The Washington Post,  and the Vast Left-Wing Conspiracy as Reflected in Titles of Its February 29 Edition

1.       “GOP Divisions over Trump Presidency Grow”

2.       “Trump’s Rhetoric on Muslims Plays Well with Fans, but Horrifies Others”

3.      “Spray Tans, Pants Wetting, and Little Hands: The GOP Race Goes in the Gutter”

4.      "Trump’s Feigned Ignorance about the KKK Raises Disturbing Questions”

5.      “These New Trump Numbers Should Terrify Republicans”

6.      “The Trump Albatross”

Meanwhile,  TV is giving Trump more air time than all other candidates combined.

Moral?  One media's elite is another media's beat.

Con Artist – Con and Pro

Rubio says Trump is a con artist.

Trump says he, Trump, is  the smartest.

My dictionary says that a con,

Is to trick, deceive, or serve as a pawn.

The polar opposite of con is pro.

A pro artist tells you what he is for,

What lies at the heart of his basic core.

It remains for the public  to decide,

To pick sides, whether con or pro to deride.

March 1 we shall see on Super Tuesday,

Who is making them most voter headway.

Ugly Realities of High Drug Costs

To witness ugly realities of protecting patients against high health care costs,  look no further than the current squabble over controlling high drug prices.

Look no further than the Patient Protection and Affordable Care Act,  wherein the pharmaceutical companies provided substantial support for the Act in exchange for avoiding direct price negotiations with the drug industry.

Look no further than the dire prospects of  reduced innovations by the industry and reduced company investments in new drugs and diminished public access to those drugs.

Look no further than the dilemmas of bringing  high costs of bringing a new drug to market without compromising its safety.

Look no further than the Pfizer  merger deal with Allergan which would move Pfizer’s headquarters to Ireland and save the company $35 billion in taxes on profits of $148 billion earned and stashed  abroad.

Look no further than the U.S. corporate tax rate of 35%, the highest in the industrialized world, which encourages tax inversion moves like  Pfizer and a host of other drug companies.

Look no further than the 10% to 15% across the board increases in drug prices in 2015.

Look no further than the political poundings of Hillary Clinton,  Bernie Sanders, and Donald Trump on drug companies as the villains in the failure of the health law to bring down premium costs.

Look no further than the Fourteenth Amendment of the Constitution which says that no state “shall deny any person within its jurisdiction the equal protection of the laws."

Look no further than Congressional lawmakers “who may have little appetite for direct government negotiation of drug prices.( Rena Conti and Meredith Rosenthal, “Pharmaceutical Policy Reform – Balancing Affordability with Incentives for Innovation,” NEJM, February 25. 2016).

Look no further than the rapid  rise of generic prescriptions, which now make up  81% all prescriptions,  but cut profits of drug firms who raise the price of old and new  brand-name drugs to make drugs to make up for losses.

Look no further than the “rise of the unprotected”,  who are protesting en masse against a government of “ protected people who don’t seem to care much about their unprotected fellow citizens.” (Peggy Noonan, “Trump and the Rise of the Unprotected,” WSJ, February 27-28, 2016).

Look no further than the outrage over the escalating rise of drug  prices and the role of Big Pharma lobbyists, who spent $18.4 million in 2015 to protect the industry. “Public outrage is boiling,” says John Rother, who lead the Campaign for Sustainable Rx  Pricing.  (Robert Pear, “Lobbyist for Drug Makers Threads a Thicket of Outrage,” NYT, February 26, 2015).

The ugly realities?  There is no single, easy, silver-bullet answer to high and escalating drug prices in America.   Economic freedom has a price.

How Would You Like Your Eggs, Sir?

An unhatched egg is to me the greatest challenge in life.

E.B. White (1899-1985), American Essayist

I had a dream last night. I was in a bistro.  This exchange took place.

Waitress:  How you like your eggs, Sir?

Me:   A single egg, please. What are my choices?

Waitress:  It depends on what cook is in.

Me:  Who are the cooks, and what are their specials?

Waitress:  Well, with Rubio, it’s Sunny-Side Up.  With Cruz, it’s Ranchero, Dark-Side Up.  With Clinton, it’s Once-Over-Lightly.  With  Sanders, it’s European-Omelette.   And with Donald Trump,  it’s American Scrambled.

Me:  Who’s in?

Waitress:  At the moment, it looks like Clinton and Trump.

Me:  How long will the Once-Over Lightly  and American Scrambled Take?

