CMSBS and CJR

I am aware  what you must be thinking,

CMSBS is bureaucratic language stinking.

Well, you’re partly right but mostly wrong.

 CMS is a well-known governmental dipthong,

short for Centers for Medicare and Medicaid Services,

BS stands not what you think but for Bundled Services,

By 2019 CMS hopes to merge bills for episodes of care

into a consolidated bill for preop, op, and postop fare,

Thereby making care seamless and collaborative,

under the illusion everything will  be co-operative.

CMS will start with artificial hip and knee insertions,

and  presumably for other types of joint reversions.

CMS will call this CJR – Comprehensive Joint Replacements-

to wipe out any trace of  multiple bill placements,

Hospitals, doctors, and rehab services are not yet ready,

And for the new billing arrangements are unsteady,

But never mind,  CMS says what health care needs now,

is a  federal acronym to rein in the runaway cash cow.

Are We a Bottom-Up or Top-Down Health Care Nation?

Despite the conceits of New York and Boston, almost nothing starts there.  In the course of my daily work, I have been overwhelmingly impressed with the extent to which America is a bottom-up society.  Trends are bottom-up, fads top-own.

John Naisbitt, Megatrends, 1982

Bottom-Up Thinking

Here I shall argue that America is a bottom-up,  not a top-down society;  that every health care organization,  large or small, rests on its own bottom;  that individual self-reliance beats government dependence;  that there are limits of government intervention into the health system; that government tyranny may  result from control of economic decision-making through centralized planning;  and that the chief danger of government economic omnipotence  is loss of individual enterprise  and serfdom.

America was founded on the belief  that government is best that governs least,  that the majority at the bottom rules over the minority at the top;  that equal opportunity trumps equal results;  that you cannot standardize individual behavior through government fiat; and that, in the end, market competition is more efficient than  government  coercion.

Top-Down Thinking

ObamaCare epitomizes top-down thinking.   It does this largely through a series of mandates – individual  mandates,  business mandates,  religious mandates,   and physician mandates. The physician mandates rest on  the thesis that one can calculate “value” through an interlocking system of electronic health records, that one can regulate physician behavior  through centralized planning, that  outside experts and managers, not physicians or patients,  and that government, not markets, know best.

The Other Side of the Argument

There is, of course, another side to this argument, namely,  that ObamaCare has ensured coverage to roughly 20 million previously uninsured people;   that Medicare and Medicaid and ObamaCare now cover roughly 150 million Americans and are widely popular and inextricable ;  that outcomes based on data are more objective than subjective judgments by patients and physicians;  that the people have spoken in favor of Obama in 2008 and 2012; and that government compassion for all should override passion for individualism, which generates greed and social inequities;  and that  economic populism, and business ethics  as exemplified by conservatives, has no. place in civilized society.

I  do not know how to resolve these differences  so I turned to  Topsy-Turvy,  my medical market guru,  for guidance.

