Doctor Shortge - Three Cooper Reports on Physician Shortages, Patient Access, and Quality Care

I would like to bring to your attention three reports by Richard “Buz” Cooper, MD, professor of medicine and principal of the Leonard Davis Institute of Health Economics at the University of Pennsylvania.

• One, “Physicians and Their Practices Under Health Care Reform: A Report to the President and The Congress,” prepared on behalf of The Physicians’ Foundation, and distributed to members of Congress, the White House, and the media, on September 8, 2009 (available at www.physiciansfoundation.org)

• Two, “Regional Variation and the Affluent-Poverty Nexus, Journal of the American Medical Association, September 9, 2009.

• Three, “Wrong Turn on Health Reform, “ Washington Post, September 11, 2009.

Opportune Time

These reports come at an opportune time in the wake of these events: President Obama’s speech before Congress on September 9,; his campaign stops across the country to rally his followers, the first today in Minneapolis; the taxpayer march on Washington today of 100,000 people ; and 10,000 physicians assembling in D.C. the same day to protest Obama health care policies. These events follow the raucous town hall meetings of August.

The Physicians Foundation

I believe Dr. Cooper’s report before Congress. supported by The Physicians Foundation, a 501C3 non-profit organization representing 650,000 practicing physicians in state and local medical societies. lends perspective, context, and rationality to the otherwise emotional debate over health care.

Contents of Three Cooper Reports

Perhaps the most objective way to present the contents of Dr. Cooper’s three reports is to use his words summing up their contents.

• One, the “Cooper Report,“ to the President and Congress is a 53 page document. Here are Dr. Cooper’s words about its contents with a list of its other authors,

“Our report is intended to inform the discussions of health care reform about the deepening physician shortages, the needs of physicians' practices in a reformed health care system and the effects of poverty and other social determinants on health care utilization and outcomes. Its conclusions are that, without adequate numbers of physicians, the health care system cannot function; without adequate attention to the structure of physician practices, the system cannot function efficiently; and without adequate attention to the pervasive effects of poverty and other social determinants, it cannot function economically.”

“ We hope you will find this to be useful as the critical issues that it addresses are discussed in the months ahead.

Richard (Buz) Cooper, MD, Professor of Medicine, University of Pennsylvania
Tom Getzen, PhD, Professor of Healthcare Management, Temple University
Michael Johns, MD, University Chancellor, Emory University
Barbara Ross-Lee, DO, President for Health Sciences, NY Institute of Technology
George Sheldon, MD, Distinguished Professor of Surgery, University of North Carolina
Michael Whitcomb, MD, Emeritus Editor in Chief, Academic Medicine “

• Two, Dr. Cooper’s summary of his JAMA article

“The affluence-poverty nexus offers a number of insights. First, it reconfirms the complex interplay between individual and communal dynamics in determining health care utilization and outcomes. Second, it demonstrates that when total expenditures rather than expenditures from Medicare or any single source are considered, regions with more health care inputs have better aggregate outcomes. Third, it suggests that while health care reform has the potential to narrow regional differences in wealth and health care resources, a substantial degree of variation is likely to continue for many decades. Fourth, it provides evidence of the high costs borne by the health care system because of poverty and its associated social determinants."

“As the United States confronts difficult fiscal choices, there should be no illusion about the relationship among physician supply, health care spending, and outcomes. Nor should there be uncertainty about how poverty affects health care utilization. The reality is that more is more and that poverty leads to less, and the false assertion that "more is less" should not detract from efforts to ensure that the United States will have an adequate supply of physicians for the future.“

• Three, excerpts from the September 11 Washington Post Op-Ed piece.

“President Obama pledged on Wednesday that ‘reducing the waste and inefficiency in Medicare and Medicaid would pay for most’ of his health-care plan. This echoes remarks from Peter Orszag, his director of the Office of Management and Budget, who has claimed that one-third of health-care spending, more than $700 billion, is wasted annually.”

“Those Orszag comments come straight from the Dartmouth Atlas, which announced that the United States could save 30 percent of its health-care expenditures if high-spending regions were more like low-spending ones. But this can't be how we'll pay for reform. The numbers are too good to be true.”

“Orszag has argued that if Medicare spending could be as low in Newark as it is at Mayo, the nation could save billions. But this theory doesn't hold up in practice. Consider: One-fourth of the folks in Newark live in poverty, compared with less than 10 percent of those in Rochester. And national surveys show that poor people consume more health-care resources -- 50 to 75 percent more than average. They are sicker and they stay sicker, despite the best efforts of physicians and hospitals. Mayo is a fine institution, but it isn't more cost-effective than other hospitals in its home region, nor are its operations in Jacksonville, Fla., and Phoenix more cost-efficient than other hospitals in those cities. So why would it be more cost-effective in Newark?”