Waitress:  I don’t know.   The egg hasn’t hatched yet.

Me:   Do you have a Left-Over Obama-Omelette?

Waitress:  No, it was not selling, and we had to break too many eggs to make it.

What Manner of Man

What manner of man is this Donald Trump,

When on his back Rubio and Cruz jump.

What kind of political genius,

Brings together voters heterogeneous.

What kind of man versed in real estate deals,

Know so much about how the voter feels,

What manner of man to the manor born.

Can upon rivals less well off heap such scorn,

Is it because he is  using his own  dime,

While accusing other rich of high tax crime.

It takes rare mix of social intelligence,

Combined  with blatant  belligerence,

 And pure intuition and impure insults,

To get the desired election results.

Some describe his strategy as chutzpah,

Others  to his knowledge of the bourgeois,

When political  push comes to shove,

Trump understands all of the above.

Voter Anger and Voter Turnout

The GOP debate in Houston was  about  voter anger and turnout.  Donald Trump has capitalized on unprecedented  anger.  He has galvanized turnout  among voters, many of whom have never voted before.  GOP  voter turnout was up 24% in  Iowa,  New Hampshire, and Iowa, while in Iowa and  New Hampshire turnout was down 21%.

In 2009,  Pollster Frank Lutz in his book What Americans Really Want ---Really (Hyperion),  gave this statement to 6400 Americans “I’m mad as hell and I’m not going to take it anymore.”,  and asked them to comment:  72% agree and 28% disagree. 

These numbers haven’t changed during the disappointing  Obama Presidency.  Anger has a mind of its own.   People are mad as hell.  They want change – any change.  Anger propels this change – no  matter how irrational, how lacking in specificity.   People who have never voted before are coming out of the woodwork,  blue collar workers, the poorly educated,  the highly educated,  evangelicals,  the Middle Class detritus, unhappy Democrats.

In Houston shoot-out  GOP debate last night    candidates missed the GOP presidential candidates missed an opportunity,  the chance to talk about  the historic GOP turnout  in the primaries compared to Democrats.   The turnout discrepancy  bodes well for Republicans and could be the basis for a rout in November.

Yet,   turnout and lack of enthusiasm for the Democrat nominees,  wasn’t even mentioned in the debate.   Instead,  we witnessed  a shouting match between Trump,  Rubio, and Cruz.  Rubio and Cruz cancelled each other  out,   assuring Trump will be the nominee.    Kasich performed well,  and I wouldn’t  be surprised if he is Trump’s running mate.

What does Trump get that others miss?  

Trump gets it. People are mad as hell.  They aren’t going to take it anymore. 

They aren’t  going to respond to policy talking points  without action, without moving Congress and the nation  off the dime. 

They ‘re not going to swallow slick rhetoric.  They’ve had enough of ObamaSpeak  and GOP establishment  condescending talk. They want straight talk,   no matter how contradictory or  how marred by shifting positions over the years.

They’re not concerned about policy details.    To them the devil isn’t in the details, e.g, Trump’s tax return, but in cutting taxes for themselves, in the sweep of  Trump's main themes, in Trump’s not being beholden to special interests,  lobbyists, or big money.  

People want to be winners again.  They want a country they can be proud of.    They want optimism, they want opportunity,   and they want America to be great again.

They know instinctively that something is wrong in the Middle East, with the failure to support Israel and face down ISIS.   

They’ll take Trump’s word for it that he will build a wall and deport illegal immigrants.   It’s   not how he will do it but  what he says he will do.

They know something has gone askew with the Middle Class,  with the sluggish economy,  with the unaffordable health premiums and deductibles.   They don’t particularly care about the dearth of details or specifics in Trump’s health plans.  It is good enough for them when he says he will keep ObamaCare’s pre-existing conditions but create competition by making health plans portable across state lines and not letting people die in the streets.   He will take those villainous health plans and pharmaceutical firms to the Trump cleaners.

Have a Super Tuesday on March 1,  and beware the Ides of March on March 15.   Hold onto your seat belts.  It’s going to be a bumpy ride.

Something  Rotten in Bernie Sanders’ Medicare-for-All Plan

Something is rotten in the state of Denmark

Shakespeare,  Hamlet

Bernie Sanders envisions his Medicare –for-All plan  as something akin to what exists in Denmark,  where universal coverage prevails,  where its 5.7 million people are among the happiest in the world,  where there is a high per capital income level, where there is a high level of social equality,  and where the rich pay more than their fair share in income taxes.