 Topsy-Turvy: An Interview with a Medical Market Guru

Q: Why do you call yourself a Topsy-Turvy Medical Market Guru?
A: Because the medical markets are turning upside down. The top is where the bottom should be, and everything is inverted or reversed from where it ought to be. A guru, of course, is someone who knows everything about everything. That’s me.
Q: Explain. Please.
A: Well, everything is consolidating at the top, in hospitals, health exchanges, health plans, and government but they are decentralizing at the bottom in the form of patient-centered, consumer-driven care with removal of those “silos” between different parts of the health system. Everything in the future will be “coordinated” and dictated by data, evidence, and value, as defined from the top-down but resented from the bottom-up.
Q: Examples. Please.
A: Take hospitals. They’re getting bigger and bigger and will soon employ 70% of all doctors and 90% of young doctors, but hospitals are setting up offices and clinics outside their walls to make their services more convenient. Of course, all hospitals and all doctors will have electronic records. Meanwhile doctors at the bottom in private practice are a dying breed.
Take health exchanges. They are a perfect example of top-down government. By February 15, the end of their 2nd sign-up period, the exchanges will have 12.7  million members. Yet 250,000 doctors at the bottom have decided not to accept health exchange members.
Consider Medicaid. It is growing like Topsy. It will soon top 70 million membership. Even conservative states, like Indiana, are reeling in more Medicaid recipients. Yet some 30% to 40% of doctors, depending on the state, refuse to accept those in Medicaid or health exchange plans. And as many as 20% no longer accept new Medicare patients, who are growing in numbers at the rate of 10,000 a day. Bottoms-up are is down.
Think about ObamaCare as a whole. It’s a budgetary sink hole , the main driver of our soon-to-be $20 trillion national debt. Yet ObamaCare is approaching a state of no return, of not going back, of irreversible government gains. It is now a creature of the IRS, who will have every American filling out a form about their insured or uninsured status, and who will penalize 6 million of us for not having a health plan.
Q: So?
A: Well, the Republicans at the top want ObamaCare reversed or repealed, but they can’t because nearly 13  million uninsured are now being subsidized in federal health exchanges,.
Republicans say the top pillars of ObamaCare – individual and employer mandates – will collapse, and the whole thing will come tumbling down. Democrats claim "massive disruption" would ensue, and hospitals and health markets would suffer terrible economic consequences.
The GOP claims ObamaCare is like Humpty-Dumpty. Critics say once Humpty-Dumpty falls off the Wall, all the President’s horses and all the President’s men won’t be able to put Humpty-Dumpty together again.
Q: Do you buy that argument?
A: No. A Peter Pan analogy is better. Peter Pan was the story of a boy who never grew up. As long as he could fly and sprinkle magic dust on everything, everything would be “fair,” and everything would come out OK for everybody. Everyone would have their "fair share"of society's cake and could eat it too.
Six of 10 Americans believe in Peter Pan and magic dust. If the Supreme Court disassembles federal subsidies, 60% of people in a Kaiser poll say government should restore the subsidies and Humpty Dumpty can be put together again.
Q: Oh, Guru, are there other factors that may destroy these fairy tale myths?
A: Two.
One is the power of smart phones and the Internet. In the last quarter, 75 million people bought Apple smartphones. These people, many of whom are millenials and middle class and many of whom resent redistribution of their incomes and health benefits, may change the system bottom-side up by demanding return and evidence for their dollar.
Two is the behavior of physicians. Nearly 50%, actually 46%, give ObamaCare a D or F grade, another 30% to 40% aren’t taking Medicaid or Medicaid patients, and 20% have either switched to cash only practices, dumped third parties, or are contemplating doing both.
If a fairy tale sounds too good to be true, it usually is. Life, you see, isn't fair. You have to work to make it fair, and Government, as hard as it tries, can't speak or act for you. Only you can.

 

 

 

 

 

50 Most Influential Physician Executives and Leaders 2016

On the basis of peer review survey,  Modern Medicine has selected the 50 most influential  physician executives and leaders in America.  In this era of  ObamaCare,  these leaders  reflect the trends of the time, namely,  health care consolidation into integrated health organizations(19),   academic institutions (4) ,    hospital systems (6) , controlling government agencies(9)   large health plans (3) , various associations (7)   with special interests (2).      

 

 

 

 1. Robert Califf , MD,

Commissioner Food and Drug Administration

2. John Noseworthy, md

President and CEO Mayo Clinic

3. Patrick Conway, MD

Deputy administrator for innovation and quality, chief medical officer, CMS

4. Robert Wachter, md

Professor and interim chairman, Department of Medicine University of California at San Francisco

5. Toby Cosgrove, md

President and CEO Cleveland Clinic

6. Richard Migliori, md

Executive VP of medical affairs and chief medical officer, UnitedHealth Group

 

7. David Torchiana, md

President and CEO Partners, HealthCare

 

8. Benjamin Chu, md

Incoming president and CEO Memorial Hermann

9. David Feinberg. md

President and CEO Geisinger Health System

10. Jonathan Perlin, md

President of clinical services and chief medical officer,  HCA

11. Gary Kaplan, md

Chairman and CEO Virginia Mason Health System

 

12. David Shulkin, md

Undersecretary for health, Veterans Affairs Department

13. Steven Safyer, md

CEO Montefiore Medical Center

 