“To really achieve health-care reform, and find a way to pay for it, the president will have to give up on the Dartmouth suggestion and grapple with some painful truths. First, medical care is inherently variable in different regions of the country -- socio-demographic differences matter. Second, more is more and less yields less -- the best care is the most comprehensive care, and it costs more. Finally, poverty is expensive -- the greatest "waste" is the necessary use of added resources when coping with patients who are poor. If we want a technologically advanced, socially equitable health-care system, we will have to organize our finances accordingly. There is no quick fix. That's what we should be talking about. “

Reece Take

Four of the interrelated central themes in my book Obama, Doctors, and Health Reform are:

• One, the next big political health care crisis will be lack of access to doctors. This will be aggravated by 78 million baby boomers entering Medicare in 2011 and a dramatic expansion caused by millions of uninsured citizens entering the market.

• Two, the growing doctor shortage, expected to peak at 150,000 to 200, 000 in a decade;

• Three, government policies that systematically pay doctors less each year, this year scheduled to be a 20% cut;

• Four, doctors declining to accept new Medicare patients because Medicare fees will make it difficult to maintain and sustain practices.

Although incremental reform is essential and necessary, the health system is too complex to reform, re-engineer, and overhaul in one fell swoop. Medicare is not a good model on which to reform health care. For two reasons. It has no cost controls. It is not representative of the system as a whole'

Medicare Is No Model for Health Reform; Many doctors Refuse Medicare Payments Because Payments Are So Low

Wall Street Journal, September 11, 2009
By GRACE-MARIE TURNER AND JOSEPH R. ANTOS

Prelude: Periodically an article comes out that deserves reprinting. This is such an article. I have long predicted the next big crisis will come when the 78 million baby boomers entering Medicare in 2011 suddenly find to their shock that there are too few doctors to serve them. The reasons for this access crisis will be two-fold: one, an existing and growing doctor shortage; and two, a refusal by many doctors, as many as 40%, to accept new Medicare patients, because Medicare fees do not meet the cost of doing business.


Democratic leaders at both ends of Pennsylvania Avenue continue to battle over whether a new government-run health plan, modeled after the popular Medicare program for seniors, must be included in health-reform legislation.

President Barack Obama told a New Hampshire town-hall meeting last month that "if we're able to get something right like Medicare, then there should be a little more confidence that maybe the government can have a role." Did the government really get Medicare right? Here are the top 10 reasons this program should not be a model for reform, and why it would be dangerous for the federal government to be put in charge of any more of our health sector:

1) Medicare is going bankrupt. The Medicare Trustees estimate that the program will run short of money starting in 2017. Medicare will drown in a sea of red ink, with spending over the next 75 years outpacing dedicated revenues by nearly $38 trillion.

2) Private payers are bailing out Medicare. According to Milliman, an independent actuarial firm, Medicare—and to an even greater extent, Medicaid—underpays doctors and hospitals, shifting costs to private insurers. Milliman estimates that the average family in a private PPO health plan pays an additional $1,788 a year to compensate for underpayments by Medicare and Medicaid, representing a "hidden tax" on commercial payers totaling $89 billion a year.

Providers could not keep their doors open without the higher payments from private insurers. A recent letter to Congress from 13 leading health-care delivery organizations, including the Mayo Clinic, said "many providers suffer great financial losses associated with treating Medicare patients." They said that if these rates were expanded to patients who currently have private insurance, the result "will be unsustainable for even the nation's most efficient, high quality providers, eventually driving them out of the market." That means we would say goodbye to some of the best health-care systems in the country.

3) Expansion of entitlement programs threatens our economic security. Congressional Budget Office Director Douglas Elmendorf broke the bad news in July. Reform legislation before Congress would worsen the federal government's already bleak budget outlook, increase the deficit, and drive the nation more deeply into debt. Instead of bending the cost curve down, Mr. Elmendorf told senators their reform proposal would "significantly increase" costs.

4) Low administrative costs are a mirage. The claim that Medicare's administrative costs are only 3% is fantasy. If all Medicare costs—such as revenue collection, personnel and enforcement—were accounted for, its administrative expenses would be at least twice as high. And it still wouldn't be providing services private insurers do, such as nurse hotlines, decision-support tools and fraud detection, or paying the income, property and provider taxes that private plans must pay.

5) Medicare is rife with fraud. According to the FBI, between 3% and 10% of all health spending is lost to health-care fraud. Despite the president's promise this money could be recaptured to pay for his reform agenda, Congress has shown itself to be remarkably incapable of curtailing fraud and abuse in government health programs.

6) Medicare short¬-changes seniors. Medicare exposes patients to unmanageable costs if they become seriously ill—even limiting the total number of days a patient may spend in the hospital. The program covers only about 50% of the health costs of seniors, and most have supplemental insurance to fill in the gaps. This is not a model for comprehensive coverage.

