Asia is 2 to 4%. Obesity leads to chronic diseases - diabetes, hypertension, cardiovascular disease.

Now it may be that U.S. prosperity leads to overeating and obesity. It may also be that poverty leads to overeating on cheap health foods, and lack of quality food stores in poor inner cities and rural areas. It may be lack of good nutrition knowledge among all classes of Americans. Obesity is a complicated multi-causal issue.

Where the money is coming from to finance political campaigns is certain to be part of the Democratic debates. Democrats are likely to argue that money coming from 158 wealthy mostly Republican families is bad for the country because it pares regulations, limits income taxes, capital gains, and inheritances.

This week's debaters will ignore the realities that most of the cause financing Democrats comes from unions, wealthy liberals like George Soros, and Hollywood moguls like Steven Spielberg and Jeffrey Katzenberg.

Conservatives will counter by saying economic growth, not government regulation and heavy taxation, is the surest road to lifting the poor and middleclass out of poverty.

Whichever side prevails, there is no doubt that there is never enough resources or money to go around to finance top of the line health care for everyone or for that matter, to change culture to your way of thinking.

Saturday, October 10, 2015

Obama Doctrine Explained

How to explain Obama doctrine is the problem. Niall Ferguson explains it this way (“The Real Obama Doctrine,” WSJ, October 9).
Ferguson explains the Obama doctrine is based on:

1) The cautious mindset of a skillful and imminently successful politician who knows how to make promises and who seeks to avoid confrontation with domestic and foreign adversaries at any personal price, including American prestige and power.

2) A covey of inner-circle cautious Obama-protective lawyers advising the president how to implement minimal risk policies , how to outflank Congressional opposition with executive actions, memoranda, waivers, and delays; and how to use top-down government regulations to subdue and control businesses , who may generate wealth but produce social inequality.

3) The desire to differ as much as possible from his predecessor, i.e., to withdraw from the Middle East rather than engage with troops on the ground or arm one’s allies, make peace and concessions and punish economically through sanctions and charm rather than challenging militarily.

I have spent the last 7 years trying to figure out what the Obama doctrine is.
I have puzzled why majorities in the House and Senate and dominance of state governorships and legislatures, paradoxically, do not produce new “hope and change” to replace the old failed “hope and change.” The people elect their Congressional representatives, and government is supposed to represent the people.
I have wondered why doctors are not part of the reform equation, and why, despite the health law’s continued public and Congress disapproval , often by double-digit margins, there has been no repeal or retraction of individual and employer mandates, medical device and Cadillac taxes, the Independent Payment Board, and no rejection of autoenrollment requirement that all small businesses enroll full-time workers into ObamaCare plans.

On other national policy issues, I have pondered why there has been no pro-growth agenda, a path to prosperity; no corporate tax reform designed to cut rates from 35% to 15%, a move that would bring back corporations and jobs back to America; and full cash deductions for businesses who invest in the future.

The answer is procedural – political gridlock because of threatened Presidential vetoes requiring 67 votes to override. 60 votes required in the Senate to pass any major piece of legislation, and filibusters that block any bill from coming up for a vote.

Republicans say they can get around these problems through a political process known as reconciliation, which is immune to vetoes and which requires only 51 votes for passage. But for reasons I do not understand, reconciliation never seems to happen. Perhaps it is because of disarray and ideological splits among GOP House members. I suppose another reason may be that a cautious, careful, leader, to preserve his reputation and ideological standing, never seizes the initiative or seeks compromise to bring about reform.

Friday, October 9, 2015

On Not Being a Surgical Statistic

When I used to motor the 400 miles from my home in Tennessee to Duke Medical School, my mother would say to me,”Richard, don’t be a statistic.” She was referring to road death statistics.

A single death is a tragedy, multiple deaths are a statistic. This is particularly true with surgical deaths. Surgery is designed to save lives, not end in death.

But how to avoid surgical deaths?

One answer may lie in statistics, or the law of large numbers. This law, according to my dictionary, is “The theorem in probability theory that the number of successes increases as the number of experiments increases and approximates the probability that the number of experiments for a large number of experiments.”

So much for statistical jargon. Translated this means the more surgeries you perform the better the results are likely to be.
This, in turn, means that big hospitals what perform large numbers of surgical procedures are the place to go, especially is have a condition that requires complicated surgery.