In other words, in the eyes of  Bernie Sanders,  Denmark is a state of domestic and health care bliss.  Perhaps that is why, at first blush,  50% of Americans like the idea of a single payer system with no premiums, no co-pays, no out-of-pocket costs.  But the approval rating drops to 24% when Americans know the trade-offs – higher taxes for all, including the middle and lower classes, giving up employer coverage,  and  being subject to more government controls.

For the whole story,  read the following from Kaiser Health News ( Jordan Rau, “Support for Sanders’ Single Payer Plan Drops with Control and Cost Concerns,”  February 25, 2015)

“The poll from the Kaiser Family Foundation found that 50 percent of Americans favored the single-payer idea, but support was highly partisan: seven of 10 Democrats and two in 10 Republicans liked it. (KHN is an editorially independent program of the foundation.) However, only 24 percent of people would like to establish such a plan if given other options, including expanding the existing Affordable Care Act, according to the poll. A majority of Democrats favor the incremental approach rather than creating a universal government plan.”

“Campaign-style attacks on a plan like the one proposed by Sanders could wither its general popularity, the poll found. Support was reduced by nearly half when people were told that a single-payer plan would increase taxes or “give the government too much control over health care.” Support also dropped substantially after people were told a government plan would require eliminating or replacing the existing health care law.”

”Some of those opposed to a single government plan could be swayed by positive arguments, such as it would guarantee all Americans have insurance as a basic right or that the plan would eliminate premiums, copays and other costs borne by employers or individuals. At most, 13 percent were converted to favoring the idea, leaving 30 percent still opposed.”

”The words used to describe a single-payer plan also affected opinions, the poll found. “Medicare-for-all” was the most popular, with 64 percent of Americans responding positively. “Guaranteed universal health coverage” appealed to 57 percent of people. Only 44 percent liked “single-payer health insurance system” and 38 percent liked “socialized medicine.”

“Most Americans think that if guaranteed universal coverage through a single government plan was put into place, uninsured and low-income people would be better off, but there is little consensus among the public about how it would impact their care personally,” the pollsters wrote,"

Bad Data In,  Bad Data Out (BDI, BDO)
It's elementary,  my dear Watson!
Attributed to  Sherlock Holmes
As  I work on my new book,   Noise!! Until the 2016 Election Results Are Known, The  Health Debate Is Mostly Noise, two articles came to my attention:

One,  “The Big Data Future Has Arrived, “(WSJ, February 24) by Michael S. Malone,  a prolific writer on social issues,  in which he argues  powerful computers, ubiquitous sensors,  and the Web will transform our lives by making the connections between  man and machine more personal, productive, and empowering.

Two,  “Will Feeding Watson $3 Billion Worth of Healthcare Data Improve Its Decisions “? by  Ross Koppel, PhD and Frank Meissner, MD in The Health Care Blog, February 24.   Koppel is a senior fellow at the Leonard Davis School of Economics (Wharton) and Meissner is  a cardiologist in El Paso,  Texas.    The two ask whether IBM’s purchase of Truven Health Analytics,  and payer and patient data  at the Cleveland Clinic’s “Explory’s” and Phytel, a software company,  will improve health care. 

Watson,   IBM’s  computer system, is designed by  analyzing health care  data to create artificial intelligence  to supplement  human intelligence to improve health care outcomes.   

The two  authors’ central  questions are:

Will flawed  data from payers, physicians,   and patients,  each inaccurate and biased on their own ways,  be misleading or wise guides to future care?   

Will this data, in their words, produce “digital flatulence” or “digital decisiveness”? 

Will Watson’s $3 billion  diet of undigested data produce more noise than knowledge?

Their  answers, like the data, is ambiguous , because: 

 Medicine is an art rather than a science,  data collection  is full of ambiguities.

Clinicians are often rushed and confronted with  limited time constraints, unfriendly EHR interfaces  and a byzantine list of 68.000 codes to pick from,  the EHR output is imprecise and flawed.

Hospitals  often enter EHR data calculated to maximize DRG revenues, that data is biased towards procedures,  such as expensive cardiac workups even though the diagnosis of coronary artery disease is at best,  ambigious.   “ It’s rare,” they say, “ to find a patient admitted to a hospital with chest pain who is not admitted as anything other than Acute Coronary Syndrome (ACS)—rather than a less expensive diagnosis.

