Monday, March 31, 2008

Obesity, Diabetes -The Next Big Thing in Elective Surgery: Health Industry Bands Together to Reduce Obesity and Its Complications.

What: Johnson & Johnson, Allergen, Inc, venture capitalists, surgeons, and outpatient surgery centers have banded together to promote the use of silicon gastric bands to address problem of morbid obesity, defined as 100 pound overweight, and its myriad complications – diabetes, hypertension, catastrophic cardiovascular events, heart failure, sleep apnea, and osteoarthritis of knees Gastric banding exploded 50% last year to 200,000 procedures per year, up from 35,000 in 2000, a 6 fold increase.

Why: Gastric banding fills a huge niche (no pun intended) in elective surgery field. It is relatively safe, relatively non-invasive, relatively free of complications, cheaper than gastric bypass ($17,000 v. $25,000), can be performed in an outpatient setting, is easy for surgeons to learn, does not change the basic plumbing of the GI tract, may be as effective as bypass surgery, and lessens and may even cure the diabetes that accompanies morbid obesity, and addresses a gaping need – one 1% of morbidly obese people have undergone surgery.

When: Surgeons in Europe and Australia introduced gastric bands in the 1990s. In last two years, the number of procedures has expanded dramatically since Johnson & Johnson, Botox-maker Allergen, Inc, and venture capitalists have began heavily promoting its use through websites, direct consumer ads, surgeon-training programs, and capital provision. Gastric bands are also being marketed via roadside billboards, the Internet, radio, TV, and on “Dr.Phil” and “Oprah Winfrey” programs.

Surgeons make tiny incisions, snake in a camera, and through video manipulation, wrap a band of silicon around the upper stomach, limiting the stomach size as a receptacle for food. The band may be periodically adjusted depending on patient response and weight loss.

Where: Training sessions are conducted nationwide, but biggest markets to date have been in Texas and California, and other entrepreneurial-minded environments.

Who: The number of procedures has grown enormously since Medicare, the Blue Cross Blue Shield Association, TriCare, and other insurers have started paying for procedures. It is said avoidance of complications, drugs, and diets justifies cost.

Electronic Medical Records - The EMR Funk

I’m something of a combined wonk and a monk when it comes to EMRs. Experts proclaim EMRs as the answer to health care woes, yet physicians resist them. Why this funk? This is a question only a wonky monk like myself can answer.

The word “wonk,” my dictionary says, is someone who is boringly, narrowly, and obliviously preoccupied with something For some time, I have been boringly, narrowly, and obliviously preoccupied with EMRs and why they are in such a funk in the real world of medical practice.

This funk stuns a lot of people after all the EMR hype. You’d think doctors would flock to EMRs. Instead 80% to 90% of doctors don’t install these electronic marvels..

The word “monk” comes from an Old English word, meaning “alone.’ A monk contemplates and prays alone. I pray EMRs will succeed, I contemplate why they don’t, and I tend to be alone in my opinions.

Out of my meditations have come these thoughts.

• First, the unworkability of EMRs. EMRs may not work for physicians because of high costs, practice disruptions, productivity losses, opposition by staff or partners, harassments of data entry, miserable returns on investment, and paranoia among physicians that EMRs are for the benefit of health plans, rather than for the benefit of patients or themselves.. The data gathered, doctors fear, will be used against them to rank them and even tank them.

Second, the irrelevancy factor. Every specialty has its own work and thought flow patterns. Many of these patterns share little in common. For some, throughput is most important; for others a comprehensive understanding is paramount. A chief information office of a large multispecialty groups pointed out to me dermatologists, obstetricians, and ophthalmologists, and other specialists have completely different electronic needs than generalists. For a dermatologist, whose interests are skin-deep, a comprehensive EMR may bring nothing to the practice. It is simply irrelevant.

