Thursday, July 28, 2016

Events Driving ObamaCare  and Election
Events, my dear boy, events.
Harold McMillen (1894-1986), British Prime Minister, when asked to question  what drives governments off course
Events are in the saddle and drive mankind.
Ralph Waldo Emerson (1803-1882)
External events are driving the government off course in its ObamaCare and foreign affairs policies that affect the election.
In economics these external events are called “ externalities,” which are defined as a side effect of a policy or activity that affects other parties without this being reflected in the goods or services involved.    Or, more simply,  costs or benefits that a party that did not choose to incur that cost or benefit.  Or simpler yet,   complications or adverse consequences,  often beyond the immediate control of the party putting forth  or implementing the policy, act, or law, or activity.  Some events are beyond the reach or control of government.
With ObamaCare, these externalities include:
·         The unanticipated spike in premiums due in early November just before the November 8 election.

·         The departure of major insurers,  like United and Humana,  from exchange markets.

·         Negative Supreme Court rulings on legalities of subsidizing exchange patients without Congressional approval.

·         Physicians’ reluctance to accept Medicare, Medicaid, and ObamaCare patients because of low reimbursements,  penalties, and hassle factors.

·          Increasing  lack of affordability of premiums, deductions, co-pays, and out-of-pocket costs for unsubsidized  patients.

·         Lack of access because of mounting physician shortages.

Externalities affecting the election include:

·         FBI director James Comey’s catalogue of events showing the extreme” carelessness” of Secretary of State Hillary Clinton in her personal use of an email server.

·         The Wikileak email dump of the Democrat National Committee’s emails indicating  a systematic  bias against Senator Bernie Sanders.

·         The hacking attacks by foreign governments and others on U.S. government files and national security agencies.

·         The increasingly frequent ISIS atrocities killing thousands of innocent civilians in the U.S. and elsewhere culminating in the beheading of a Catholic priest in France.

·         The funding,  financing,  administrative costs, and charitable work of the Clinton Foundation,  which are focusing on the payment of millions of dollars to  President Bill Clinton for speeches of unknown content and which are currently under investigation by the FBI and Congress.  

Where all of these events will go or what other events may occur no one knows.   Republican critics are waiting for the other foot to drop.  Democrats are hoping they can prevent untoward events from surfacing at the height of the presidential campaign.   One cannot always control the forces of nature or humanity, or the forces and consequences  set in motion by one’s own acts.    

Wednesday, July 27, 2016

Everything You Need to Know about Health and Disease
You can always count on Americans to do the right thing – after we have tried everything else.
Winston Churchill

Winston had it right when it pertains to health care. 
We have tried market care,  government care,  Medicare,  Medicaid,  and a blending of the four- ObamaCare.  
We have tried blaming the doctors, the pharmaceutical companies,  the big insurers, the progressives, the insurers.
None of it has worked too well.    So now we have decided to step back and examine the real culprits – our genetic background – our age, race, education, sexual orientation, and gender - and  our lifestyles – what we eat, how much we exercise, some, drink, and sleep.
Doctors have known this for a long time – you cannot prevent or treat a chronic disease, or transform a life style or stop a bad habit– in a 15 minute office visit.   The truth is: what goes on outside the office or the hospital, not what goes on inside, that determines health  or stops a disease in its tracks.
Precision Medicine Initiative
The  Obama administration  finally recognizes this reality.  In concert with thousands of researchers, scientists,  physicians, clinics, data experts – the administration  has asked for million volunteer patients  , to join in a “precision medicine initiative” to collect information from questions, physical exams,  electronic health records,  DNA   and genomic analyses  and other sources to from a “precision medicine cohort.” 
The idea behind this $130 million federal initiative  to solve the mysteries of disease and why it occurs,  says Rhonda K.Trousdale, MD, an endocrinologist at Harlem Hospital  is 
“To use data to find correlations between peoples’ life style, family history, environment,  and genomic data – to figure out what factors contribute to disease and how they effect different populations in different ways.  That’s what precision medicine is all about.”
Bringing Together Various Players in Health System

I like this project.  It brings together all the players - patients, physicians,  investigators,  information technology geeks, politicians -  in our culture,  our health system, and our government in a conjoint effort.
And it takes advantage of the latest technologies- rapid reductions in the cost of high-throughput genomic sequencing, targeting  potential molecular targets for therapy,  particularly for killer diseases like cancer, diabetes, and cardiovascular disease.  
It uses widespread access to iphones and other devices to  makes it possible to collect data form patient volunteers.   The initiative empowers clinicians, patients, and investigators to work together  towards more personal care  to improve outcomes.
This initiative may take 10 years to bear fruit.   But it is bipartisan,  recognizes the realities of genomics,  life style factors, and genomics in the evolution of disease, and emphasizes factors beyond what occurs in hospitals and doctors offices, which treat diseases after the horse  has left the barn  and have little control on what happens outside the barn.