Patients are often not forthcoming about their lives for reasons of embarrassment, privacy concerns.   Patients  have understandable, primarily economic reasons to deceive about their health insurance. They may be using the name of a friend or relative who has health insurance, they may have a spouse’s or ex-spouse’s insurance, they may wish not to have certain procedures or conditions shown on their insurance records.

As I write in my book,   there are other  confusing noise pollution factors as well:

·         The Noise over the clash of cultures between health care proponents and followers. 

·         The Noise between President Obama’s ideology and its economic consequences.

\ 

·         The Noise of  physician demoralization,  shortages, and passive resistance.

·         The Noise of middle class discontent over broken promises of lower costs and keeping your doctor and health plan. 

·         The Noise over Negative Forecasts  predicting ObamaCare repeal.

Because of these multiple sources of confusing background Noise and because of the bias inherent in the  payer, physician, and patient sources of data,  Watson’s quest for enlightment through sheer data  may be a case of  BDI, BDO (Bad Data In,   Bad Data Out). 

 Still, as Koppel and Meissner argue,  IBM’s quest for data Holy Grail is worth a try, why not give it a shot?  

The Inevitable Isn’t Inevitable

There is no good in arguing with the inevitable.

James Lowell (1819-1891), Democracy

In a free-wheeling Democracy like the U.S., nothing is inevitable.  I will argue here,  that depending on unpredictable events, people will always reserve the right to change their minds no matter what the computers predict.

Take the Big Data or Megadata revolution.  In  yesterday’s WSJ (“The Big Data Future Has Arrived,” February 23,  veteran writer  Michael S. Malone,  argues that Big Data will  transform our lives because it will delineate how we think,  how we vote,  how we maintain our health,  how we shop, and what we buy.  

Big Data,  Malone believes,  will reshape our lives.  Maybe so.   But to paraphrase an old expression,   it’s human garbage in,  human garbage out.   Humans still have minds of their own,   although data may reveal what’s likely on those minds. 

No doubt  powerful computers,  ubiquitous sensors, and the Web will influence those minds.    Maybe big data will personalize, make more productive, and empower our lives,  but based on what I ‘ve seen so far in health care,  I’m dubious megadata will  necessarily enhance the quality of care.

Or take politics.   We have had more data-driven polls than anyone can count.     But because of such factors  last-minute mind changes,  surges or falls in turnout,  personality quirks of candidates,  and late breaking  gossip or  scandal,  results are beyond the reach of data.  Hillary Clinton is said to be inevitable ( Howard Kurtz, “ Clinton Is Inevitable Once Again,” Fox News,  February 23).    But is she inevitable?  The outcome of the FBI investigation  is not in, and there are emails  and primaries yet to come.  

Donald Trump says he is inevitable.  But Lou Cannon, who wrote a biography Ronald Reagan is doubtful ( “Why Trump  Isn’t Inevitable,”  Real Clear Politics,  February 23).    Cannon notes that Reagan lost 6 primaries before winning one,  that Trump only has ,9 delegates of the 1237 required for the nomination,   that his popularity is stuck in the mid-thirties,  that 28% of Republicans say they would never vote for him,  and that primaries with favorite sons (Cruz in Texas, Rubio in Florida, and Kasich in Ohio) have yet to be held.

It ain’t over until the Fat Lady sings, but in about a month, following the big second winner take-all primaries,  she  is likely to yodel a victory song

Big Data doesn’t make it all inevitable.

Results will always be questionable.

Don’t bet on the final winning horses,

Because not everything is measurable.

 

Employer Mandate 

In the debate over the ACA’s future,  you seldom see much discussion about how employers are responding to the health law.     Yet without the employer mandate,  ObamaCare is a toothless tiger.

Employers now cover more than 160 million Americans,  more than half of America’s 320 million people.   The health law makes provision of health benefits mandatory for employers with over 50 employees. In 2015 employers with more than 100 employees must meet federal standards,  and in 2020 employers will be subject to a 40% excise tax (the so-called Cadillac  tax)for coverage over a certain value.

How are employers responding?   Those with less than 50 employers  are reducing  part-time workers to less than 30 yours to avoid exceeding the rule defining full-time workers.

They have also sought to end eligibility for coverage and ended coverage for spouses and dependents.

