Wednesday, September 28, 2016

Three Trends I Missed in 2004
Twelve years ago,  I wrote a book  “The Doctor In America: Inside the Physician Culture.”  The book was never published.   At the time, I was editor of a newsletter Physician Options, was a contributor to,  and had just published a book A Managed Care Memoir,  an account of my personal journey through the highways and by ways of managed care across the U.S.
The book contained 19 chapters, containing commentary on the  physician culture and resistance to change,  new directions for 2005, improving Care in independent practice,   hospitals and physicians interactions ,  revitalizing primary care,physician  interaction with pharma, consumer driven care,  the power  Health Savings Accounts, and the question: “Can physicians adapt to consumerism and patient-centered care?”

In the new directions chapter,  I cited 8 trends.

1.        From a youthful society to an aging society obsessed with looking younger

2.      From inpatient to outpatient care

3.      From prescription drugs as an incidental expense to an intolerable cost burden

4.      From costs absorbed by employers to costs shifted to employees

5.      From national to world concerns about infectious disease

6.      From enough physicians and nurses to shortages of both

7.      From laissez faire medicine to activist programs to prevent and managed disease

8.     From a la carte care to standardized care ti improve quality, consistency, and outcomes

What I failed to see  were the massive movements to hospitalists,  to physician extenders,  and to ObamaCare.

·         Hospitalists -  From its inception in 1996,  the number of specialists called “hospitalists” has grown from a few hundred to 50,000.   The two physicians who first described  “hospitals,”  we have these words, “This new field is substandially larger than any suspeciality in internal medicine (the largest of which is cardiology with22,000 physicians, about the same size as pediatrics (55,000(, and in fact larger than any specialty except general internal medicine (109,000) and family medicine (107.000),  Apr9oximately 75% of U.S. hospitals… now have hospitalists).
  • Nurse as Physician Extenders  -   Thomas Bodenheimer MD and Laurie Bauer, RN, of the Cetner of Excellence in Primary Care (T.B.) and the School of Nursing (L.B.) at th University of California in San Francisco, make these predictions ( “ In the primary care practiced of the future, the physician’s role will increasingly be played by nurse practitioners (NPs).  In addition, the 150 million adults with one or more chronic conditions will receive some of their care from registered nurses (RNs) functioning as care manager.”  This is because of primary care shortages.  The number of primary care entrants is 8000, but the number of primary care physicians  retire each year will reach 8500 by 2020.

  • ObamaCare -   In 2004,  I failed to anticipate  that a national health reform law,  the Patient Protection and Affordable Care Act of March 2010, would be enacted, even though national pressures were building to protect patients against rising costs and medical bankruptcies.   Like everybody else I also failed to see the economic collapse of 2008, which made the election of President Obama inevitable.     We are now more than 6 years into ObamaCare, also commonly referred to as the ACA.   Although it has reduced the number of uninsured by 20 million and lowered the number of uninsured to just above 9%,  the ACA (Accountable Act) has been unpopular from the onset, largely because it has failed to live up to its promises of keeping your doctor and health plan and lowering premiums.   Instead millions of Americans have been forced to switch doctors and health plans, and their premiums have increased by $7500 rather than the promised $2500 reduction.      The fate of ObamaCare will be determined by the 2016 presidential election.                                     


