Market Reforms - Health Care Choice – U.S. Health Care’s “Wild Card”

Choice is the right, power, and chance to choose. It’s freedom. It’s also variation – the bane of those who preach “zero variation” in human behavior and human services.

This is America, and we vary as a people.

Choice lets patients choose one doctor – or many doctors. Some say multiple doctors are bad. It’s best, they argue, for each patient to have one medical “home.”

This is America, not the United Kingdom, where patients must go through a family physician.

Here people have choices from whom to seek care. Managed care failed when it tried to route patients through gatekeepers. Medicare patients now average seeing six doctors yearly. Patients with multiple diseases average 11 doctors, mostly specialists, often unknown to each other. This is bad, critics say. Choices ought to be few, and each patient should have one record, shared by all doctors.

This is America, and some say a personal health record violates privacy and invites job discrimination.

People can choose to go to one doctor, or to groups. In groups, advocates say, doctors can confer with one other, work as teams, provide multiple options, coordinate care, and offer one-stop care. For first visits, however, 90% of patients still choose solo or small groups for first visits. It’s about neighborhoods, word of mouth, and personal referrals.

This is America, and patients can choose solo practitioners or groups.

In America, people can choose to be uninsured or uninsured. Some have no choice. They can’t afford premiums. But two-thirds of those without coverage work. Some choose not be insured. Being young and healthy, they may see no need for insurance. In Massachusetts officials claim insurance is an obligation, not a choice, but many uninsured, given a choice of paying or not paying, prefer not to pay,

This is America, and people can make irrational choices.

Some say a free marketplace offers more choices, better quality, and lower costs. Doctors, it’s hoped, will compete openly on costs and quality.. “Transparency” will make it clear in advance what things cost. Costs will drop for all care, as they have for cosmetic and laser eye procedures.

This is American capitalism at work, and markets will decide.

Government and corporations seek to correct bad habits by banning smoking in public places and at work, raising “sin” taxes, forcing food vendors to post nutritional labels on their products, and banning trans-fats.

This is America, and people can pick their poisons.

Doctors have choices, too. They can choose to be paid fee-for-service or on salaries, practice in solo or in large groups, or in hospitals or academic institutions.

This is America, and doctors can choose where they want to work and how they want to be paid.

Doctors can choose to see patients – or not to see them. With a scheduled decline in Medicare payments of 10% next year, nearly 30% of doctors say they will choose not to see new Medicare patients. As many as 50% of doctors don’t accept Medicaid patients. Doctors say they have no choice. Medicare and Medicaid payments don’t cover overhead.

This is America, and doctors can choose whether to accept patients to stay in business.

Doctors have a choice whether to invest in EMRs. Only 15 to 18% do. Some say EMRs are the electronic Holy Grail. EMRs will improve care, patient safety, and efficiency. Doctors say EMRs cost too much, invade privacy, and are good for government and health plans, not for doctors and patients.

This is America, and doctors can choose to reject information systems.

Doctors can choose to follow clinical guidelines, which may standardize and improve care, and end variation. Only 50% of doctors choose to meet all indicators.

This is America, and doctors can choose to follow their own judgments.

More than 80% choose to practice as specialists. Specialists have more respect and earn more money. A final year medical resident survey indicates <1% will choose to practice n towns of 10,000 to 25,000, 4% in towns of 5.000 to 50,000, and 81% will choose to practice in cities of 100,000 or more.

This is America, and doctors can choose what specialties to enter and where to live.

Doctors can choose what drugs to prescribe. With drug formularies, and government and health plans policing brand name use and identifying “outliers, ” choices are narrowing. Some patients are asking doctors to dispense cheaper drugs. Everybody is looking for more bang for their buck, an inevitability in an inflationary health cost environment.

This is America, and doctors can still pick which drugs to prescribe.

Critics say doctors work in a “cottage industry,” meaning they vary in their practices, resist standards, and practice individually, using their own clinical judgment. Doctors counter by saying government and health plans have no business “practicing medicine.”

This is America, and some doctors still think of their “cottage” as their “castle”

Health Reform Predictions - Early Odds on Health Reform Horse Race

Four horses are at the starting gate.

•Status-Quo (SQ): SQ may prevail because any significant reform gores someone’s ox, pardon, horse, i.e., other entrenched, special, vested interests. On the other hand, absolute SQ seems unlikely in this era of accelerating health care inflation. Odds: 7/10

•Single payer(SP): SP unlikely because of America’s culture—the Red/Blue cultural war, distrust of government, preference for incrementalism, distaste for programs requiring greater taxation, and current struggles of coverage-for-all programs in Massachusetts, California, Pennsylvania, and Illinois. Could happen with Democratic sweep in 2008. Americans want something simple, understandable, and equitable, with one billing source. Odds: 3/10

•Consumer-Driven System (CDS): CDS hard to explain. Going too slowly politically for government and business payers, and populace as a whole. Essential ingredients are: more health care choices, universal $15,000 tax credit for all families, same tax code deductions for corporations and individuals, HSAs, medical malpractice reform, and nationalizing insurance market across states. Requires Republican president in 2008. Odds: 2/10

Serious Managed Care (SMC): Highlights: The three (Ts) - quality, price, and outcomes transparencies, the three Ps (provider profiling, P4P, and protocols), and the big E (exclusion from networks of doctors and hospitals who fail to mind their Ps and Ts). Combines elements of previous three scenarios.

