Heath Reform: Specialists Do What They Do - and Sometimes What They Didn't Used to Do

August 3, 2011 - My wife has a dear friend, her former nursing instructor, who is full of worldly wisdom. Recently, when my wife asked her advice about visiting a specialist, her old friend said,

“Remember, specialists do what they do.”

In short, specialists do what they are trained to do.

There are others ways of saying this, of course.

• Give specialists a hammer, and they will use it to hit the nail they are accustomed to hitting on the head.

• When a primary care specialist refers a patient to a specialist, he or she expects the specialist to do what he or she does.

• When patients visit specialists, they expect specialists to do what they do.

New Twists

There are new twists to these old wife's tales. Specialists are doing what other specialists do. They are extending the reach of their expertise to other specialties – even if means invading other specialized territories. Specialists are subspecializing. They are becoming sons of niches.

The classic example of this is the work of invasive cardiologists who by inserting cardiac stents, are depriving cardiac surgeons of bypass procedures. Now, because CMS has cut fees for stent for cardiologists by 40% or so, cardiologists have become “barbarians” by extending their work services to concentrating on such previously neglected things as mitral valve prolapse, patent foramen ovales, and ablation of triggers for atrial fibrillation, and cardiologists moving into the fields of neurology and vascular surgery.

The barbarian thesis is the brainchild of DrRich, Richard Fogoros, MD, a former professor of medicine in the fields of cardiology and electrophysiology. In a The Health Care Blog, in a piece called "Atilla, the Cardiologist, " DrRich opines at some length about “the Great Cardiology Migration," into heart-related problems as responsible for transient ischemic attacks, strokes, migraines, and even Alzheimers.

The editors of The Health Care Blog asked me to comment on Dr. Rich’s thesis.

Here was my response.

What Doctor Rich is explaining in 2835 words is the balloon effect of medical economics.

If you press down on the top of cardiologists' main financial balloon, as the CMS is doing on by slashing cardiology fees for stents and implantable pacemakers, secondary balloons begin to pop out below as cardiologists expand their interests to other organ systems in order the maintain the overall volume of the balloon.

There are three morals to this tale:

• One, the heart supplies all other organs, therefore the entire body falls and diseases of all organ systems falls within cardiologist’s balloon. The cardiologist is no buffoon.

• Two, broad minded cardiologists do not suffer from hardening of the categories. They do not restrict their attention to hardening of the arteries.

• Three, old cardiologists never die, they just resort to coronary bypass procedures.

And here was the comment of Brian Klepper, PhD, an imminent health care analyst, and a friend of mine, who observes.

DrRich writes an entertaining post, but the day of the barbarian cardiologist is drawing to a close. Specialists of all types, manipulating the payment system to advantage through an unholy alliance between the AMA’s RUC and CMS, have exhausted our ability to pay without limit. The mauraders may arrive, but the corn is gone, and there is no plunder left. It’s a bummer when there’s nothing to pillage.

DrRich fantasizes a plain of endless FFS, where the riches never end. That’s the world of 2000, not 2015. The pendulum is swinging the other way now. Purchasers can use data to see who is over-reaching. A few may escape notice for a while longer, but for the most part, they’re toast, an anachronism that will be annihilated by the progress of a more evolved, smarter market.
In other words, DrRich, as bombastic as he is verbose, doesn’t have a clue that the conditions that allowed plunder in the past have changed. The cardiologists’ days of excess, like Mubarek’s, is over.

Cardiologists Cornered by Data and Codes

Doctor Klepper may be right. When the government has enough data, cardiologists will no longer have anywhere else to hide from federal authorities and other payers. And when the Reimbursement Update Committee and CMS narrow the coding gap between subspecialists like cardiologist and primary care and “endless FFS” fades into history, there will be no more “plunder.”

I am not as confident or as judgmental as Brian, I would characterize many of the new things cardiologists are doing as innovative.

The Law of Health Reform Thermodynamics

Besides, I am a believer in the Law of Health Reform Thermodynamics - For Every Federal Action Decreasing Specialist Fees, there is an Equal Reaction among Patients and Physicians.

This Law is shown at work in a today’s lead article in USA Today, which reports that costs of Medicare and Medicaid advanced by an unprecedented 10% in the second quarter, in reaction of the new Health Reform Law, designed to cut the costs of care by decreasing specialty fees. Patients reacted by seeking more care while the getting was good, and specialists were happy to supply the care.

The Gettysburg Address: Reformulated as Health Reform Parody

August 2, 2011 – Here, in a parody of the Gettysburg Address, I anticipate the coming Civil War over health reform that will follow resolution of the Debt Crisis dispute as surely as dawn follows dark.