14. Rodney Hochman. md

President and CEO, Providence Health & Services

 

15. Prem Reddy, md

Chairman and CEO, Prime Healthcare Services Prime Healthcare Services

16. Roy Beveridge, md

Chief medical officer Humana

 

17. Atul Gawande, md

Surgeon, professor, writer, researcher Harvard Medical School and Harvard School of Public Health

18. Charles Sorenson, md

President and CEO Intermountain Healthcare

19. Elizabeth Nabel, md

President ,  Brigham and Women's Health Care

20. Mark Chassin. md

President and CEO Joint Commission

21. Eric Topol, md

Chief academic officer, Scripps Health; director, Scripps Translational Science Institute Scripps Health

22. Vivek Murthy, md

U.S. surgeon  general, U.S. Public Health Service Commissioned Corps

 

23. Peter Pronovost,md

Director, Armstrong Institute for Patient Safety and Quality; senior VP for patient safety and quality. johns Hopkins Medicine

24. Ram Raju, md

President and CEO NYC Health & Hospitals

25. Bruce Siegel, md

President and CEO America's Essential Hospitals

 

26. Risa Lavizzo-Mourey

President and CEO Robert Wood Johnson Foundation

27. Francis Collins, md

Director National Institutes of Health

 

28. Humayun Chaudhry, md

President and CEO Federation of State Medical Boards

29. Richard Gilfillan, md

President and CEO Trinity Health

 

30. Tejal Gandhi, md

President and CEO National Patient Safety Foundation

 

31. Penny Wheeler, md

President and CEO Allina Health

32. J. Mario Molina. md

President and CEO Molina Healthcare

 

33. Thomas Frieden, md

Director Centers for Disease Control and Prevention

34. David Pryor, md

EVP and chief clinical officer Ascension

35. David Blumenthal, md

PresidentCommonwealth Fund

36. Victor Dzau, md

President National Academy of Medicine

37. Troyen Brennan, md

EVP and chief health officer CVS Health

 

38. Craig Samitt, md

Chief clinical officer Anthem

39. Kenneth Davis, md

President and CEO  Mount Sinai Health System

 

40. Lynn Simon. md

President of clinical services and chief quality officer Community Health Systems

 

41. Francis Crosson, md

Chairman Medicare Payment Advisory Commission

42. William Roper, md

CEO, UNC Health Care, University of North Carolina at Chapel Hill UNC Health Care

 

43. Susan Turney, md

CEO Marshfield (Wis.) Clinic Health System

 

44. James Madara, md

Executive VP and CEO American Medical Association

 

45. Craig Thompson, md

President and CEO  Memorial Sloan Kettering Cancer Center

46. William Conway, md

Executive VP and chief quality officer, Henry Ford Health System; CEO, Henry Ford Medical Group Henry Ford Health System

47. Lynn Massingale, md

Co-founder and executive chairman  Team Health

 

48. Ronald DePinho, md

President  MD Anderson Cancer Center

 

49. Karen DeSalvo, md

National coordinator for health information technologyHHS

 

50. David Bailey, md

President and CEO Nemours Children's Health System

Physician Leadership and Physician Culture

Future shock...the shattering stress and disorientation that we induce in individuals by subjecting them to too much change in too short a time.

Alvin Toffler (1928), Future Shock

To say physicians are undergoing cultural change is an understatement.    To say this change represents “future shock” in an overstatement.

Nevertheless, among physicians, the need for cultural change is profound. This change requires adjustments in thinking about clinical, management, and leadership affairs.  It requires changes in thinking about individual physician performance and collaborative physician performance.

Traditionally, physicians have handled complexity by specializing, mastering individual clinical/academic skills, and celebrating this mastering.  Physicians have shown a disinclination for followship and collaboration.   We stand on our own two feet and nobody else’s. 

We have focused on clinic/academic performance rather than organizational leadership.  We have been inattentive to training and preparing for leadership.   Our general attitude has been that every physician puts on his/her pants the same way, and you cannot and indeed, should not, differentiate leaders from followers.  In short, to paraphrase George Orwell, all animals are equal,  and no animal is more equal than the others.