I thought of large numbers theorem, when I read two articles in the October 8 New England Journal of Medicine.

The first, “Scoring No Goal – Further Advances in Transparency,’ by Lisa Rosenbaum , MD, medical correspondent for the Journal, explains that the surgical score developed by ProPublica, an organization devoted to identifying quality of care as delivered by individual surgeons, may not achieve its goal . ProPublica studied outcomes of 17,000 surgeons performing 8 elective procedures, and concluded the higher the volume of procedures by an individual surgeon, the better the results. It assumed such a scorecard would root out doctors who performed too few operations to be good at them. The author concludes such a scorecard is deeply flawed and can destroy the careers and reputations of excellent surgeons. Besides, the data isn’t statistically meaningful doesn’t capture the expertise of individual surgeons who are not in the position to cherry-pick low risk candidate to make their statistics look good.

The second, “Pledge to Eliminate Low-Volume Surgery,” by David Urbach, MD, of the University of Toronto, describes the campaign by leaders of 3 large hospital systems – Dartmouth and Hitchcock Medical Center, the Johns Hopkins, and University of Michigan Health Center. The campaign is called “Take the Volume Pledge” and is dedicated to the proposition that complicated surgeries should be referred to high volume institutions if surgeons have not performed the requisite number of operations to be competent at them. The volumes recommended are” bariatric surgery 20 to 40, esophagus 5 to 20, lung 20 to 40, pancreas 5 to 20, rectum 5 to 20, carotid stents 5 to 10, complex aortic surgeries 7 to 20, mitral valve repair 10 to 20, and hip and knee replacements, 20 to 50. The idea is to redirect complex procedures to high volume hospitals. The author comments that most surgeries will continue to be done as smaller hospitals, and a more important goal should be to improve structures and processes at these small hospitals.

Volume alone will not improve surgical results, and statistical results alone can’t be used to judge surgical quality. Bigger is not necessarily better in all cases. Besides, not surgeon wants to be considered a mere statistic. But no patient wants to become a statistic, and for certain surgical problem, the patient may fare better at large institutions who have wide experience with complicated problems.

A Chat with a Family Practice Doctor with A Less Complicated State of Mind

You must lie down with the daisies and discourse in novel phrases of your less complicated state of mind.

The meaning doesn’t matter. It’s only chatter of a transcendental kind.

Sir William Gilbert (1836-1911), Patience

I like to chat with seasoned doctors with a less complicated state of mind.

Today I discoursed with Donald Copeland, MD, who has practiced and taught in various family practice settings – solo, group, and academe – in North Carolina for over 50 years.

Dr. Copeland, a Southerner to the core, surprised me by declaring he was solidly behind Ben Carson, MD, the black neurosurgeon who is running for president.

Carson, Copeland maintains, has been there and done that and know health care inside-out and upside-down from a physician’s point of view.

Doctor Carson has an uncomplicated state of mind where national health care ought to go. At birth, give each person a birth certificate, an electronic medical record, and a health savings or health security record .

The health security record, a concept Copeland prefers, would allow every person to pay for care out of their own account using pre-tax money, and save for retirement. The term “Health Security Account” would tie in with the idea of Social Security with which most people are familiar.

Health Security Accounts, as originally proposed in 2003, would have a high deductible ($500 for individuals and $1000 for families) and would allow employers to contribute $2500 a year to worker’s accounts. It has been shown to lower premiums and save employers money.

When paying money out of their own accounts, consumers are more disciplined and sensitive to price. This cost-saving phenomenon is attributed to having “skin in the game.”

Obama acolytes are critical of HSAs because employers and workers are in control . HSAs, they contend, penalize workers with chronic disease.

Don also surprised me by saying that he thought the transition from the ICD-9 to ICD-10 coding system would be relatively smooth and painless. Just go to Google, he instructed me, and type in type in the clinical problem. For example, a patient has migraine, type in the Google search box ICD-10 Migraine, and the various codes for migraine will pop up. It gets more complicated with common conditions like diabetes, hypertension, and coronary artery disease, which have dozens of codes for the illness itself and its various causes and complications, but with a little practice, coding for common diseases is doable.