7) Medicare's model is obsolete. Its basic benefit structure uses a fee-for-service model designed in 1965 which has not been altered since, except to add prescription drug coverage almost 40 years later. In contrast, private plans are continually evolving. They create incentives for patients to become more informed about their health choices, and offer innovative programs for disease management, wellness and prevention, and care coordination to improve quality and save money.

8) Payments are too low. Washington decides how much doctors, hospitals and other providers will be paid down to the smallest detail, with mountains of regulation and paperwork to track the politically driven process. Medical professionals are in a perpetual battle with Congress over their payment rates, and many physicians refuse to accept new Medicare patients because payment rates are so low. With few exceptions, Medicare's solution to cost containment is the club of price-controls, not innovation and efficiency.

9) Medical decisions are made in Washington. Patients and their doctors are slowly losing the ability to decide what course of treatment is best. Medicare's decisions to cut funding for the cancer drug EPO, implantable cardiac defibrillators and virtual colonoscopies, for example, have led to epic battles between providers and politicians, while patients and their doctors watch from the sidelines. Medical decisions, which should be made by doctors and patients, are being made by politicians.

10) No one is running the show. If the government is so good at running health-care programs, why has the Obama administration not yet nominated an administrator for the Centers for Medicare and Medicaid Services? These government health programs cover 100 million Americans—the largest health insurance plans in the country—and yet the top office is vacant.

Medicare has undeniably guaranteed that all seniors have health coverage, even if that coverage is not as good as advertised. But the program is in trouble. Even though it has a blank check funded by federal revenues, Medicare will not be able to pay all the hospital bills that come in eight years from now. If you think that's bad, just wait until 70 million baby boomers turn 65 and drive federal budget deficits into the stratosphere.

Instead of pretending that Medicare is the best model for the country, policy makers should recognize that the program is as much in need of reform as the rest of the health system. Before we give the federal government authority over health coverage for tens of millions more Americans, shouldn't the government prove it can do a better job with the "public plan" we already have?

Ms. Turner is president of the Galen Institute. Mr. Antos is a scholar at the American Enterprise Institute

Response to Obama Health Care Speech

September 11 - It’s hard to get an accurate fix on the impact of President Obama’s September 9 health care speech before a joint session of Congress. Much of the media commentary has focused on Rep. Joe Wilson (R-South Carolina) who shouted “Liar!” in the midst of the impassioned speech.

Beyond that, most reactions depend on the old adage, “Where you stand depends on where you sit.” Many Democrats say the speech was an inspiration unifying game-changer and foretells of a bill by year’s end.

Republicans felt the 47 minute talk was long on rhetoric and short on substance. GOP commentators said it “was a speech not a plan,” “he can speak but can he govern,” “full of platitudes and generalities,” “hope meets reality, ” and “good delivery bad product.”

Polls immediately after the speech indicated 70 to 75% public approval, but poll averages of today September 12 tell a different story.

Obama Job Approval

Approve 52.1%
Disapprove 34.4%

Spread + 8.7%

Congressional Job Approval

Approve 28.8%
Disapprove 62.0%

Spread -33.2%

Direction of Country

Right direction 35.6%
Wrong direction 58.8%

Spread -23.2%

Meanwhile in a Politico poll with 17,308 respondents , 38 percent registered thumbs-up for the president's address while 58 percent said thumbs-down. Of Obama’s handling of health care, most polls show a less than 50% approval and falling.

Personally I felt Obama did not answer these questions.

• How do you plan to pay for his plan? What are the details?

• How can you cut $500 billion out of Medicare when 78 million baby boomers are about to come on board?

• How can you promise the Obama plan will “not add a dime” to the deficit when you have no plan to control costs?

• How can you impose individual and employer mandates and add 45 million to the rolls without raising taxes?

One thing that alarms me about Obama is his attitude - don't tinker, don't think, just do it because I say so. Rhis is intellectual arrogance and does not lend itself to compromise.


For me the Obamacare math does not add up I understand his passionate call for the U.S. to be a moral nation, but I do not understand how he can superimpose his government –dominated plan on the current system without astronomical budget deficits and without destroying private health plan markets.

Perhaps I am wrong. The stock market reacted positively to the speech with an 80 point bump and with increases averaging about 5% in the stocks of health insurers and for-profit hospital chains. The apparent reason was the market believes the public option is now off the table, and the private enterprise system will be more free to work its magic. An Intrade poll of betters indicate only 24% think a public option will be part of the final plan.

Compromise is in the Air for Health Reform

September 8 - President Obama is meeting with his advisors to craft a speech for his September 9 speech before Congress. Obama desperately needs to present something the left, right, and center can buy into.