But medical  trends,  they are a ‘changing, as  Tim Norbeck and Walker Ray,  MD,  president and CEO of the Physicians Foundation respectively,  pointed out in a January Forbes  article,  “Four Critical Trends Physicians Must Keep Top of Mind in 2016.”  

These trends are :  1) evidence-based regulation; 2) health insurance market consolidation; 3) value-based care, 4) physician leadership.  We cannot escape them, and we must collaborate to cope with them.

Physician leadership calls for an understanding of leadership skills more than management or technical clinical skills.  It demands  a whole new mindset.   The Physicians’ Foundation knows this, and so do a growing number of physician organizations and MBA programs,  who have set up physician leadership development  programs for addressing and overcoming  cultural and administrative barriers,  for  quality and performance reporting and measurements,  for  adapting to  ICD-10 coding,  and for coping with  the pressures of a rapidly changing health system  requiring collaboration rather than individualism.

Leadership is a vast and amorphous subject.  Most of us know leaders when we see them, but leadership is a slippery subject to pin down. 

Leadership takes personal, organizational, innovation, and teamwork.   

Leadership takes a clarity of purpose,  strategic vision,  building trust and credibility, persistence  when challenged by obstacles, political savvy,  a positive attitude,  praising and recognizing emerging leaders,   self-confidence,  formal education or experience in management and leadership, and that elusive trait known as charisma.   

Leadership  takes disciplined passion,  big ideas of where the future lies,  seizing opportunities,   creating a new organizational bandwagon,  a comprehensible  defined strategy,  and  knowledge of  your limitations  and the strengths of others. 

Leadership takes building an effective team, developing a measurement system to know how one is doing, and knowing what is of value to patients and what they need.

Leadership  takes honesty,  delegating  to others, commitment, communication, a positive attitude, creativity,  intuition,   inspiration,  and a flexible approach when things go wrong.  

None of these things are safe and easy to do, but they are what physician leaders must do.

Hospital  Immersion – Seeing Is Understanding

Sometimes you can’t explain something. 

You have to see it to understand it, like  fiendishly complicated deeply nuanced  hospital care.  

This was the premise of 2 physician hospital board members,  who created “Immersion Day” for Mission Health,  a 763 bed medical center in Ashville , North Carolina ,  a $1.6 billion  enterprise.

 The 2  physicians describe the day in the March 31 edition of the New England Journal of Medicine – “Immersion  Day – Transforming Governance and Policy by Putting on Scrubs.”

Their idea was simple and obvious -  Have hospital board members, journalists, legislators, and regulators put on hospital scrub suits for day and expose them to the workings of the hospital to deepen their understanding of the workings of the hospital, its complexities, and its costs.

As an American Indian once explained,  “You have to walk a mile in another man’s moccasins to get the smell and feel  of what he does.”

“Immersion Day” begins at 7:30 AM with a orientation and a signing of confidentiality agreements, followed by exposure to pre-op care, listening to patients’ stories, then watching the surgical team put the patient to sleep,  witnessing an operation,  then joining rounds in the intensive care unit, observing critically - ill patients, talking  there with nurse, hospitalists, and case managers, then going to open-heart surgery suite,  observing an operation, then rounding with specialists,  and watching hospitalists struggle with entries into electronic health records or doing beside procedures,  and ending the 9 to 12 hour day in the emergency room, as witnesses to the overcrowded  controlled chaos with its unforgettable moments.

Board members called their Immersion Day as “eye-opening  and endlessly fascinating, “ “unforgettable and humbling,” “the best-spent day of my life,” and “ Iearned more about hospitals and health care in 10 immersion hours than 6 years sitting on the board.”

The 2 doctor authors conclude”  Deep immersion in the work of our health system has strengthened governance and engendered trust in our community, staff, and physicians, while elucidating health care for policy makers.”

Once board members – manufacturers, investors, and  bankers -  have been there and seen that, they know how a health system works. And they understand the system’s complexity, the human nuances,  the workflows and the choreography , the opportunities for error, forces behind increasing costs, and why human good flows from serving all patients regardless of ability to pay.   Knowing intimately how the health system  transforms the system by humanizing it and it creates better working relationships between the hospital board and the physician staff.