Sunday, July 24, 2016

Fox in Media Henhouse
Whatever you think about  Fox News and Roger Ailes,  who just resigned over sexual harassment issues, you have to conclude,    this man and his network were a  media phenomena.
Over the course of 20 years,  Fox came out of nowhere to dominate TV news. On  July 23-24,  the Wall Street Journal ran a full-page ad with these primetime ratings during the Republican National Convention, among TV viewers
Fox News, 7.2 million

NBC, 4.6 million

CNN, 4.1 million

ABC, 3.1 million

CBS, 3.0 million

MSNBC, 2.1 million

Pulling It Off
How was Ailes and Fox able to pull this off?
According to Dam Abrams,  chief legal analyst and former news manager for MSNBC,  here reasons why Fox has come to dominate TV news.
·         Its sparkling patriotic and bright graphics

·         Its “Fair, Balanced, and Unafraid” mantra, which everyone knew  to be a wink at straight-laced competitors

·         Its role as the only conservative alternative  against divided moderates, independents, and liberals 

·         Its emphasis on one or two “hot stories” compared to other networks’  diverse, dispassionate, and objective coverage of multiple subjects

·         Its reporters  use personal pronouns,  “I”, “We”, and “Us”

·         Its stress on controversial  entertaining personalities,  like Bill O’Reilly. who stressed patriotism,  nationalism,  and political controversy

·         Its hour-by-hour, minute-by-minute   late breaking news segments

·          And last by not least,  its openness and alacrity  in promoting Donald Trump and other Republican candidates.

How these innovations will play out in influencing the 2016 election  I have no idea.   How they will influence  outcome of the health reform debate eludes me.   But it is apparent Fox News feeds on controversy and in slaying chickens in the liberal  chicken coop.    Its news presentation  may not be fair and balanced, but it is unafraid of controversy.   It  went where others feared to tread “where there no objective norms,  no establishment rules, no journalistic sanctity.”  It was good for what ailed Republicans but not for what troubled Democrats.
Source: Dan Abrams,  “Trying to Meat Roger Ailes at His Own Game,”  July 23-24, WSJ

Will Premium Spikes Announced Week before November  Election Puncture the ObamaCare Balloon?
In recent years, spring has brought with it a new tradition: headlines about proposed premium increases under the Affordable Care Act (ACA) and predictions of the law’s demise.
Benjamin D. Sommers, MD, PhD,”ObamaCare’s Skyrocketing Premiums?  Why the Sky Isn’t Falling,” New England Journal of Medicine,  July 21, 2016

Insurers are asking for these premium increases in the following states.   
One, in states in which the federal government reviews the rates, and either accepts or reduces them.

Texas,  BCBS, 60%

Oklahoma, BCBS, 49%

Missouri,  Humana, 34%

Wyoming,  BCBS, 10%

Two,  in states in which  state insurance regulators review and modify rates.   These states and insurer rate increase requests are;