Twenty score and 97 days ago, our President and his party brought forth on this continent a new health plan, conceived in Washington, and dedicated to the proposition that all men are created equal and deserve equal health care although their representatives are spared and are more equal than others.

Now we are engaged in a Great Civil War, testing whether this nation’s health system so conceived and so dedicated can long endure its future cost. Now in Congress we are met on the battlefield of this Great War. It is altogether fitting and proper that we do this if we are to advance the causes of access, affordability, and quality for all our citizens.

We have come to dedicate our time and our debating skills to the effects and aftermath of that plan – its assumptions, financing, ripple effects of greater taxes, unforeseen consequences, economic dislocations and casualties, bankruptcies, subjugations, and exchanges of sovereign States; creation of the individual mandate, announced intentions of millions of small and large businesses to drop present employee coverage by 2014, introduction of universal managed competition, payment for compulsory comparative effectiveness but not for individual choice and personal judgment, imposition of physician fines for non-compliance, phasing out of private practice and fee-for-service medicine, scaling down of hospitals as the centerpiece of our health care universe, social engineering required to revamp one-sixth, soon to be one-fifth, of the economy of our great nation, and viability of a hybrid health system, half-private and half-free, and half-public and half-slave.

The world will long note, and long remember what we say here, but it cannot forget what we say here. It is for us, the living and future debtors, rather to be dedicated to the great task for the unfinished work so far ignobly advanced, that those who protested did not do so in vain – that this nation shall have a new birth of freedom – and that health care of the people, for the people, shall not perish from the earth.

New York Times Features Health Leads, Inc., Story: Doctors “Prescribe” Social Cures To Meet The Needs Of The Poor

August 1, 2011 – In case you missed it, I would like to bring your attention to a back page piece, “Home Cure” in the "Sunday Review" section of the New York Times. The piece is an excerpt from Fixes, an online column by David Bornstein and Tina Rosenberg at nytimes.com/opinionator. David Bornstein is the author of How to Change the World and the founder of Dowser.org, a Web Site focused on social entrepreneurship.

The New York Times article concerns Health Leads, Inc, an organization supported, in part, by a $ 1 million grant from the Physicians Foundation. It tells the story of Dr. Jack Geiger, a Mississippi Delta physician who in 1965 wrote prescriptions for malnourished children for food – quantities of milk, vegetables, meat, and fruit that could “filled” at grocery stores – with the bills sent to Doctor Geiger’s health center. When the Office of Economic Opportunity challenged these prescriptions, Doctor Geiger replied, “ The last time I looked in my textbooks, the specific therapy for malnutrition was food.”

And it tells the story of Health Leads.

On May 11, 2011, I wrote the following blog on the Physicians Foundation $1 million grant to health leads.

The Physicians Foundation Awards $1 Million Grant to Health Leads

May 11, 2011 - Yesterday the Physicians Foundation, a charitable organization representing physicians in state medical societies nationwide, put its money where its heart is.

The Foundation awarded a $1 million grant to Health Leads, a Boston non-profit to help it expand from its current base of six cities to other locales across the land.

The Physician Foundation-Health Leads collaboration is a natural partnership. Both the Physicians Foundation and Health Leads are organizations who think “outside the box” to help vulnerable citizens find resources outside the mainstream of care.

Physicians often find themselves trapped in a box, unable to help patients find food for their stomachs, heat for their homes, transport to medical facilities, jobs to supply the money to pay for care, decent homes in safe neighborhoods. These basics are simply beyond the reach of the current health system or the current reforms designed to improve care.

Health Leads works in 23 pediatric and prenatal clinics, newborn nurseries, emergency rooms, and community health centers in six cities across the U.S. Last year, Health Leads trained and deployed 660 college volunteers to connect nearly 6,000 low-income patients and their families to the resources they need to be healthy. By providing a transformative experience for hundreds of college volunteers, Health Leads is producing a pipeline of new leaders who will have both the conviction and the skills to transform health care from the bottom-up.

How does Health Leads make this transformation possible?

• One, by giving doctors the power to “prescribe” food, shelter, job training, and transportation by writing prescriptions to find these resources.

• Two, by recruiting college volunteers to serve at Health Desks in various health care settings to direct patients and families to community resources, in the process serving as a training ground for health careers and as a sort of domestic Peace Corps.

In the hospitals and health centers where Health Leads operates, doctors can “prescribe” food, housing, or other critical resources—just as they would medication. Patients take their prescriptions to the clinic waiting room, where Health Leads’ college volunteers are ready to connect them to these resources. Nearly 60 percent of Health Leads patients secure at least one critical resource – receive food, get their heat turned back on, find a job – within 90 days of getting their “prescription.” All patients receive ongoing follow-up until their needs are met.