This buy-in will take compromise. Compromise proposals, now floating among Democrat and Republican leaders, includes,

• Low cost insurance with a catastrophic lid for those 25 or younger.

• Basic coverage for poor people now ineligible for Medicaid.

• A non-profit member-owned insurance cooperative in the states.

• A stripped-down benefits package for people with good income who heretofore have chosen not to be insured.

• A requirement that insurers report proportion of premiums spent on non-medical expenses.

• A requirement that hospitals list standard charges for all services.

As Edmund Burke (1729-1797) observed, “All government, indeed every human benefit, every virtue, and every prudent act, is founded on compromise and barter.” Even though it is late in the game, let the horse-trading begin.

The horse trading may take some time. Health reform, after all, is a mighty big horse. One big horse - the public option horse - is dead for now. Another big horse - a $6 billion fee on health insurance in exchange for bringing 46 million uninsured onto their rolls - is said to be still alive and kicking.

Tomorrow is the Night

Poem anticipating President Obama's sppech before Congress on health reform

Tomorrow is the night
To do or die

Tomorrow is the night
To ride your horse to the sky

Tomorrow is the night
To give the reasons why

Tomorrow is the night
For a rousing rallying cry

Tomorrow is the night
Not to be one bit shy

Tomorrow is the night
To look the right in the eye

Tomorrow is the night
Backing down to deny

Tomorrow is the night
To say costs won’t go too high

Tomorrow is the night
To announce your new deal will fly

Tomorrow is the night
To explain why others lie

Tomorrow is the night
To say why things won't go awry

Tomorrow is the night
To define the bonds that tie

Tomorrow is the night
To say the time is now nigh

Tomorrow is the night
For the old college try

Tomorrow is the night
The political odds to defy

Tomorrow is the night
To let gov't option out to dry

Tommorrow is the night
To do or die or compromise

A Tale of U.S. Health Care Compared to Other Nations

It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to heaven, we were all going direct the other way - in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only.

Charles Dickens, A Tale of Two Cities
English novelist (1812 - 1870)

The Dicken’s quote sprang to mind as I was listening to a Brian Lamb interview on C-Span with T.R. Reid, author of the Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care (Penguin, 2009). Reid, reporter, documentary film makers, and author of ten books, , spent the last three years touring the world, looking at the health systems of leading industrialized nations.

Best in Some Ways But Unfair

Reid concluded we have the world’s best trained doctors and best equipped hospitals but the world’s most “unfair” health system. It is unfair, he says, because the U.S. culture has not embraced the moral imperative of providing universal coverage of the same quality for rich and poor.

As far as our health system goes, we live, in short, in the best of times, but the worst of times. It is an age of the best of medical technologies, but an age of social foolishness. It is an epoch of belief in medical wonders, but an epoch of incredulity that we do not evenly apply these wonders to all. It is a season of scientific Light, but is a season of social Darkness. It is the spring of hope in that universal coverage may be upon us, but it is a winter of despair in that it may not happen. As the world's richest nation, we should have the best of everything before us. With the recession, we may have nothing before us. We are all going to heaven if we do the right thing, i.e, providing universal coverage, but we all seem to be going the other way. In short, it is like Dicken’s time in which the noisiest authorities say we suffer, for good and evil, when compared to other cultures.

More Complicated Than Lack of Morality

It is more complicated than the U.S. being morally deficient. Our history as a culture, more than our lack of morality, complicates universal coverage and fairness. America was founded 233 years ago, in 1776, on the notion that a weak government is the best government, that government should not intrude on individual freedoms, and that equal opportunity trumps equal results for all.

Reid makes the mistake of equating the health of nations with their health system. Health systems contribute only about 15% to health outcomes. The rest is due to life styles, the homogeneity of its culture, obesity, family cohesiveness, factors such as domestic violence and automoble fatalities, and socioeconomic conditions.

In the U.S. health system, a culture of individualism plays a role. We believe strongly in individual rights – the right to live as one pleases within limits, the right of assembly, the right to speak out, the right of a free press, the right to pursue opportunity , the right to become rich, and the right to bear arms. These traditions pose problems.

Uneven Results

The U.S health system produces uneven results. It sometimes discriminates against those without means. It often does not provide care for non-citizens. It is noisy and argumentative, as demonstrated in town hall meetings. It leads to lousy health statistics. If one were to take the health outcomes of 20% of us who are recent immigrants, legal and illegal, and a 100,000 or so of us killed on the streets and highwaysl out of the equation, our outcome statistics would surpass those of most other nations. It is decentralized and comprised of many subsystems – private and public. It resists a command and control centralized decision making.

To sum up, the U.S. health system is sometimes messy, and sometimes unfair. It does not lend itself easily to a homogenous health system covering all and treating all equally. This is not an excuse. It is an explanation.