Michigan, Humana,  39%

Oregon, Providence Health Plan, 24%

Tennessee,  BCBS, 63%

North Carolina,  32.5%

Not to Worry
Critics say these requested rate increases indicate a failure of ObamaCare to deliver on its promise of lower premiums.
Not to worry,  retorts, Benjamin D. Sommers, MD, PhD,  of the Harvard School of Public Health,  a consistent supporter and advocate of ObamaCare.
Why worry?
First, spring requests for increases are just opening bids.   Rates are likely to be reduced in the “rate review” process at least 30% of the time.
Second,  consumers can shop for less expensive plans with lower premiums
Third,  80% of consumers who purchased coverage on the exchanges qualify for ACA’s tax credits  which lower costs of premiums.
Not So Fast
Not so fast,  counter critics.   It is difficult for consumers to switch .    Some states do not offer credible competite plans.   After 2016, two of the health law’s provisions – risk corridors and reinsurance – expire.   And although 12 million people receive tax credits, an equal number – three million in the exchanges and nine million with insurance outside the exchanges,  will be forced to buy full unsubsidized care.  In any event, taxpayers will have to foot the bill for exchange subsidies.
Sommers admits premium growth is not “unworthy of policy and media attenation.”  Taxpayers  will have to fund subsidies ACA tax credits and Medicaid expansion , but to scrap the law  would “ignore the devastating effect that repeal would have on the estimated 20 million who have thus far gained insurance under the law.”
Spoken like a true “redistributionist.”  In Sommers’ view, which emphasizes social justice and compassion,  repealing the ACA is not an option.   Only living with it and refining it is.   After promising in the beginning that  the ACA would lower premiums by $2500 per family per year,   you must now live with the reality that the ACA has systematically raised premiums, often  to unaffordable levels for the unsubsidized beyond the reach of federal largess  and beyond the ability of insurers to sustain lower premiums.   In retrospect, lowering premiums was a fool’s errand.   You cannot cover more people while offering more benefits  for less money and lower premiums.  You can fool most of the people most of the time,  but not all of the people all of the time.

Friday, July 22, 2016

Make American Doctors Proud Again
Make America safe again
Make America work again
Make America first again
Make America great again
Four Themes of 2016 Republican Convention
Well, it’s one convention down, and one to go.  All in all,  the four themes worked.  Republicans had a positive convention.  Now we shall see what the Democratics convention have to offer.  
Trump missed the boat on one issue.  It was failing to talk more about  the future of ObamaCare and the  positive role of physicians in providing that care and giving them the respect they deserve.  
Not About ObamaCare
This blog is not  about whether ObamaCare is repealed or replaced.  
Whoever is elected,  elements of ObamaCare will be changed.
- Individual and employer mandates and how health exchange subsidies are paid will be modified. 
-- Provisions for not excluding those with pre-existing conditions and for covering young people under 26 will be retained. 
--The Public Option will not be passed. 
--Decline in the number of uninsured under ObamaCare  from 16% to 9% will be celebrated. 
--Number remaining uninsured (29 million) will be lamented.
--Merits of government-based  coercion  coverage versus market-based choice  coverage will continue to be debated.
Loss of Respect for Doctors
What  the Trump campaign failed to mention was the loss of respect for doctors in providing that care.   Doctors feel under siege from  critics, the media,  lawyers, regulators,  and government officials who insist physicians be responsible  for installing  and maintaining  electronic health records to collect data the government says it needs to dictate how physicians practice.   It comes down to: who decides – government or doctors .  It comes down to whether doctors should be treated as trained professionals or data-entry clerks  or regulated serfs for government.
Coburn and Krauthammer
As Tom Coburn, MD, the Oklahoma senator remarked in 2009 – “The idea that a bureaucrats somewhere will make decisions about health care and coverage  I think is untenable to most Americans.” 
Or as Charles Krauthammer  observed in a 2015 Washington Post piece after attending his 40th Harvard Medical School reunion,” My colleagues have left practice all say they still love patient care, being a doctor.   They just couldn’t stand everything else….the never-ending attack on the profession from government,  insurance companies, and lawyers,,, Progressively intrusive and usually unproductive rules and regulations, topped by an electronic health records mandate that produces nothing more than billing  and legal documents, that have degraded medicine.”    In other words, documenting had replaced doctors as the main mission of clinicians.
Collective Paranoia
As a consequence of this loss of respect and misguide mission, a collective paranoia has set in among physicians.   Physician burnout and suicides are mounting.   Practitioners  are abandoning private practice.  Two-thirds of doctors feel the quality of medicine is deteriorating.  Physician shortages , now 50,000, are expected to grow to 100,000 by 2020.
In his acceptance speech,  Trump should have defended doctors  just as  he so effectively defended the police.  The police help maintain law and order and protect  people again crime.   Physicians help maintain health  and protect people against disease.
Yet seldom is heard an encouraging word.  We need to be told so we can again take pride in our profession.  Peter Pronovost, MD, head of the Johns Hopkins Patient Safety Institute, advanced this novel proposal in the July 21 Health Care Blog,  "Let's trust our doctors." It's worth a try, and it would make doctors feel better.