“As we continue to identify new ways to enhance healthcare delivery, we are extremely proud to fund the ongoing efforts of Health Leads,” said Dr. Walker Ray, Vice President of The Physicians Foundation and Chair of the Research Committee. “In a system that is massively overburdened by strained resources, innovative models that foster collaboration between college volunteers and physicians can have real impact on our nation’s healthcare.”

The Physicians Foundation’s funding will help Health Leads expand its operational capabilities, allowing the organization to serve significantly more patients. By developing an information technology infrastructure to enhance tracking of patient outcomes and by hiring additional program managers and staff, Health Leads will be able to deepen engagement with physicians and clinic partners.

“Health Leads is grateful for the assistance of The Physicians Foundation in helping us to build the capacity we need to scale our program model over the next four years. Since we received their funding, we have been able to serve more than 2,600 patients, putting us on track for an increase of more than 60 percent over last year,” said Rebecca Onie, Co-founder and Chief Executive Officer of Health Leads.

“We have also launched discussions to build an evaluation partnership with the Mayo Clinic Center and rolled out a new client database to all of our sites that will enable us to better track and report client outcomes. The Foundation's support has been invaluable in helping us make significant progress on these strategic goals."

Tweet: The Physicians Foundation, a doctor organization, has awarded a $1 million to Health Leads, to help patients find food, housing, & jobs.

Health Costs: Nothing Exceeds Like Success

July 31, 2011 - Everybody knows health costs exceed our ability, individually or as a nation, to pay for them. But nobody admits this inability stems from the overwhelming success of medicine to provide what people want.

As comedian Milton Berle cracked, “When it comes to my health, money is no object."

This morning , I was thinking of how well medicine has succeeded. As our Sunday morning coffee gathering, a bunch of old guys were whooping it up at the old salon when the subject of an 88 year friend came up. He was suffering from shortness of breath and periodic blackouts.

One said,”He needs an nuclear heart scan to see what’s wrong.” A second remarked,” He needs a pacemaker, like Cheney.” A third chimed in, “ Maybe he needs a new heart.”

I brought up the subject of cost and pointed out one of us had a pacemaker costing $150,000 – but, even though I was the only doctor in group, I was dismissed.

Thanks to people’s trust in modern technologies, costs have exceeded everybody’s expectations. Consequently, health costs are 17% of GDP, and with costs expected to grow 5.8% a year over the next ten years or so, health costs should reach 20% of GDP by 2020.

Economists agree that medical technologies account for 70% of health inflation, and that these technologies rarely save money, despite all the rhetoric about "disruptive technologies."

Why is this? A number of reasons. Since World War II, Americans have invested heavily in research. We are aging and require more life-saving and function-saving technologies. And the media is quick to seize upon new "breakthroughs" and to broadcast this news to world. There's a shortage of good news these days, and health advances fill the bill - and increase the bill.

Technologies work. Ask your friends, family, and neighbors, and everybody will have a story of how hip and knee replacements has stopped pain and restored function; cataract surgery has averted blindness; stents, pacemakers, and ventricular assist devices have forestalled death; and CT scans and MRIs have provided invaluable diagnostic information.

There is also the “self-interest”factor.

• Every patient wants to live another day, with the hope that the next day will be better than the last.

• Most doctors know that specialists deploying the latest technologies are the important key provider of longevity and improved function.

• Specialists know that patients, health plans, and government itself pay more for specialists performing procedures.

• Hospitals know that their largest profits reside in high tech fields – cancer, orthopedics, heart, and the new kid on the block, robotic surgeries in multiple fields.

Small wonder, then, that the health care system is often the biggest economic game in any community, region, or State, that hospitals, doctors, and various health care facilities are the biggest employers during this recession (Health care has added near one million jobs since the recession began), and that Medicare and organizations like AARP with 50 million members (and its partner UnitedHealth,which boasts its 70,000 employees cover 78 million Americans and supplies all of AARP’s Medicare supplemental policies, are among the most powerful economic and political players in America).

Nothing exceeds like success, which, unfortunately, breeds beneficial excess to those who depend on health care success.

Obamacare: How Many More Things Can Go Wrong?

Never very popular to begin with, Obamacare continues to face strong opposition from millions of Americans who are indignant that Congress passed it over strong and vocal opposition. They know it is wrong for America. Obamacare is wrong for families, wrong for patients, wrong for business, and wrong for our children’s futures.