• Third, lack of application of EMR information at the “inflection point.” An inflection point is that point in patient care when the patient and the doctor need information the most. For the patient, this may be when a cancer diagnosis is first made, what specialists to go to, what tests will ensue, what lies ahead. For the emergency room doctor, the inflection point may be when a patient enters the ER after being referred by a primary care doctor. What information do I have on this patient, and how can I get it quickly? A simple email from the primary care doctor will do and is preferable to a personal health record or an EMR download. A standard EMR does little to address inflection points.

• Fourth, the emphasis on documentation rather than doctoring. Doctors are trained to be doctors rather than data entry clerks or documentation experts. Doctors don’t give one whit about complete documentation, unless, of course, it results in getting paid. One model that may work is the worksite clinic, in which others enter the data, an EMR is on site, the EMR contains relevant best practice information, and the doctor can spend his or her time doing real doctoring rather than dealing with documentation details.

• Fifth, failure to appreciate the importance of chunking.

In an excellent book, Edgeware: Insights from Complexity Science for Health Care Leaders (VHA, Inc, 1998), its authors point out most effective decisions occur at the edge, the margins, of care. Striving for complexity can be the enemy of good care. The book talks of “chunking,” allowing complex systems to emerge out of the links among simple systems that work well and are capable of operating independently. Simple workable systems build confidence, and simplicity is something complex EMRs that try to be everything for everybody sorely lack.

Sixth, failure to stress “readiness training” for EMRs, EMRs and health 2.0 enthusiasts have failed to recognize practices must be made “ready” for EMRs. Electronic practices and paper practices are different ballgames with different work flows and thought patterns. Paper practices don’t become electronic at the snap of a finger, or the click of a mouse. In electronic practices, patients often don’t have to be present at the point of care; doctors hesitate to do anything without examining the patient. The American Association of Family Physicians (AAFP) addresses this problem with a formal readiness program. The AAFP claims 37% of its 93,000 members have adopted EMRs and another 13% have signed contracts to have systems installed. This is two to three times the national rate of EMR adoption. Doctors are conditioned to think: Ready, Fire, Aim! This doesn’t work with EMRs.

Sunday, March 30, 2008

Managed Care - The Industry Everybody Loves to Have

In the Spring of 2007. 113 hospital and physician organizations completed a survey on their attitudes towards managed care- a common enemy.

The words used to describe managed care were, in no particular order.

• Inflexible
• Rigid
• Incompetent
• Arrogant
• Greedy
• Unresponsible
• Pushy
• Unethical
• Careless
• Clueless

The managed care loser, in order of enmity, were,

• United HealthCare, 91%
• WellPoint/Anthem, 48%
• Cigna, 47%
• Aetna, 37%

To improve relations, doctors and hospitals suggest,

• Honest P4P programs
• Data exchange
• Streamlines business practices
• Clarity

Emad Rizk, MD, president of McKesson Health Solutions, says managed care can improve by

• Pick geographic areas in which they have more than 15% market share.
• Select a disease or populations in which they want to improve their image.
• Target hospitals and doctors with which they want better relations.
• Agree upon clinical process.
• Agree on outcome goals you want to achieve.
• Share financial incentives you will give.
• Agree on how to share data.

* Summarized from “Managed Care Can Improve Relations with Providers,”, March 19, 2008.

Saturday, March 29, 2008

Hospitals and Doctors, future - The Future of Hospitals and Baby Boomer Physicians

This is not a good time to be a hospital CEO.

From the Bush Medicare budget request over the next five years comes this news.

• The largest amount of Medicare cuts, by far, will come from hospitals: $15 billion from an across-the-board reduction in the annual updates for inpatient care; $25 billion from special payments to hospitals serving large numbers of poor people; and $20 billion from capital payments for constructing hospital buildings and the purchase of equipment.

And from the mean streets come these pieces of news about baby boomer physicians.