Thursday, July 21, 2016

Private Practice Physicians - Elephants in the Room
An “elephant in the room” is a subject  nobody talks about but everybody knows is there.  The elephant  tends to be a huge refractory problem that nobody wants to address because there are no glib answers.
Government and Private Practice Elephants
For health reform progressives the elephant in the room is private practice. About 30% of private physicians now practice solo and 50% are in groups of 6 or less.  These physicians are “fragmented” and do not uniformly follow government regulations.   For physicians, the elephant in the room are government regulations,  mandates, penalties, restrictions, and what CMS will pay for.
Private Practice – A Thorn in ObamaCare’s Side
These physicians are a thorn in the government’s efforts to develop a nation-wide integrated uniform standardized system based on data.     Electronic heath records (EHRs are the  pillar or such a system.   EHRs are the chief data gathering device justifying government policies that stress outcomes management,  evidence-based medicine,  pay-for-performance and other quality improvement schemes which have yet to bear statistical proof of their usefulness.   
EHRs -  A Pain in Private Practice’s Side
Private physicians resist and even detest  EHRs.   Clinicians complain EHRs are not ready for prime time,  are not clinically useful,  do not communicate with other EHRs,  distract from patient care,    do not offer information that improves outcomes or quality, and add  unnecessary overhead.  
What Is  CMS  to Do?
What  is  government, bent on reform,  to do?   Well, according to an article in the June  newsletter of the American Association of Physicians and Surgeons (AAPS)  ObamaCare and government policy wonks think the best way to slay the private practice elephant in the room is to squeeze the income and decrease the joys of private practice. 
Imposing Regulations and Penalties
How?  By systematically imposing a series of regulations and penalties on private physicians that take time away from patients (their chief revenue source)  lower payments for  CMS and ObamaCare patients (below those of private payers by 30% to50%,  and reimburse private physicians below the cost of staying in practice (by 10% to 20%).
Once You Have Them by Their Wallets
Once you have doctors by their wallets, policymakers thinking goes,   physicians’  hearts and minds will follow.  They will either quit practice early, become hospital employees,   join large integrated health system,  and become quiescent salaried employees,  anything to avoid becoming data entry clerks for government
Death by Regulation and Financial Suicide
The AAPS article calls this approach to discouraging private practice   “death by regulation”.  Rather than go this route and commit “financial suicide” doctors will choose other options.   Selling their practice to a younger physician is not an option since young physicians prefer the security and time-off and balanced life style of employment.
Here is how the article describes the situation as a 5 Act drama.
Act I
“Act I of the saga to socialize medicine and destroy private medicine in America began in 1965, with the passage of Medicare, then Medicaid. Almost immediately,  cost escalation began, as predicted by AAPS. Before 10 years had passed, the federal government was already violating the promises enshrined in the amendments to the Social Security Act that established Medicare, “
Act II

“Act II began in 1972 with “landmark” Professional Standards Review Organizations (PSRO) and more utilization review regulations, soon followed by Medicare fee caps and then the Resource-Based Relative Value Scale (RB-RVS).

“Act III was the bold Clinton initiative to expand federal control into all of American medicine, using the managed-care mechanism that had gotten a federal boost with the HMO Act of 1973. While the Clinton Health Security Act itself did not pass, the backup strategy worked: the State Children’s Health Insurance Program (SCHIP) plus the incorporation of essential elements of the Clinton Plan into the Health Insurance Portability and Accountability Act (HIPAA). These included vast expansion of the funding and powers of federal law enforcement, draconian civil monetary penalties, and harsh prison sentences for “healthcare” crimes that previously might have been called billing errors. In the guise of “privacy,” the foundation was laid for forcing adoption of electronic health records (EHRs), a necessary surveillance tool.”
Act IV

“Act IV, the Affordable Care Act (ACA), herded almost everyone into federally regulated third-party payment schemes. The costly bureaucracy drove increased hospital consolidation,  impelling independent physicians to join Big Healthcare systems. Largely thanks to ACA, the HHS paperwork burden has increased to 700 million hr/yr, up by 300 million since Obama took office. It takes 354,500 full-time private-sector employees to comply. There are 86 new ACA rules pending, one with an estimated cost of $41.8 billion.”
Act V

“Now comes Act V, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), with 962 pages of newly released regulations. This could be the coup de grĂ¢ce. “

“The new physician payment rule would be “financial suicide” for small practices, said Farzad Mostashari, who spent 2 years leading the White House effort to implement EHRs. “
“Details of the Merit-based Incentive Payment System (MIPS), CMS estimates that 87% of the nation’s solo practices (nearly 103,000 physicians) will face a penalty in 2019, amounting to $300 million. Practices of two to nine physicians would pay about $279 million).”