Sunday, September 25, 2016

Debate: An IQ (Intelligence Quotient) Versus an EQ (Emotional Quotient) Contest
It’s 24 hours before the Hillary Clinton-standoff.   The debate is  billed as the biggest TV draw since the Super Bowl,  pitting a non-emotional woman of experience and  substance against an angry male  ignorant of nuanced  political and diplomatic  issues but  focused on business outcomes .  
Going in, the polls indicate a virtual tie. 
The stakes are huge.  According to the WSJ,  one third of voters will make up their minds after witnessing the debate.  To no one’s surprise, the NYT jumped the gun by endorsing Clinton  as an even-minded.  It berated Trump as an empty-headed bigot full of lies and deceit.   This NYT’s attitude is exemplified by its listing of Trump’s “31 biggest whoppers” from September 15 -21. No mention is made of polls showing that 60% of  public thinks Hillary Clinton is distrustful.  Instead. The Times endorses Clinton of her intellect, experience, and courage.
Most agree Hillary Clinton carries the torch for the status quo and  the Obama legacy with a shift to the left , free-college education and so forth,  while Donald Trump claims the Obama-Clinton legacy is a disaster for the economy and for America’s leadership in world affairs.
So far, not much is being said about the state of health reform.  Ms. Clinton says she will fix what’s wrong with health reform, with more taxes and a public option, giving government more control.   Mr. Trump says ObamaCare  will be repealed,  health saving accounts will make consumers more accountable,  state lines will be erased as barriers to competition,  and competition will lower premiums ,   and Medicare, Medicaid, and Social Security entitlements real remain untouched, thanks to the booming economy under his watch.
It’s up to the voters who decides who wins the debate and the election.  Will it be the sophisticated elite, intelligentsia,  celebrities,  the mainstream media, the Obama coalition,  and vested Wall Street interests  represented by Hillary Clinton?   Will it be the raw silent majorities,  and the American middleclass, and blue collar workers, two-thirds of whom think the country is headed in the wrong direction?
Or will it be ObamaCare, the progressive movement that has insured 20 million of the previously uninsured?  Or will it be middle class and young taxpayers, who resent ObamaCare’s redistribution health policies at the cost of soaring premiums, unaffordable deductibles and loss of their preferred doctors
That ObamaCare is unraveling  there is little doubt.  Insurers are pulling out of most health exchange markets.  Government sponsored plans are collapsing.  Premiums in 2017 will be $7500 higher than promised in 2010.   Physician and hospital networks are narrowing. And multiple critics are warning the dreaded ObamaCare’s dreaded “death spiral” is at hand.
What and who has undermined ObamaCare.  Some say it’s the failure of the health law to live up to its promises.  Some say it’s because insurers were unable to estimate risk because they could not ask about preexisting conditions.  Some says it’s due to the individual and employer mandates.  Some  say you simply can’t achieve increased coverage with affordability at the same time.    

Most say Americans simply don’t want to give up their plans or physicians.     People don’t want government dictating  which services they should receive and from where.    Americans want their health care services delivered  a la carte rather than as a government buffet where everyone is equal but some are more equal than others and where government policies promise homogenation and standardization.
In the end, I believe the debate will be about policy details,  or  transgressive e-mails, but about emotional entrails concerned over our decline as a society and a nation.  The voters’ reaction may well  be a gut rather a mind reaction.


Friday, September 23, 2016

Health System Harms
First, do no harm.
Hippocratic Oath

When American physicians graduate from medical school, we generally take the Hippocratic Oath to do no harm to patients.
This oath is sometimes hard to achieve since medicine is an imperfect art and often requires invasive care,  toxic medications,   and treatments with unpredictable  and fatal outcomes. Differential diagnosis  may produce the wrong diagnosis,  and the right diagnosis may evolve over time.
What complicates matters are high expectations among patients,   the perception that perfect outcomes are the norm,  the growing belief that  huge amounts of data generated by electronic medical records, and Internet accessible, frequently false, information  promoted by the social media will  improve the quality of care.  
Because of pressures to make the right diagnosis under the pressure of time constraints induced  by federal regulations and  entering  data on EMRs, American physicians feel under siege and are growing  paranoid  for taking the blame for escalating costs and for taking the blame for imperfect results.   Physicians feel like hamsters forced to run faster and faster.  This paranoia, and the demands for  entering more and more patient data and absorbing the cost of more and more federal regulations weighs heavily on the medical profession.
The situation is not helped when the AARP Bulletin , with 50 million readers,  in its 2016 September edit, has this headline emblazoned on its front cover Warning! How the Health System Can Harm You.
In the article, Richard Laliberte, lists these 12 ways the health system can cause harm.
1.       Wrong Diagnosis

2.       Sloppy Practices

3.      Lax Hygien
4. Poor Communication
5. Dismal Discharge Planning
6. Drug Blunders

7. Knowledge Gaps

8. Dangerous Doctors

9. Buried Information

10. Outpatient Black Holes

11. Small Thinking

12.  Physician Burnout

All of these harms can and do occur under time and regulatory and medical legal pressures,  but also may give a false sense of  alarm about their frequency of occurrence  the health system. 
The author concludes:
“Be an assertive patient – but not an obnoxious one.  Don’t act as well-meaning clinicians are deliberately crewing up your care, or threaten to call your lawyers.  Be friendly and respectful, and don’t wastr carrgivers’ time on extraneous complaints they can’t so anything about, such as parking or the cost of medications.”