The return of serious managed care may be the horse to watch for these reasons.

•All other horses are fading in the stretch.

•Horse owners - business leaders, desperate for health inflation relief and desire to be globally competitive, have the technology and political leverage to effect a change.

•Trainers for horse owners - health plan executives, now have the whips, management platforms, and information technologies to track and clamp down on providers.

•Horses themselves, now have the tools -- physically integrated systems, Toyota-lean models to cut costs, and virtually integrated systems - with leverage to make “right” things happen – price and quality transparency, sharing comparative data, paying for total disease episodes rather than fee-for-service, and managing chronic disease.

•The workhorses, and the studs - primary care physicians, and a few specialists, are either demoralized, or having a hard time making a living, paying malpractice premiums, paying off educational debts, and in their distress, are joining hospital staffs as salaried employees, running work site clinics in corporate settings, or in one way or another, consolidating into larger organizations to managed realities of more competitive world. To breed truly competitive race entries, they will need to develop new training methods, new business models, and entrepreneurial and innovative ways of doing things to win present and future races. Odds: 6/10

Ladies and Gentlemen, please place your bets and tell us how you would change the odds in favor of your favorite horse.

E-Medicine - Lost in Cyberspace? Try Googling Yourself.

About five years ago, Dr. John Bachman, professor of primary care at Mayo in Rochester, told me I could find almost anything I wanted to know on google.com. At the time, I was interested in Internet tools to increase practice productivity and use of computers for patient interviewing. John was right, of course. He usually is.

Later I learned it pays to google yourself. In fact, Joseph Scherger, MD, clinical professor of preventive and family medicine, University of California, San Diego, in “Google: Searching for a Reputation,” AMA News, April 23-30, 2007, wrote, “ I think everybody should periodically google themselves.” To gain insight into your standing in the medical world, Scherger advised, review yourself on google.

I followed Scherger’s advice and googled myself.

•Under Richard L. Reece, MD, I found 19 entries

•Under medinnovationblog, I discovered a dozen entries

•Under my latest book Innovation-Driven Health Care, I unearthed another dozen entries.

Try it yourself to see if the google algorithm can serve as your GPS in Cyberspace.

As we all know by now, the Internet changes everything. Google may be the greatest innovation ever to hit the Internet. The stock market agrees. Google is far outpacing Microsoft, Yahoo, and WebMD. Google is rated the world’s top brand, its brand worth $66 billion, more than GE, Microsoft, or Apple.

Accordingly, all of you doctors out there. Google yourselves from time to time to assess where your space in cyberspace.

How?

Simply go to google.com. Type your name in the search box. If you want to know the good news and the bad news about yourself, re-enter your name with modifiers like “praise ” or “complaints.” If you’re really curious, you might even extend your googling to yahooing or altavistaing.

Google is simple. It’s easy. And information about yourself is just a click away.

For you humanists and technologically impaired or challenged non-nerds out there, I close with three couplets.

To see how you rate, Google yourself,
just to make quite sure you’re top-shelf.

Go ahead and self-Google.
It’s no ego- boondoogle.

Think of self-googling.
As self-doodling.

Regional Care - A Love Letter to Minneapolis

A Love Letter to Minneapolis



August 2, 2007


Dear Minneapolis:


When the 35W bridge fell, my heart sank. We raised our two sons near there. I practiced near there. My hospital was near there. I frequented the Minneapolis Club near there. I saw Twins games near there. I could see the IDS tower and the University of Minnesota campus from there. The 35W bridge connected Minneapolis and St. Paul, the two beating urban hearts of Minnesota.


The bridge lies at the very heart of Minnesota health care. Two great teaching centers, the Hennepin County Medical Center and the University of Minnesota Medical School and Hospitals are nearby. Routine open-heart surgery, enabled by Lillihei’s bypass machine, started at the U. The U’s medical school and hospital administrator school have produced many national health leaders. It is not by chance that Minnesota has been the nation’s healthiest state for many years, or that it has the nation’s lowest rate of uninsured. You have a gift for organizing to do the right thing.

You’re a great city with a big heart, and you’re the heart of a great state. You’ve learned how to mix and match health care special interests, business and politics for the greater good. You’ve mastered the art of building large and effective health care organizations. Your leading businesses contribute 5% of their profits to the arts. You’re a city with a heart – a heart temporarily severed.

Don’t worry. You’ll be OK, Minneapolis. The physical infrastructure linking your great centers of education and commerce may be down for a time, but your bridge to the future, your social infrastructure, remains intact. You’ll be fine, and those of us who lived and thrived there will always love you for what you are.