The rules make the federal government and its proxies the arbiters of “quality” and “value,” and require physicians to allow CMS to access all medical records of all patients. A new class of intermediaries must keep the data for CMS audit for 10 years minimum, if not a lifetime in targeted cases, writes AAPS director Kristin Held, M.D., in a meticulous analysis of the rules.”
Chinese Water Torture and  Death by Chicken Pecking
In management circles,  the government approach of piling on regulations and penalties is known as either “Chinese Water Torture,” i.e.,  one, dropping water on the forehead of restrained person until it drives the insane or the case of doctors makes them insolvent,  or two,   being “pecked to death by chickens’  through  a steady stream of annoyances  or nuances which eventually exact such  a heavy burden  that it makes practice insufferable  and no longer gratifying or satisfying to a training professional interested in healing and relieving pain rather complying with government regulations.

Sunday, July 17, 2016

Is Data the Health Reform Answer?
“In God we trust. All others use data” is the mantra of health care managers and CMS officials who administer ObamaCare rules.
Data - The Foundation for Health Law Policies
Data is the foundation for policies such as outcome management,   pay-for-performance,  evidence-based medicine, and the new kid on the Medical Management Block  MACRA (Medicare Access and CHIP Reauthorization Act of 2015).  The latter is based on data collected in ACOs (Accountable Care Organizations), which are experiencing health care delivery pains because of hospital and physician opposition and disillusionment.
Attractiveness of Data
Data management has an attractive ring to it.   It is neutral. It is objective.   It is collectable at the site of care.    It is capable of being standardized.   And theoretically it can be implemented across the health care landscape, among physicians of every ilk and specialty.
Is Data Relevant: On What Does It Depend?
But like any other human-directed endeavor, data depends on its relevance.  It is germane to the problems being addressed, e.g., the cost and quality of care.   Is it affordable?  Does it protect patients?   It has variables,  like the nature of questions being asked to get the data, the truthfulness of patients.   It depends on costs of data collection.  It depends of its usefulness as a communication tool.   It depends on how the data is interpreted and applied,  and if it is of any benefit  to patients and physicians  or administrators. 
EHRs as Data-Gathering Tool
It is essential for the government to recognize that two-thirds of physicians  do not find electronic health records,  the chief collection tool of government, useful.   I  won’t go into the reasons why.  Suffice it to say,  the majority of clinicians find EHRs to be a waste of time and money because of their poor design and expense of feeding the data-eating monster.
I am beingtoo dramatic.    But let me say this. Among most private physicians,  especially those in small practices,  EHRs offer gloom for improvement.
A Private Physician’s Lament
To show what I mean,  consider these words of Niran Al-Agba, MD,  a physician in private practice in Washington state (“Dear Mr. Slavitt, Please Come Visit My Office,  The Health Reform Blog,   July 11, 2016.    Andrew Slavitt is the administrator of CMS.
“Andy, if you want to fix primary care you must do some field research.  Come spend one day, or even a week at my office or another small primary care physicians’ office.  You need to see what we do on a daily basis and actually understand the view from a small practice perspective. This knowledge deficit is at the core of CMS’s problem.  You cannot repair what you do not comprehend.”
“Once you understand what we are capable of doing, how we do it, and how it actually SAVES money in the long run, while still providing high quality, then you are ready to tackle Focusing on Primary Care for Better Health.  The bottom line:  you must pay us more for what we are doing if you want to increase our overhead expenses.  Tasking us with additional administrative burden in order to earn extra money is not actually paying us any more for our work.  We would be working harder, not smarter.  Do you understand that?”
First and foremost, the largest stumbling block for reducing expenditures of a small practice is addressing the certified EHR. Why do you need all this data?  Your days at McKinsey & Company have hooked you on its necessity to make management decisions, but your background is in healthcare insurance and expenses is a far cry from the provision of primary health care or value-based care.”
“The EHR mandate has damaged our profession as a whole.  It has been destructive to the physician-patient relationship as well. Technology has not improved safety, efficiency, or patient satisfaction and has only served to increase physician dissatisfaction.  Physicians are overwhelmed, hopeless, and trying to get out of the practice of medicine altogether.  You do not belong between me (the physician) and my patient – move out of the way.  Please.”
“If you want me to collect mountains of data, then prove it actually increases quality, reduces cost, and decreases our workload before I get on board.  There is very little margin to work with in my office, and if I make a wrong decision, my practice (and many others) will be dead in the water.   Find technology that is useful to both physician and patient while being affordable at the same time.  Stop adding complicated algorithms and programs to increase reimbursement while expanding our administrative burdens.”
“Second, value will materialize if you pay us more for what we do.  Higher reimbursement allows us to slow down and talk longer with each individual patient.  Make our lifestyle something to which others want to aspire and you will find more primary care physicians wanting to work in smaller areas.  Primary care physicians, actually ALL physicians, deserve better.”
“Have you not realized small practices provide urgent and emergency care, acute and chronic care, plus everything in between?  Care coordination, we already do it!  Winging it when there is NO specialist to refer to at all, we already do! It is value, pure and simple.  You cannot get anything more out of us.  There is nothing more to give.  If primary care is rendered obsolete because we could not keep up with your overwhelming demands, access will be in jeopardy.  Access will be worse than it is right now.  What will you do then?”
“As to your Collaborative Care Model, supporting mental and behavioral health through a team-based, coordinated system involving a psychiatric consultant, behavioral health manager, and the primary care physician sounds like a dream come true.  My county with a population of 260,000 has NO psychiatrist.  Not one.  Many states all over are experiencing the same provider shortages.  Can you grow psychiatrists somewhere at an accelerated rate, like that clone army in Star Wars, and drop them randomly by plane throughout the United States?  That would be a good start.  They could be raised to believe indentured servitude is their destiny.  I think it could work if you put that on your task list.”
“CMS employees have not spent one day inside a small primary care practice.  It is necessary at this point in time that they do.  You talk about encouraging innovations to connect people with primary care.  Here is the thing Andy, primary care physicians do not need innovations to connect people.  We use phones, interact face-to-face with our patients, and chart to document the entire process.  If we were not good at connecting with people, we would not be successful primary care physicians.”