Thursday, September 22, 2016

Trickle-Down Medicare
David Blumenthal, MD, President of the Commonwealth Fund, and heads of 4 other foundations – The John A. Hartford Foundation, The Peterson Foundation, the SCAN Foundation, and the Robert Wood Johnson Foundation, have joined forces to improve care for high-need, high-cost (HNHC) patients,  most of whom are Medicare recipients with chronic disease.
These patients, 5% of the population, account for an estimated 50% of costs. Blumenthal writes that 3 steps will be required t meet the needs of these patients.
·         Understanding this diverse population better.

·         Identifying “evidence-based programs” that offer integrated care at lower costs.

·         Accelerating adoption of these programs on a national level.

The programs to which Blumenthal refers are Accountable Care Organizations , which now number 848 and cover 28 million Medicare patients, MACRA (Medicare Access and Children’s Health Insurance  Reauthorization Act), and other so-called alternative payment programs to be introduced in 2017.   These programs are all intended to replace the Sustainable Growth Program, which has been in existence since 1997,  by phasing out fee-for-medicine which, in the eyes of CMS, encourages fragmented and unnecessary care.
The through to give “providers” incentives to provide better quality care at reduced costs, presumably by closer collaboration ,  bundled payments,  gathering vast amounts of data from electronic health records, and intervening early in care to improve and maintain patients’ health, while saving money , improving quality and outcomes, reducing costs, and, as an incentive, letting hospitals and doctors share “savings, if any.
All of these programs are, in essence, experimental demonstration projects.   ACOs have been around for more than 5 years,  and have a mixed record.  Many of the original “Pioneer ACOs,’ have dropped out of these organizations, because of lack of savings, expenses in setting up and implementing,   federal penalties exacted, and provider and hospital dissatisfaction.    MACRA has yet to be implemented,but is looked upon with dread by many physicians in  surveys.
I wish CMS lots of luck,  HNHC, like most large federal programs bearing new acronyms, will require a vast new bureaucracy to enforce and high levels of collaboration among physicians, primary care physicians,  specialists , hospitals, communities, social service organizations, academics, researchers and others to carry off.  It will  entail phasing out fee-for-service, still the primary mechanism for charging for physicians’ services.   Finally, it will succeed only if it minimizes the number of referrals to specialists and reduced their fees,  not a small tasks when one considers that two-thirds of physicians are specialists  who will not commit financial hari-kari voluntarily.
Source: David Blumenthal, MD, et al,  “Caring for High-Need, High-Cost Patients- an Urgent Priority,” NEJM,  September 8. 2016.