Grace-Marie Turner, James C. Capretta, Thomas P. Miller, Robert Moffit, Why Obamacare Is Wrong for America(Broadside, An Imprint for HarperCollinsPublishers), 2011

Anything that can go wrong will go wrong.

Murphy’s Law, saying, 1950s

July 30, 2011 - The past week was a bad week for Obamacare because of two major negative developments.

• ONE, Thomas P. Weil, PhD, has written a paper, bearing the title “ACOs Doomed for Failure.”

ACOs, the organizational foundation of the Obama plan to reduce costs and improve outcomes, are slated to begin operation on January 1, 2012.

Weil says ACOs will fail for five reasons: 1) they over-estimate physicians‘ capacities to motivate patients with chronic disease to change their behavior, which has been established over a lifetime and which is unlikely to be altered enough to change the course of their diseases; 2) ACOs require a nearby well functioning multispecialty group; 3) a fully-functioning EHR system linking all parties is necessary; 4) resolving nitty-gritty operational issues – calibrating quality goals, adhering to burdensome rules, being proactive and competitive, implementing a physician reporting system, and resolving anti-trust issues – have a long way to go; and 5) ACOs may anger the public because their major priority is to limit utilization of services desired by the public and physician alike.

• TWO, The National Federation of Independent Businesses (NFIB) have just released an extensive survey indicating 57% of small businesses are either likely or somewhat likely to drop coverage for employees when the law takes effect in 2014. Since the health law passed, 12% of small businesses have already terminated coverage. A year from now, 55% says they are “not too likely” (18%) or “not at all likely” (37%) to offer coverage. Finally, 57% say they would likely continue coverage if they had the option of giving employees a “tax-excluded contribution,” an HSA or its equivalent, which would give employees more control over choice of coverage, ownership of a portable policy not dependent on jobs, and incentives to shop for better value.

Two Questions

These two developments raise two questions: How many things have to go wrong before we consider scrapping or severely modifying Obamacare? How long must we wait before Obamacare cuts costs and expands access?

So far what’s gone wrong includes: sharply rising costs and declining access since passage, threats of multinational corporations to drop drug coverage for retirees, issuance of over 1500 waivers to unions and small businesses and some States bypassing Obamacare to avoid its regulatory burdens and expenses; dropping of the audit of business expenses over $600, continuing disapproval of the health law by 55% to 60% of Americans; rejection of the idea of ACOs by most major physician organizations; a survey by McKinsey and associates of American businesses indicating 30% plan to drop coverage in 2014 when Obamacare kicks in in earnest.

Everybody , including critics of the new law, agrees reform is necessary to reduce costs and expand coverage, the twin goals of Obamacare. Of good intentions toward achieving these goals, Obama and the Democrats are right; on opposing the results, higher costs and lowered access for the insured and previously insured with unforeseen consequences. Republicans are right.

I’m reminded of the story of the Blind Men and the Elephant , which might now be modified to read.

And so these men of health reform
Disputed loud and long.

Each in his own opinion
Exceedingly stiff and stern.

And each was partly in the right,
And all in part were wrong.

After the Debt Crisis Resolution, The Deluge

After us, the deluge.

Attributed variously to Madame Pompadour and to Louis XV, after the crushing defeat of the French at Rossbach, 1757

July 29, 2011 - What comes after the debt crisis, the resolution of which all the politicians and the President tell us today is inevitable?

I am not so sure about the resolution, but I am sure of this.

After the debt crisis ends, the deluge will be a deadlocked heated debate over what to do about how, how much, and when to cut from Medicare and Medicaid.

The first salvo came this week in the form of ubiquitous TV ads featuring three people – an older white man, an older white woman, and an older black lady. The three are saying, ”What were you thinking when you decided to cut $100 million out of hospital care for Medicare and Medicaid? What were you thinking?”

What they, the politicians, were thinking, of course, is that hospital costs for Medicare and Medicaid patients are the biggest single force driving government health care costs and the national debt.

Unfortunately, what government giveth is very hard to taketh away.

The demographics of aging, the influx of baby boomers into Medicare in 2011, the coming of a guaranteed 32 million and probably millions more into Medicaid in 2014, the continuing demand for access to medical technologies the increasing desire for more physician services, the shrinking physician supply, the accelerating physician shortage, and the Great Divide between Democrats and Republicans on how to avoid certain Medicare and Medicaid bankruptcy and default will dominate Presidential debates leading up to November 2012.

The debate will be all about supply and demand - with demands – of money, programs, physicians, political will, and truth – exceeding the supply .

The three D's - Demagoguery, Demonization,and Demographics - will dominate the deluge debate.