By and large,  however, employers are continuing to offer coverage for two reasons:  the great tax incentives  for providing  coverage,  and the positive incentives for recruiting and retaining workers.   In addition, employers are turning to self-insurance, managed care, competitive bidding from insurers,  wellness programs, and increasing employee cost-shared through defined contribution and consumer-drected higher deductible plans (CDHPs).    

The idea behind CDHPs is to  switch costs to employees,  to  decrease utilization  by avoiding unnecessary coverage, and  to encourage tax-deductible savings for future retirement.  The principle  vehicle  for CDHPs are health savings accounts.  About 45% of employees now offer HSAs, and the number is growing,  It reasoned that if workers have “skin-in-the game” they will shop for care.    Among the principle  providers of services (hospitals and physicians),  CDHPs and HSAs  have two negative effects – decreased use of services and costs of collecting the deductibles (which average about $2500).

A final option for employers is to move employees to the ObamaCare sponsored health exchanges to prevent them from becoming uninsured.   This co-called “play or pay” option has not been adopted to any extent.

According to Robert Galvin MD, former director of health services at G.E, and now operating partnes of Equity Health at the Blackstone Group,  a New York- based hedge fund,  most employers will continue to sponsor health benefits  because of tax advantages  as a recruiting and retention tool  rather than move to health exchanges.

(Robert Galvin, ND, “How Employers Are Responding to the ACA,” NEJM,  February 28, 2015).

If Republicans win the Presidency,  all bets are off  with promised repeal of the ACA and ending the individual and employer  mandates.

The Voters Have Spoken

Primary results read like a Shakespearian soliloquy,

Instead of “To be or not to be”, the results read, “What was is not to be.”

That’s what South Carolina voters were telling  us,  when, on exit polls  70% said they voted for Donald Trump because “he was telling us the way it is.”

That’s what Jeb Bush was telling us when  he explained “The Iowa,  New Hampshire, and South Carolina voters have spoken, and I accept their decision.”

These statements speak volumes about the mood of the country.

The country wants  change they can believe in. 

The country wants straight talk,  even if laced with an occasional profanity. 

The country wants winners.  

The country wants someone to stand up to the “establishment,” wherever and whatever that it.

The country wants to see the end of the professional elite,  on both sides to the political  aisle.  

The country no longer wants straight conservatism,  or straight progressivism.

The country wants results, no matter how those results are  how  these results are packaged ideologically.  

The country wants solutions,  nor party sponsored  policy resolutions.  

The country is willing to take risks to resolve the problems that plague  our middle  class and threaten our fundamental  values.

The country has decided  it ,

“ tis ‘nobler in the mind to suffer

The slings and arrows of outrageous fortune,

Or to take arms against the sea of troubles,

And by opposing end them.”

The country has decided 'tis nobler to oppose traditional  misfortunes than to continue them.

Control Your Health Care Costs by Paying Cash

I’ve been reading  Control Your Destiny Or Someone Else Will (Doubleday, 1993).  It’s the story of how CEO Jack Welch (born 1935) turned G.E. into the world’s most competitive company.

Welch is now retired, is a best selling author (Winning), and is married to former editor of the Harvard Business Review.

I was wondering if Welch’s six rules for competitive success apply to physicians.

The six rules are:

1)       Control your destiny or someone else will.

2)     Face reality as it is, not as it was or as you wish it were.

3)     Be candid with everyone.

4)     Don’t manage, lead.

5)     Change before you have to.

6)     If you don’t have a competitive advantage, don’t compete.

One,  the destiny of physicians lies in controlling  their relationships with consumers and patiients.  The hue and  cry nowadays  are consumer-driven care, consumer-centric care,  and patient engagement.   This is something physicians are very good at.  Yet someone else, mainly government and insurers and big hospital systems,  seek to control physicians’ destinies  by serving as middlemen.

Two,  the reality is that health care reform is a very tough game,  and big organizations  have leverage over physicians through their size, corporate structure, and marketing clout.

Three,  candidly,  physicians have been losing the game and are selling out and becoming  passive employees of hospitals and large integrated health systems.

Four,  leading , not managing, is key to getting back into the game.  This may be happening.   Through organizations like  Unified Physicians and Surgeons,  physicians are clawing back into the limelight by insisting that things like  the time  and hassles spent on credentialing,  interfering with patient relationships, mandatory electronic  health records, and data-driven care,  are often counterproductive, distract from patient care, and do not advance quality or cut costs.

Five,  physicians must  change if they are to ward off being secondary actors in reforming our health system.   They must  take a more central role in reform.  They must  join the reform conversation.    They must become more vocal, more visible, and more positive on how to reform the system.