Confessions of a White American

I am an educated male white American.   I confess I have misgivings about being labeled as a bigoted racist,  sexist, homophobe,  xenophobe. 
I  do not regard myself as bigoted, either to the left or right.   I wince when either candidate calls the other a bigot, as a person who is utterly intolerant of any creed, belief, or opinion that differs from not his own.
In America, everyone is entitled to his own opinion, and I respect their point of view.   This applies to blacks,  yellows, browns, and Muslims, no matter what beliefs or religious views they hold.   I am, however, offended when they carry these views to extremes, either by rioting, murder,  discrimination,  or hayhem, as was the case in the New York City pressure cooker bombs or the riots in Charlotte.
I am not a sexist, one who discriminates against women by thinking they are only fit for housework, raising children, or being subservient to men. Those days are long gone.  Women are equal to men, and in many respects, superior. Women make great doctors,  lawyers,  managers, chief executives,  politicians, and national leaders.
I detest homophobia.  Like most others,  I have dear friends and relatives that are gay, or as we like to say who are part of the LGBT community.    I have no hang-ups about them being allowed to marry or to hold responsible positions in teaching,  scouting, or other responsible positions.
I am not a xenophobe.  Come on in, as millions have done before you.   Do it legally.  Do it by pledging allegiance to American values.  Do it by becoming a responsible American citizens.   I would prefer you become assimilated, but I will understand if you want to retain the aspects of your native culture.    I hope you will learn English, and I’s sure you will, as second generation immigrants invariable do.
I  confess I am more of a nationalist than a globalist, and I do not believe in open borders.   But I believe globalism is here to stay and will accelerate with the social media and universal interconnectiveness.   But this should not be done by sacrificing privacy.  Certain things are best kept private, personal, and confidential.
I am what I am, but please don’t call me bigoted.   I am open minded, but I cannot remain close-mouthed on every issue.   There are limits to my tolerance and my compassion.   Some things are my own business and should remain so.   Individuality and personal freedom are, after all, fundamental American values.  They make us who we are.

Sunday, September 18, 2016

Obama Redoubling Efforts To Shore Up Health Law As Concerns Grow About Marketplaces, September 16, Kaiser Health News
The president met with insurers this week to press them to continue to support the effort, and the administration is preparing for a rocky opening of the fall enrollment period because of concerns about rising premiums and limited choices. Nonetheless, on one key measure the law is a marked success: the drop in the number of people without insurance.
Politico: Obama Steps In To Save Obamacare
Deep into the final year of his presidency, Barack Obama is working behind the scenes to secure Obamacare’s legacy, struggling to bolster a program whose ultimate success or failure will likely be determined by his successor. With no lifeline coming from the divided Congress, Obama and his administration are redoubling their pleas for insurers to shore up the federal health care law and pushing uninsured Americans — especially younger ones — to sign up for coverage. The administration is nervously preparing for its final Obamacare open-enrollment season just a week before Election Day, amid a cascade of headlines about rising premiums, fleeing insurers and narrowing insurance options. (Demko, 9/16)
The Associated Press: Behind Health Law's 'Growing Pains,' More Serious Problems?
President Barack Obama told insurers this week his health care overhaul has had some growing pains. But with premiums rising and marquee insurers bailing, could the real diagnosis be "failure to thrive?" The medical term refers to when patients, often youngsters but also adults, fail to achieve or maintain proper weight. This is the fourth election cycle in which the Affordable Care Act has been in play, struggling for political traction and a healthy level of acceptance from a divided public. (Alonso-Zaldivar, 9/15)
The New York Times: By One Measure, Health Care Law Is A Record Success
Included among the many uplifting economic numbers released by the Census Bureau on Tuesday was a remarkable one about health insurance in the United States: Only 9.1 percent of Americans do not have coverage, the lowest level ever recorded by the agency. ... So does that mean the Affordable Care Act is solving the puzzle of getting people covered, a major goal of the law? It certainly looks that way. About 18 million more people have coverage now than did in 2013. But the new numbers also highlight where the law is not working well — and how difficult it will be to drop the uninsured rate much lower. (Abelson and Sanger-Katz, 9/15)
Cleveland Plain Dealer: Republicans Want Change In Obamacare: Rates Rising, Insurers Leaving
Obamacare is a mess, crammed down the throats of Americans by Democrats in Congress. Premiums are soaring and insurers are backing out, cutting consumer choice. The next Congress must repeal and replace it. These were the primary messages in a U.S. Senate committee hearing today that was scheduled by, and dominated by, Republicans. ... A partisan imbalance in a congressional hearing doesn't mean the critics are wrong or right about the Affordable Care Act, also known as Obamacare. But the hearing offered a preview of what's to come in 2017 – both for insurance and for politics, depending on which political party controls the White House and Congress. (Koff, 9/15)
The Hill: Senate Dems Unveil New Public Option Push For ObamaCare 
Senate Democrats and liberal groups are unveiling a new push to add a public option on ObamaCare on Thursday. The effort is led by senators including Chuck Schumer (D-N.Y.), on track to be the next Democratic leader, and Bernie Sanders (I-Vt.), who galvanized liberals in his presidential campaign with a push to go even further and set up a “Medicare for all” system. Sen. Jeff Merkley (D-Ore.) is spearheading the effort. (Sullivan, 9/15)