Dr. Copeland is a big fan of direct cash medicine, which is uncomplicated and avoids complicated regulations, coding, and asking for permission to do this or that. You can treat almost any patient, even if they are on Medicaid or Medicare, and you can spend more time with patients and less time with paperwork. For cash transactions, you do not need to be a concierge physician, although that is one way to go.

Finally, Don dwelled on problems stemming for hospitals employing and controlling physicians practice patterns. The problems include loss of autonomy, doubling of costs of patient visits, and compulsory referrals to hospital specialty units, where most hospital profits are.
It was a pleasure to chat with Dr. Copeland about such transcendental matters. Sometimes a chat with a clear-minded friend has a way of simplifying and clarifying complicated matters.
P.S. Here are 3 previous blogs I have written about Health Savings Accounts.

1. October 9, 2009, Interview with Don Copeland about Organization Overkill

2. July 17, 2011, Health Savings Accounts : A Return to the Obvious

3, February 13, 2013, Health Savings Accounts Tied to High Deductible Plans - The Essence of the Best in Consumer-Driven Health Care

Thursday, October 8, 2015

Wishful Thinking – Putin, Trump, and Medicare Premiums

Wishful thinking is thinking based on the belief that you will be pleased with what you imagine will happen rather than what is really happening based on evidence, rationality, and reality.

We are all victims of this misplaced optimism.

Examples are:

1) Putin’s aggressive actions in the Middle East. He can’t possibly mean what he says or does – confronting Obama and telling U.S. to get out of way, putting troops and military equipment in Syria to prop up that horrendous dictator, President Assad, the cause of 250,000 deaths and 4 million immigrants. Surely Putin bluffs. Surely with Russia'sfaltering economy and NATO’s condemnation, Putin knows he is stumbling into another Mid Eastern quagmire. Surely Putin will have second thoughts.

2) The media’s and the Republican establishments’ oft-quoted opinion that Trump’s presidential bid will surely end with a bombastic and dramatic collapse when people regain their senses. Given his narcissistic, assertive, and against-the-grain proposal he will surely self-destructive. But what will happen if Trump continues to lead in all the primaries and gathers enough delegates to win the nomination . What if Hillary withdraws from the race due to an FBI indictment or due to losses in New Hampshire, Iowa, and South Carolina? What if Trump trumps Sanders, Biden, and Maloney? What then?

3) And what about those projected monthly premium spikes from $104.90 to $159.30 for individuals and $318.60 for a family? Surely that can’t be. Surely Democrats and Republicans alike will move to protect Medicare recipients, a vital voting bloc, against such 52% premium increases they can ill afford. Up until now, Medicare enrollees have been a protected species, insulated against rising health costs. Look at the bright side. Seven of ten Medicare recipients will continue to pay $104.50. Only 30%, among them new Medicare enrollees, those with incomes over $85.000 per individual and $170,000 per family, will have to cough up for premium increases. Surely goodness, mercy, political survival, and social justice will prevail over the health costs of longer lives, rising costs of prescriptions, and higher health costs for outpatient, preventive care, durable medical equipment, and ambulance rides. Surely we will get what we wish for.

Wednesday, October 7, 2015

Obama Orwellian Doctrine

War is peace. Freedom is slavery. Ignorance is strength.

George Orwell (1903-1950), 1984

My way is highway.

Blame is transferable.

Failure is success.

Freedom is regulation.

Apology is Americana.

Tuition is unfair.

Taxation is redistribution.

Wealth is unjust.

Debt is justice.

Capitalism is exploitation.

Socialism is OPM (see below)

Taxation is freedom.

Ego is id.

Compromise is veto.

Reset is sunset.

Rhetoric is action.

Minority is majority.

Right is wrong.

Left is right.

Bottom-up is top-down.

Division is agreement.

Victory is quagmire.

Behind is ahead.

Stagnation is progress.

Recession is prosperity.

Indecision is decisiveness.

Retreat is advance.

Vacuum is fullfillment.

Abstract is concrete.

Delusion is reality.

Disapproval is approval.

OPM - Other Peoples' Money

Physicians and Freedom to Practice

Among physicians, a widespread belief persists that ObamaCare restricts their freedom to practice.
For more on this belief,

One, view the video featuring Michael D. Strickland, MD. Committee chair of United Physicans And Surgeons Association. The video address bears the title, “If We Are Not Free, We Are Not American,: and be obtained by clicking on

Two, visit, for easy and free viewing of45+ Speakers 30+ Hours of Content 30+ Medical and Other Organizations and Key Ideas, Resources and Solutions, and their links,to regain control of our own profession as physicians, and our own healthcare, as patients.