The urge for physicians to be employed by hospitals will surge. Younger and older baby boomer physicians want security, time off, regular hours, vacations, malpractice coverage, and relief from the risks of running a business. This makes hospital CEOs wary because they took a financial bath during the late 1990s when they acquired hospital practices. Still. doctors need intensivists, hospitalists, ER doctors, and even general surgeons – positions in which doctors can enjoy 40 hour work weeks. For hospitals, these doctors, often in short supply, do not come cheaply. It costs as much as $443,000 to recruit a cardiologist, $471, 000 an orthopedic surgeon, $263.000 an internist, and $246,000 for a family physician.

• At the same time, more physicians are seeking independence from hospitals. The shift to ambulatory care is in full swing, as doctors seek autonomy. Unfortunately, for the hospital CEO, many physicians seeking less dependency - orthopedic surgeons, cardiovascular specialists, proceduralists of every ilk – contribute the most to hospital bottom lines. The lure of being your own person of controlling your own destiny in terms of income and clinical practice is well nigh irresistible. This means hospitals must hire these specialists for internal coverage and external coverage.

• Conflicts over call coverage will haunt hospitals. Legally hospitals have to be open 24 hours a day and to accept all comers to the emergency rooms. This is tough when uninsured rolls are growing, and people tend to go to the ER rather than bother their doctor. Furthermore, specialists are reluctant to come in at all hours to treat patients they have never seen, who pose formidable malpractice risks, and who cannot afford to pay.

• The physician shortage is intensifying. The Council on Physician and Nurse Supply, an independent group of healthcare leaders based at the University of Pennsylvania, has called on the White House to convene a special conference to address an estimated 30% national shortage of physicians and nurses. The council estimates the U.S will be 150,000 to 200,000 short of physicians by 2020, and nursing schools must produce 30,000 more nurses a year to keep up with demand. This shortage places new economic demands for hospitals, who must pay more recruiting expenses or hire locum tenens physicians or traveling nurses to fill the gaps.

Small wonder hospital CEOs place physician relations and nurse shortages as number one and two on their agendas. The good news is that hospitals have been running record profits over the last five years and have a cushion to address these problems. The bad news for hospitals that no immediate solutions are in sight. They good news for doctors is that they are in greater demand and call the tune. The bad news for some, not all, is that they must become employees rather than independent practitioners.

Friday, March 28, 2008

Insights - Healthleaders Magazine - Insiders’ Insights

The March glossy issue of Healthleaders Magazine just hit my desk. Healthleaders is a Massachusetts based publishing firm that has a website,, a research firm, a conference giver, and a book publisher.

Their March issue’s cover story is “Your Hospital, The Entrepreneur, How Funding Early-Stage Ventures Now Can Yield Health Returns Later.” It features a story on hospital innovation. It talks of Ascension Health and its venture capital fund, and Vanderbilt University and its venture fund.

At Vanderbilt, William W, Stead, MD, associate vice chancellor for strategy and transformation and chief information officer, leads its innovation team. Says Stead, “It takes a particular mindset to be an effective entrepreneur. And there are a limited number of academic teams, certainly academic ones, that understand entrepreneurial people well enough to know how to lead them.”

Innovation runs in the Stead family. William Stead’s brother, Eugene Stead, MD, headed Internal Medicine at Duke, while I was a student, and he pioneered and founded the concept of Physician Assistants after observing that medics returning from Vietnam had great skills but nowhere to apply them.

But that's another story. T

he March issue also contains two “Insider Insights”, two short pieces on what health insiders think. One piece quotes me as editor of Physician Practice Options Old Saybrook. Connecticut, and the other citss Vince Kuraitis, principal of Better Health Technologies, LLC, of Boise, Idaho.

Here are our respective comments:

Reece: Doctors are highly skeptical about IT relieving the burden of their practice for a couple of reasons. One, with electronic medical records, they don’t seen any return on investments. Two, it disrupts their practice. And three, it costs too much, especially when you include maintenance of technology. That is one of the principal reasons only 10 percent to 20 percent of doctors in small practices have gone to EMRs, and only 20% communicate by e-mail. E-mail communication, in their minds, is not part of their normal practice flow, so they have not adapted to that yet. Some health plans do reimburse for time spent e-mailing – it’s seen as a way of giving patients more options. It’s an evolutionary thing, however, and we are clearly in the early stages.