Saturday, September 17, 2016

Demonization of Trump and His Followers:

Going to Hell in a Deplorables Basket

In her latest attempt to demonize Donald Trump by portraying him unfit or the Presidency, Hillary Clinton has declared that half of his supporters are “racist, sexist, homophobic, or xenophobic” and fall into a “basket of deplorables” and are irredeemable “ and “not American.”  That pretty much covers the hate-mongering bigotry landscape.

Half   of Trump  backers make up roughly 20% of the U.S. populations.  These supporters are thought to include conservatives,  white males,  veterans,  policemen, evangelicals,  blue collar workers,  people dissatisfied with the status quo,  workers have lost income over the last 20 years,   65% to 70% of citizens who think the U.S. is headed in the wrong direction,   consumers unhappy with ObamaCare,  anti-Hillary millenials,  those unhappy with the erosion of traditional values, and those of us who inhabit center-right America.

These Trumpites are wondering.   Am I a deplorable?   How do I know if I’m deplorable?  If I don’t hate anybody, can I still be categorized as a deplorable?  Am I irredeemable – a lost cause, beyond restoration as a caring human being? Is there any hope for me?

Well,  to the  condescending elite,  you may be a deplorable if you exhibit the these behavioral  traits:

If you believe in:

·         Being incorrect, i.e. challenging the views of the current administration.

·         You insist on standing for the national anthem.

·         You  know all the words to the Pledge of Allegiance.

·         If you use your own money to pay, rather than an EBT card,

·         If you call an Islamic terrorist, an Islamic terrorist.

·         If you do not believe Global Warming is settled science.

·         If you believe  in the Keystone pipeline and fracking as  ways to  lower energy costs and make America energy independent.

·         If you say “Merry Christmas.”

·         If you believe you should show some form of ID to vote.

·         If you think the National Debt is a problem for future generations.

·         If you want to keep your doctor and have a choice of health plans across state lines.

·         If you believe all individuals are different and their behavior cannot be homogenized and standardized, i.e.,  all voters don’t fit into the same deplorable basket.

·         If you believe you have the right to fly the American flag in your front yard.

·         If you believe America is an exceptional nation, where individualism and freedom transcend government control.

·         If you don’t think you should have to press “1” for English when seeking information.

·         If you believe immigrants should take a pledge to uphold American laws and values.

·         If you maintain the will of the people should prevail over the will of the elite.


Thursday, September 15, 2016

Big Brother Is Watching, Documenting, Dictating, and  Paying You
Big Brother is watching you.
George Orwell,  1984
He who pays the piper calls the tune

           Times are changing
            In the good old days, after World War II, physicians got much of what they wanted.  They had access to more resources and unprecedented economic growth.  The public wanted more health care, more physicians, and more hospitals. Physicians were respected,  were deferred to,  and received the money they wanted.   The medical world was theirs for the taking.

             But then came Medicare in 1965, rising costs,  diagnostic related groups,  managed care,  the HMO Act of 1973, medical technology advances,   computer driven CT and MRI scans, renal dialysis, organ transplants, and joint replacements, and open heart procedures,  stents, and the relentless rise of government and  corporate surrogates such as insurers,  hospitals, integrated health organizations,  big pharma, and the so-called medical industrial complex.

           Along with this rise came shifting sources of power and influence.   Physicians were no longer that only game in town.   They had to set aside time, energy, and personal resources to form organizations and to devote their time to activities they did not find personally satisfying to keep their place in power spectrum.

         Power became diffuse.   Government, because it was paying for more and more care, began to dictate the terms of patient engagement – what procedures  could be done and what price.    Physicians had to negotiate with insurers to remain in their networks.