Three, read the following article from today’s Kaiser Health News

Whistleblower Doctor Warns About Hospitals Hiring Physicians

By Jay Hancock October 7, 2015

There is a good chance that your once-independent doctor is now employed by a hospital. Dr. Michael Reilly, a Fort Lauderdale, Fla., orthopedic surgeon, does not believe this is good for physicians, patients or society.

For years he watched Broward Health, a nonprofit Florida hospital system, hire community doctors, pay them millions and minutely track the revenue they generated from admissions, procedures and tests.

“We are making money off these guys,” Broward Health’s CEO told Reilly, according to a federal whistleblower lawsuit filed against the system by Reilly and the U.S. Justice Department.

Last month Broward Health agreed to pay $70 million to settle allegations that it engaged in “improper financial relationships” with doctors under laws prohibiting kickbacks in return for patient referrals.

Giving doctors incentives to generate medical revenue is widely deemed unethical because it tempts them to order unneeded treatment or send patients to lower-quality providers. Physicians with a financial interest in a medical facility tend to prescribe more procedures than those who don’t, studies show.

Lawmakers have repeatedly tried to ban or limit such behavior at least since the 1970s. What happened at Broward Health and numerous other hospitals suggests they haven’t succeeded. Now that hospitals everywhere have gone on their own physician acquisition sprees, Reilly worries the same thing will keep occurring.

“We have got to get hospitals out of the business of hiring doctors,” he said in an interview. “It’s potentially detrimental to the patient, and it’s terrible for health care.”

Hospitals, burdened with large, fixed costs and anxious to ensure patient referrals and revenue in a changing industry, are doing the opposite.

“Doc binge buying rolls on” was the June headline in Modern Healthcare, an industry magazine. A third of doctors now work directly for hospitals or for practices with at least partial hospital ownership, estimates the American Medical Association.

Broward Health is a taxpayer-supported system with five hospitals and a publicly appointed board.

More than a decade ago it launched an expansion drive that included hiring previously independent physicians and paying CEO Frank Nask and other executives large bonuses if the institution increased revenue and the bottom line.

It agreed to hire orthopedists and cardiologists for more than $1 million a year — far more than average for such specialties. It paid orthopedic surgeon Dr. Erol Yoldas, also team doctor for the Florida Marlins baseball team, nearly $1.6 million in 2009.

Reilly rejected an employment deal with Broward Health after his lawyer told him it was illegal, he said. His whistleblower complaint, originally filed in 2010, was unsealed last month.

The system carefully tracked the return on its investment in the other doctors, recording the value of referrals and pressuring them to increase volume if they lagged, the lawsuit said.

Although Broward Health paid an enormous sum to settle allegations of wrongdoing, it did not admit those allegations, which is typical in such cases. CEO Nask retired last year. Nobody in the system has been charged with criminal wrongdoing.

Yoldas did not respond to requests for interviews. Nask did not respond to messages left at a number listed in his name.

Thanks to an uncoordinated system that pays for procedures instead of keeping people healthy, 30 percent of U.S. health care dollars spent in 2009 were wasted on unnecessary treatment, excessive administrative costs or fraud, calculates the authoritative Institute of Medicine.

Reilly responds carefully when asked whether doctors employed by Broward Health were ordering unneeded procedures. He’s concerned about possibly getting sued by a system with “deep coffers,” he said.

“I wasn’t allowed to review medical records,” he said. But when he sometimes saw patients who had been recommended for surgery by those doctors, he added, “I never agreed with the previous opinions.”

Reilly preferred working as an independent — on staff at hospitals but not employed by them. He didn’t feel compelled to generate revenue by ordering procedures, he said.

If Broward Health pushed a brand of artificial knee he felt was wrong for a patient, he could do the operation elsewhere. If he had concerns about the system’s radiology department — as some doctors did, according to the lawsuit — he could refer people to a different facility.

Fewer and fewer doctors have the same freedom, Reilly worries.

Some believe the AMA underestimates the portion of physicians employed by hospitals. Hospitals have been especially keen to hire primary-care doctors, the specialty that generated the highest referral profits for Broward Health, according to the lawsuit.