Six,  physicians  cannot effectively  compete with large organizations  in  national marketing campaigns or in governing all aspects of the system.  They must act locally,  sometimes act in concert with hospitals,   and present attractive options to consumers.

One of these options is lower costs for consumers through direct cash transactions.   In this age of  high premiums and unaffordable deductibles,  physicians can offer deep cash discounts.    In today’s Wall Street Journal,  reporter Melinda Beck  describes this option  “How To Cut the Health Care Bill: Pay Cash:  Hospitals and Other Providers Increasingly  Offering Cash Prices Far Below What They Can for Insurance.”   She gives three examples of how consumers cut hospital bills over insurer bills by 15% of an MRI of the foot, 47% for tonsillectomies, and 45% by an MRI of the knee.    

There is nothing new about this.  It’s Free Market Health Care.    The Surgery Center of Oklahoma  often charges 1/6 of what hospitals charge for routine outpatient surgeries.  Concierge medical practices charge far less than traditional insured practices by offering retainer cash prices for bundles of primary care services.   For patients,  as my wife’s father used to tell her,  “A dollar bill is your best friend.”

Concierge Medicine for the Rich

 In 1999 I wrote “No Margin, No Mission” for The Physician Executive. The article opened with this paragraph,

“A tough-minded Catholic nun, the CEO of a major not-for-profit health system on the West Coast, captured the dilemma of our health system with this down-to-earth comment:” No margin, no mission.” This article and many others indicate any organization, however noble its mission , whether “for-profit” or “not-for-profit,” must make a profit to survive as an institution and to serve its constituents. Whether a business or a charitable organization runs the enterprise makes little difference. Both need to make profit to survive. No mission is more noble than caring for the sick. That's what medicine and hospitals are for. But to say openly that one must "make a profit" running a hospital, medical practice, or health insurance company or "compete for patients" is unseemly.”

I thought of that article today when I  read “Hospital Care Aimed at the Rich; Mass General, Founded for the Poor, Plans to Open a Concierge Practice,  in the February 13 issue of the New York Times.

Massachusetts General catering to the rich? It’s an unsettling thought,  a liberal institution like Mass General  openly announcing  it would open a concierge practice.   The practice would start with 3 doctors,  would charge an annual retainer of $6000,  would offer 24 hour access,  and would be tied directly to Mass General’s vast cadre of specialists.

Mass General is worried about declining reimbursements from health plans and the government.  It says it wants to make money providing for the rich to carry out its “core mission of providing for the poor.

The upsides of its concierge practice are  more revenue for the hospital and more ability  to care for the poor.   The downsides, in the eyes of critics,  are giving momentum to the concierge movement,  which now has 6000 exclusive practitioners and 6000 more practices  offering part-time concierge care,  and creating a model that exemplifies  “two-tier medicine,” with one level of care for the rich and another for the poor.  In other words,  no margin, no mission.  Or in the words of one cynic, "When they say it's the mission and not the money, it's the money."

My hunch is that this creation of concierge practice  is part of  a larger mission,  which I described in a previous blog.  On December 17, 2015,  the New England Journal of Medicine published an article  “Unfinished Business – Removing Barriers to Access and Coverage.”   Towards completing that “unfinished work,  the NEJM proposes to led the the transformation of health care delivery by launching  a “ NEJM Catalyst.”

The  proposed NEJM Catalyst is a “resource’ will “provide health care leaders with information to provide these leaders with information that can help them redesign patient care, change the structure of their institutions, contemplate new relationships with outside organizations, and reconsider the ways in which incentives are being used.

The NEJM Catalyst will have 4 overlapping themes.

1) The “New Marketplace,” which will focus on health policy and markets impacts on payer and provider consolidation, value-based payment, competition and consumer choice.

2) “Care Redesign” which will concentrate on how to create and sustain the teamwork needed to provide high-value care, and the practical ways of organizing care to enhance health as well as sick care.

3) “Patient Engagement: Behavioral Strategies for Better Health.” This will focus on what is known about the use of incentives (financial and non-financial ) to engage patients in improving their own health.

4) “Leadership.” This will be about engaging clinicians in to enhance the value of care .

Mass General, which is closely linked to the NEJM,  is experimenting in creating a new  marketplace, redesigning care,  engaging a new set of patients to provide for the old set of patients ,  and taking a leadership role in health reform.