         Government become more watchful, meddlesome, and intrusive, and with new computer technologies, they had the power to impose their will.   Government  decided tat power could be exercised in the form of electronic records  which could be installed in every doctor’s office and could be used to document  everything entailed in the diagnostic and therapeutic activity.   Furthermore,  it could used to determine what was of “value” to the patient,  what was the proper optimal quality/outcome equation,  what separated the good doctors from the bad doctors,   what they should be paid,  and how this magical electronic technology could be used to centralize power,  to homogenize and standardize physician behavior, and achieve continuous quality improvement and total quality control.

             But government failed to recognize that  there is no magical way to influence physicians and to bring them to heel, that quality is an elusive concept,  that individual physicians and patients cannot be reduced to data points,  that physicians and patients alike cherish privacy and confidentiality ,  that data on populations may not apply to individuals,  and that somebody must decide what to do and how to diagnose and treat individual patients.

Wednesday, September 14, 2016

ObamaCare News Last Five Years
Over the last 5 years,  I have written 2480 blogs at my Medinnovation and Health Reform website
News items inform many  of these blogs.  I estimate that 80% of these news items contain bad news about ObamaCare implementation, with the exception being reduced numbers of uninsured,  which declined from 33 million to 29 million in 2015 and by 20 million since 2010.
Reporting bad news is inherent in news coverage. Bad news sells better than good news.   All the news that’s fit to print is  often  bad, of your your ideology or your position on health reform
Today is no exception.

News items today include:

·         Nobody Can Predict the Outcome of This Election 

·         Employers’ Average Premium Costs Are $18,000 for Families

·         Washington’s Wake-up Call

·         Another ObamaCare Co-Op Fails,  Leaving Only Six
·         ObamaCare Insurers’ Exit Being Felt in Battleground States

·         MACRA Trojan Horse for Value-Based Care

·         Can ObamaCare Be Fixed?

Uncertainly rules the day.  ObamaCare’s fate hinges on the election.   Soaring premium may influence the outcome.
The health exchanges are in deep trouble with insurers abandoning many states,  leaving 31% of America’s 3000 counties with only one plan. 
The young are not signing  up for exchanges because premiums cost twice at much as remaining uninsured and taking the $695 premium hit and because you wait to sign up when you get sick.   

Tuesday, September 13, 2016

Accelerating IT Adoption Among Clinicians: The Fundamentals
Two New England Journal of Medicine articles inspire this blog.
·         “Counting Better – The Limits and Future of Quality-Based Compensation, “ by Christopher Dale, MD, Michael Myint, MD, and Amy Compton-Phillips, MD, of Swedish Health Services, in Seattle., August 18, 2006.  The authors speak for the Swedish Medical Group, a 1200 multispecialty group, which is having troubles redesigned a compensation package  that does not rob “clinicians from the joy and meaning of partnering with patients to create health ‘ by relying too much on performance metrics.

·         “Accelerating Innovation in Health IT,” by Robert Rud, PhD, David Bates, MD, and  Calum MacRae, PhD, or RAND and various Harvard-based Harvard organization, September 1, 2016.   The authors comment on lag in health IT, on physician dissatisfaction with EHRs, on the disconnect between IT developers and clinicians,  and how to bridge the disconnect – involvement of multidisciplinary teams, focusing on users’ needs,  redesigning care processes,  having the freedom to experiment and fail quickly.= 

Accelerating Adoption may be even more fundamental than that,  by asking what clinicians need and  are already  doing. 
What every clinician needs – 1)  the patient’s demographics and chief complaint and medical history; and 2) what most clinicians already collects – the patient’s weight  and height, vital signs, and basic laboratory information.
Computer Interview
The former could be provided by the patient in computer interview  conducted at the patient’s home computer or in a waiting room  and processed by an existing clinical algorithm ( the commercially available “The Instant Medical History” is an example), and this could be combined with the vital signs, to produce a narrative history and rudimentary differential diagnostic summary available when the patient enters the examination or interview room.     This can save the doctor as many as 6 to 7 minutes for each patient encounter.
Merits of Computer Interview