Not only does hospital employment “dramatically” boost chances that a doctor will refer to that hospital, but it also raises odds that patients will end up at a higher-cost, lower-quality facility, finds a recent study from Stanford University researchers. Like Broward Health CEO Nask, many hospital bosses get bonuses for increasing revenue and profits.

In the last two years the Justice Department has settled more than a dozen cases under the Stark law, which prohibits improper financial inducements to doctors in return for patient referrals.

“My wish would be that the hospital-physician employee contract would go away,” said Reilly, now retired and entitled to $12 million of the whistleblower settlement. “You could pick just about any hospital, and I will tell you there is a component where that contract is driven by referrals.”

He is skeptical that accountable care organizations — collaborative groups of doctors and hospitals that are supposed to focus on keeping patients healthy and not on maximizing revenue — will change the dynamic.

Hospital hiring of physicians “not only fosters an environment to motivate physician referrals, but also blunts physician innovation, discovery and ingenuity,” he said.

What should patients do? Ask their doctor who he or she works for, Reilly added. If the doctor is employed by the hospital and recommends surgery or some other expensive treatment, he said, “research the indications for the procedure” and “consider a second opinion” from an independent practitioner.

IBM’s Eight Page "Ad-Mission"

An “Ad-Mission” is an advertisement with a mission.

When I opened the lead section of today’s Wall Street Journal, I could hardly believe my eyes. Tucked inside was an eight page IBM advertisement welcoming the Cognitive Era – a new era of technology, a new era of business, a new era of thinking.

This ad-mission extends and celebrates IBM’s basic slogan – Think. What the ad is saying is that you can’t think without computers, and with computers you outthink your competitors.

Page 1 is saying: It’s elementary, my Dear Watson. Watson is IBM’s thinking computer. Watson is the name of IBM’s founder. Watson is the sidekick of Sherlock Holmes, Doctor Watson. If you’re an ad man, it all fits.

Page 2 proclaims that 3 historic shifts have created businesses that can only think with the aid of Cognitive Computers. The shifts are 1: A World Awash in Data. 2: A World Reinvented in Code. 3 The Advent of Cognitive Computing. “Cognitive” is the new word for “Thinking.” And in business, you need to have Cognitive Engagement, Cognitive Products and Services, and Cognitive Processes and Operations, Cognitive Expertise, and Cognitive Exploration and Discovery.

Page 3- Advances the proposition that IBM Watson understand reasons and learns, and in a sense, think. Watson has 28 cloud-based applications , everything from soup to nuts.

Page 4 - Watson can analyze meaning and context of data in clinical notes and reports, combine data from patient’s files with clinical expertise and research,, and identify best treatment plans.

Page 5 - Watson can identify “hot” products and combine predictive with demographic data to reduce out-of-stock situations,

Page 6- Watson can outthink sports executives on who to draft and who to trans, can outthink energy experts on what alternative energies to use, can outthink those who file fraudulent insurance claims, and can outthink educators by helping tem spot students at risk of dropping out.

Page 7 - Watson can help executive by identifying risky and profitable merger and acquisition deals.

Page 8 - Watson can make businesses ready to design cognitive strategies, make analytics more useful. Help businesses move to the cloud, build a cognitive infrastructure , and make data more secure.

The mission described in all of these patients is designed to help businesses outthink and outperform ordinary human and to make businesses extraordinarily successful.

IBM’s cognitive outthinking human campaign should be considered in the context of IBM’s weak stock market performance with 13 straight quarters of decline in quarterly revenues and sharp drops in market caps as IBM invests heavily in cloud computing and data analytic technology to boost its declining personal computer business.

IBM’s future is in the cloud, but it depends on numbers on the ground

Tuesday, October 6, 2015

Who Is the Silent Majority?

The Great Silent Majority.

Richard Nixon (1913-1994). Speech. 1969

“Silent majority” is an unspecific large majority in a group or a country who do not express their opinion publicly.

“Silent majority” is a term made famous in 1969 by President Richard Nixon when he asked for public support for ending the Vietnam War.

“Silent majority” is perceived by progressives to be a not-so-subtle reference to conservative white people - evangelicals, Tea Party members, and Republicans - particularly in the South and Midwest – who disagree with liberal policies but who are either too stupid or too inarticulate to say so.