Saturday, July 16, 2016

Government Alternative Pay Strategy for Cutting Costs: Pitting Primary Care Against Specialty Care
Flow of funds will be determined on the basis of organizational structure, relative power of PCPs and specialists, specialists’ demonstration of their value, and the organization’s conception of their value.
Robert Kocher,MD and Anuraag Chigurupati.,MS,  “The Coming Battle over Shared Savings – Primary Care versus Specialits, NEJM, June 14, 2016
The ACA strategy for bending downward Medicare costs is now apparent.
·         Herd  primary care doctors and specialists into accountable care organizations   and large physicians groups  or integrated hospital organizations serving Medicare patients.
·         Transform fee-for-service into “Alternative Payment Models” featuring pay based on the entire episode of care from  diagnosis to treatment  in physician offices to recovery in skilled nursing facilities.

·         Under the Medicare Access and CHIP Reauthorization Act of 2015,  shift FFS patients into risk –based reimbursement models, which relying on bundled bills, population  health management,  and capitation to achieve “savings.” 

·         Create benchmarks or goals to  meet to reduce expenses,  primarily through reduced hospital stays, ER visits, lengths of stay in skilled nursing facilities, referral to specialists and intensity of diagnostic tests and procedures by specialists.

The basic idea behind “shared savings” is to narrow the gap between the average income of PCPs ($195,000) and specialists $284,000 and to reward PCPs with more of the “savings” while reducing the specialists take.  Estimated “savings” will come for example, with a $35,000 reduction in radiologist pay and a $25,000 decrease in interventional cardiologist pay.   A PCP could stand to gain $80,000 by achieving the desired savings rate. 
The authors ,  from health policy organizations at the University of Southern California,  Standord,  and Harvard,  maintain that:  As health care reimbursement shifts from fee-for-service to risk-based payments,  PCPs are well positioned economically and strategically.  Their incomes are likely to grow substantially over the next decade, at the expense of hospitals and specialists .   Specialists who fail to expand their role and develop the capabilities tnd relationships to drive value improvement will face the threat to their incomes and practices.”
Or so they hope.  To date,  Accountable Care Organizations have not delivered on their promised savings.    Primary care doctors,  specialists, and PCPS are skeptical about ACOs,  APMs, and  government “savings,” which so far have  been more delusion than reality.  As some sage remarked,”Hope! Of all the ills that men endure, hope is the only cheap and universal cure.” 
History is not optimistic about government achieving savings by pitting PCPs against specialists,  given  the fact that many PCPs often practice a little specialty care and many specialists engage in primary care.