Love,


Richard L. Reece, MD

Old Saybrook, Connecticut

Minneapolis resident from 1965 to 1990

Editor, Minnesota Medicine, 1975-1990

The Physician Shortage and Universal Coverage

If universal coverage is achieved, the physician shortage will intensify. This is already happening in Massachusetts, the state farthest down the path of coverage-for-all. A July 25 WSJ piece (“Doctor Shortage Hurts a Coverage-for-All Plan”) tells the story of Tamar Lewis, who was told by two dozen, groups they no longer were accepting new patients. In Massachusetts, 49% of internists aren’t seeing new patients. Boston teaching hospitals employ 270 primary care physicians, and 95% of these hospital doctor groups don’t take new patients,

The primary reasons for this low acceptance rate seem to be three fold: 1) a steady fall in medical students entering primary care (the percentage fell from 55% in 1998 to 20% in 2005); 2) “too little money for too much work” (mean income for primary care was $162,000 in 2005); 3) the decrease in the number of uninsured with more patients seeing doctors.

The physician shortage is likely to grow worse. Cooper, in a February 2002 article in Health Affairs, forecast a 50,000 physician shortfall by 2010 and a 200,000 shortage by 2020. According to Merritt, Hawkins, and Associate Guide to Physician Recruiting, searches for primary care physicians in 2005/2006 picked up most dramatically for internists ( 46%), family practice ( 55%), but were also up for certain specialists : general surgeons 42%, hospitalists 81%, and emergency medicine 94%..

Governor Deval Patrick of Massachusetts noted, “Health care coverage without access is meaningless.” The shortage is likely to grow even worse as America’s 78 million babyboomers enter the Medicare in 2011. Solutions suggested include: build more medical schools, change the standards and restrictions for medical school admissions, pay primary care physicians more, reduce the pay differentials between primary care physicians and specialists, employ more nurse practitioners and physician assistants, recruit more international medical graduates and make it easier for them to enter the country.

Profiling, Pay for Performance, and Protocols for Physicians

I just received a brochure “Summit on Provider Profiling & Pay for Performance: Proven Solutions to Engage Providers, Improve and Reward Quality and Optimize Financial Efficiency, “ a conference to be held Oct. 23-24 in Bally’s in Las Vegas.

Sponsors include Cigna, various Blue Cross Plans, Aetna, AmeriGroup Corp. The Regence Group, Humana, Inc, HIP Plan of New York, Harvard Pilgrim, Texas Medical Association, the Centers of Medicare and Medicae. Managed Care Week, The Executive Report in Managed Care, the Managed Care Information Center, and the Pay for Performance Reporter will report the event.

The cost for attending this day summit varies from $1295 to $2495, depending on if you want to attend the conference only or the conference and two workshops. The blurb promoting the event says “Learn from over 18 CMOs and National Medical Directors to achieve a genuine ROI!”

Here are some questions I put to doctors to see how they would react to this brochure?

What is your impression of such a conference?

•Is this a good thing or a bad thing”

•Will it help you practice better medicine and improve care for your patients?

•Do you believe such a conference, the latest emphasis of the managed care industry, will cut costs, reward good doctors, improve care, and result in better health outcomes?

•Do you think this conference will be a step forward in incentivizing doctors to practice better medicine?

• Do you think the conference will help health plans “reap robust financial and quality rewards without expanding healthcare expenditures?”

• Will P4P and physician profiling increase physician productivity, efficiency, and quality, or is it an added bureaucratic burden that will increase practice costs and lead to more hassles and overhead?

• Are profiling, pay for performance, and protocols tantamount to having third parties practice medicine – and subsidizing their judgment for the judgment of the physician?

• Are provider profiling, pay for performance, and clinical protocols an effort to justify the further existence of third party insurers?

From physicians, I expect I will get a mixed response, and I anticipate it will be mostly negative since profiling, pay for performance, and protocols threaten their autonomy and raise the specter of “Big Brother”overseeing their daily practices.

In the keynote presentation to the event, Allen Hinkle, MD, chief medical officer and senior vice president Health Value, Tufts Health Plan, will deliver an address “Capitlizing on Evidence-Based Medicine for Variation Management in P4P: Searching for Taguchi’s Tau.”

Here is the gist of what Hinkle will say:
GenichiTaguchi, a Japanese engineer born in 1924, recognized that pursuing an ideal target (τ Tau) requires understanding of why managing variation leads to superior quality. Integrating evidence-based medicine (EBM) into clinical-decision making reduces unexplained variation in health care services and defines the right target. A collaborative relationship between providers and health plans focusing on managing variation starts with accurate data and strong analytical skill. Finally, if provider-health plan incentives are aligned successfully, variation management can result in robust financial and quality rewards when linked to a P4P program without further expanding health care expenditures. Highlights of this keynote include:

•Identifying why excessive variation in health care services is a quality concern

•Understanding how efforts to manage variation must be a joint effort between physicians and health plans and designed with aligned incentives so that a true win-win exists

•Integrating EBM into clinical practice to achieve clinically appropriate variation management

•Linking a P4P approach that rewards achievement of the right cost and quality.