"Silent majority" is thought of by conservatives as people on their side of the political ledger who have
make up their base but who not gone to the polls in sufficient numbers to win national Presidential elections.

“Silent majority” is a term frequently evoked by Donald Trump as a group of people who want “to make America great again.” In a recent tweet prior to a gathering of 20,000 people in Alabama Trump tweeted “ We’re going to have a wild time in Alabama tonight! Finally, the silent majority is back.”

Or does the “silent majority” consist of Americans, 61% of whom say the country is headed in the wrong direction, because of a sluggish economy, lack of quality jobs, decline in middle class incomes, an unpopular health law, and disarray, defeats, and lack of strategy in U.S. foreign policy.

Members of the “silent majority” may be most concentrated in the rural American South where poverty , poor education , access to quality health care, and joblessness is most evident and pervasive.

In the rural South, Paul Theroux, comments in his book The Deep South, “the whites feel like a despised minority – different, defeated, misunderstood, meddled with, pushed around, cheated.”

It is in the South, where the most manufacturing jobs have been shipped to China, Mexico, and India. In the South, people feel that rich U.S. capitalists don’t care for them, and that the U.S. government spends more abroad than to destitute Southerners and adds to joblessness through EPA rules that close coal mines and drive up energy costs. And in the South, people feel paranoid and prejudiced against because of their belief in traditional moral values, marriage between man and women, fundamental Christian religions, heterosexual relationships rather than free-flowing secularism where opposite values prevail

Finally, many Southerners feel have been outvoted, outmaneuvered, put-propagandized, and out-organized .
It is to these Southerners and others of like believers, which may include the majority in the Middle Class, that Donald Trump has directed his tweets and his speeches about bringing workers back, sending illegal immigrants, back, about striking winning “deals” with foreign governments, and touting the Bible as his favorite book, with the Art of the Deal as a close second, not necessarily in that order.

Monday, October 5, 2015

Health Care Overuse

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

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

The obvious, which is not so obvious, and the simple, which is not so simple.

The Practical Cogitator, 1959

This day I ran across a Kaiser Health News article “Wellness Programs: Early Alarms for Workers’ Health or a Recipe for Overtesting.”

Its message is obvious. If you do enough testing for health: you will find something wrong, and you will do more tests to confirm what is wrong. One test leads to another. Little tests lead to bigger tests. One abnormal test results in other tests that were not usually planned.

If you do many tests based on metrics, you will either generate false positives or true positives.

Most test results are based on a mean value, plus or minus 2 standard deviations, a normal range that generally encompass 67% of normal results but with inevitable outliers. This means any metric will include normal results but also abnormals outside the normal range. Borderline abnormals may set off alarms that a worker has health problems that may eventuate in diseases later.

Take the problem known as “metabolic syndrome” – a common problem that may be a precursor to heart disease, stroke, or other cardiovascular disease. The metabolic syndrome is defined as: increased waist size, high triglycerides, low HDL cholesterol, high blood pressure, and elevated blood glucose.

These are relatively common findings in any population of workers. Who among us does not know someone with a belly or expanded waist? Elevated triglycerides are common after even modest ingestion of alcohol or a recent carbohydrate rich meal. One third of Americans have high blood pressure, and one of five are either prediabetic or diabetic.

If tests for these conditions are either “free” or mandated by an employer, it is obvious some of these tests will be abnormal, and may lead to other obvious things- a weight reduction regimen, a full lipid panel, blood pressure medications, or a glucose tolerance test. These follow-up tests are necessary to confirm a diagnosis, or to set a preventive program in motion. Workers may regard such testing as an invasion of their privacy. The testing may result in higher costs.

Screening for wellness and for early signs of disease has its problems. It may result in health care overuse syndromes. When HMOs were introduced, routine visits to the doctor and routine testing were encouraged. When ObamaCare health exchanges took hold and the uninsured were subsidized, 10 million people flocked to exchange plans- an insurers found that many of those subsidized were sicker than thought and cost $1000 more than projected, with heavy losses for insurers with losses with insurers being bailed out by government and middle class taxpayers. When new technologies are introduced - CT scans, angioplasties, joint replacements, insulin pumps, lipid lowering statins or other drugs – they are invariably used to excess.

Offer a new technology, and it will be used. Seek an abnormal result, and it shall be found.