Teletruth  and Telehealth
The preface “Tele-” is from the Greek.  “Tele” means “distance,” especially “transmission over a distance,” as in telegraph, television, or telecommunications.
To teletruth,  I have reservations about “telehealth,” a term the describes   providing  health care remotely with telecommunication tools, including telephones, smartphones, and mobile wireless devices, with or without video connections.
My reservations hinge on the words “remote,” “distance,” and “virtual” as replacements for the “real thing” – meaning one human connecting to another face-to face. Perhaps “augmented reality,” will win out over personal connections, as in PokeMan Go,  where when you go near a hospital  or doctor’s office with your mobile phone,  you can hunt and capture tiny monster diseases.
Off My Rocker
You may think I am off my rocker.     After all,  anything related to the computer and medicine and apps, will supposedly expand health care access,  promote convenience, create efficiency,  assure objectivity,  and more the patient-physician relationship more productive.
Telehealth  Beleivers
Telehealth believes telehealth smartphones will allow to teach into peoples’ home; reduce costs for 140 million Americans with chronic disease; allow monitoring people wearing devices and diagnostic systems at a distance; and create low-cost virtual visits (less than $50 a visit taking minutes) rather than visiting a physician, which takes an average of 20 days to get a 20 minute appointment  that with travel and wait time consumes 2 hours to time.
And integrated health organizations like the VA, Kaiser Permanente, and the Mayo Clinic,  are already into telehealth big time.  These organizations foresee that telehealth visits will soon exceed doctor visits.   by 2020, the Mayo Clinic  plans to serve 200 million patients, many outside the U.S.  In any case, within 5 years,  90% of the world’s population will have smartphones, so why resist the inevitable.
Telehealth Problems
So why did I still harbor reservations?  What’s the problem? It’s not one problem, it’s many problems.
In the first place,  clinicians have managed to curb their enthusiasm  over telehealth.
It may replace them.  It’s reimbursements are spotty and low;  it is not as reliable or of the same quality as a person-to-person exam; it does not include a physician examination; it lacks the ability to read, feel, palpate a lesion;  it cannot read body language or patient reliability;  it cannot access mental disease;  it requires a trained assistant to set the telehealth encounter; and so far 93% of telehealth visits are done without the assistance of a video conference.  For most clinicians, seeing is believing  and cannot replace being there with a patient.
Other Telehealth Limitations
Other limitations exist as well – fragmented insurance coverage,   potential overuse,  poor quality of physician-patient relationships,   fragmentation of care among multiple providers  whose EHRs don’t communicate with each others; concerns about malpractice liabilities; and social  obstacles (only 58% if people over 65 use the Internet), and the omnipresent digital divide abetween metropolitan and rural areas, the rich and the poor;  the educated and noneducated,  variable broad band geographic access.
Persistent Optimism
Even in the fact of these obstacles,  the authors of “The State of  Telehealth” in July 14 New England Journal of Medicine, are optimisitic that we are near the tipping point of Telehealth,  that point at which there are more routine users than early adopters.     Venture capital funding has nearly quadrupled from $1.1 billion in 2011 to $4.3 billion in 2015;  smartphones can now monitor a person’s health(as least their vital signs), facilate diagnosis, and connect patients with doctors anyplace anytime;  academic medical centers can expand their reach across the health care spectrum; and “increasingly, with the narrowing of the digital divide and the ubiquity of smartphones,  telemedicine can enable more people to receive care.”
For  all of this to happen  may lead to less personalized care.  And it may require physicians to work harder to maintain relationships with patients; to change their concept of what being a doctor is all about, and to demand more training  in the use and abuse of telehealth whizbangs,  portable diagnostic technologies, and online algorithm.