This approach has these merits; 1)  the patient’s time, not the clinician’s time,  is involved in producing the basic information; 2)  the clinicians can quickly focus on the basic clinical problem,  giving the  clinician extra time to see more patients;  3) the relevant information can be used to generate a proper code and to use in case a referral letter is required.
Insatiable Demand for User-Friendly IT Functionality
As the authors comment, “There is an insatiable demand for new, useful, user-friendly IT functionality.”   Current electronic heath record models for the most part are not-user friendly and are often developed by soft-war experts who have never set foot in a busy doctor’s office who is struggling to make ends meet.  “Emerging provider-payment models must “seek tools to help reduce costs and improve quality.’  Only then will “IT-enabled transformations… might finally come to health care.”
1.        Friedberg, et;  “Factors Affecting Physician Performance Satisfaction  and Their Implications for Patient Care, Health Systems, and Health Policy,” Santa Monica, CA, RAND,  2013.

2.      Ratwani, RM, et al:  “ Electronic Health Record Usability; Analysis of Use-Centered Design Processes of Eleven Health Record Vendors, J Am Med Inform Assoc, 2015:22:1179-1182.

3.      Jones, SS, et al: “Unraveling the IT Productivity Paradox: Lessons for Health Care,” N Engl J Medicine,  2012: 366:223-5.

Dartmouth Drops ACO: a Crowning Blow for CMMI

An ObamaCare administrator has dubbed the Center of Medicare and Medicaid Innovation (CMMI) as “the jewel in the crown of health care reform.”
A Tarnished Crown
The crown just got tarnished as the Dartmouth Hitchcock Health System announced it was dropping out as the lead  member of the Pioneer Accountable  Care Organization (ACO).
The Problem

The problem is this:  a team from Dartmouth advanced the idea of ACOs in a 2006 Health Affairs article as an innovative way to generate  “savings” for Medicare by inducing doctors and hospitals to collaborate and cooperate.    Presumably, by replacing the disjointed fee-for-service system,  ACOs would not only save money but allow doctors and hospitals to share the savings.  
ACOs Not Working as Planned

Sadly, these “savings” aren’t, for the most part, working out well, even though Medicare now has more than 400 ACOs serving 8 million of Medicare’s 57 million enrollees.   Because of financial penalties for not saving money and because of the cost of setting up and administering ACOs,  many of the participating  hospitals and doctors are taking a financial bath.
Dartmouth Takes a Bath

Robert A. Green, executive VP of the Dartmouth Hitchcock system, explained why Darmouth as dropping out, “ We were cutting costs and saving money and paying a penalty on top of that.  We would have loved to stay in the federal program, but it was just not sustainable. “  Dartmouth has to lay off 400 employees and cut its financial losses,  which amounted to $100 million for the program and $12 million for the health system.

“Not sustainable” has become the mantra for a lot  of CMMI demonstration projects, which do not work out as planned in the real world.  Health insurers, for example,  have  ceased operations of the health exchange market in multiple states,  claiming they can no longer sustain billions of dollars of losses.   CMMI is now experimenting  of testing new ways to pay for prescription drugs  reduce use of medical devices,  and hip and knee replacements.    CMMI asserts it will save $34 million over the next decade,  assuming ObamaCare lasts that long.   But Republicans are not going along  and are preposing to cut $7 million out of the CMMI budget.
Government Not Good at Innovation

The sad truth may be that government has never been very good at innovation.  Historically, the reasons for failure of “government” are clear.   Government cannot managed failure; seldom abandons a project;  is not gambling with its own money; measures its success with good intentions, not results; succrrrd by growing too big to fail and too influential to stop; and cannot go out of business, can print money to keep on going, and is propped up by taxpayer money.
Hold onto Your Wallet

When government proposes to “save money” through innovation,  hold onto your wallet.  In the hands of government, a penny or a billion)saved is not a penny  or billion saved.
In the words of Dr. Elliot Fisher of the Dartmouth Institute of Health Policy, the lead author of the 2006 Health Affairs article  proposing ACOs, “ The model has yet to achieve the benefits may advocates hoped for.”  Maybe the model of independent fee-for-service isn’t all that inefficient after all.