Kuraitis: The current system is one that is totally designed to provide in-person are – and that is what they system is reimbursed for. The assumption is that is how care is delivered, and in the days that was a valid assumption. But now we are changing the assumption that care has to be delivered and/or reimbursed in person. As a result, doctors will be doing more virtual care, and the other part of the equation is that they’ll also be getting paid for it. It will be a change in the work flow, abut I would say it is good because we are chaning the though process on what is the optimal way to deliver care. For a lot of things, you don't have to be in front of a doctor. The new technologies will improve patient care because they have the potential to make doctors more competitive.

Thursday, March 27, 2008

Physician Shortage - The Fix?

Suddenly, a chorus of voices are shouting - train more primary care doctors, pay them more, pay them as well as specialists, and empower them by giving them control over referrals.

“Let’s eliminate E & M codes. Let’s create financial incentives for serving as an ‘Advanced Medical Home’ Let’s pay primary care physicians for what they do – providing comprehensive and coordinated care for patients – rather than by fee-for-service for individual acts. Let’s tie this payment into the severity and complexity of the illness. Let’s encourage the primary care specialists to become involved in coordinating care with the specialists to whom they refer.”

Norbert Goldfield, MD, Internist, Springfield, Massachusetts, Head, 3M Informatics Group, 2007

“The Patient-Centered Primary Care Collaborative, a coalition of large employers and professional groups, has been advocating for changes in reimbursement and the roles of primary care physicians. By realigning the incentives, by using tools, data and programs to identify and manage risk at the level of primary care, and by enforcing downstream accountability from the primary care base, these models have the potential to reinvigorate primary care, and to drive tremendous new improvements in quality and efficiency, and to help re-establish health care stability and sustainability.”

Brian Klepper, PhD, health care analyst, The Doctor Weighs in Blog, March 27, 2008

United States is in the throes of a deepening physician shortage, and will experience a shortfall of 100,000 to 200,000 physicians over the next 15 years. Closing this gap will require an expansion of both medical schools and graduate medical education (GME) positions at the nation’s teaching hospitals. The Council also called for GME capacity to be increased by 30 percent. The Council warned that lifting the current cap Congress has imposed on Medicare-based funding for GME, while necessary, will not be enough.”

Press Release, Council on Physician & Nurse Supply, University of Pennsylvania Leonard Davis Institute of Health Care Economics, and AMN, Inc, America’s largest heath care staffing company

Even without health-care reform, the demand for family physicians is expected to surge by 2020, when the nation will need 140,000 family physicians. That’s a 40% increase over the family physicians at work in 2006. The fact is that costs are too high for an economically viable practice in many areas. Payments from the government and large insurance companies don’t adequately cover expenses and the burden of educational debt. The cost of malpractice insurance to practice the full range of primary care medicine, including obstetrics, is untenable. How can anybody rationally expect to build up the nation’s health on that crumbling foundation”

Benjamin Brewer, MD, family physician, The Doctor’s Office, “Primary Health Care Needs Fixing Before Universal Care Can Work,” Wall Street Journal, March 26, 2008.

“Perhaps these retainer practices, if they continue to flourish, will stimulate a resurgence of outpatient internal medicine. We will be able to continue to train internists who understand the spectrum and complexity of disease, because the retainer model provides an option for those who prefer the outpatient setting but also want complexity and comprehensiveness. Whereas many critics are concerned with the finances of this model and worry about inequities, supporters emphasize the retainer physician's ability to provide the level of care and attention that patients deserve. The retainer model originated and is succeeding because of classic market forces. Physicians and patients find our current arrangements undesirable, thus this new alternative model gives them an interesting choice. Perhaps it will save outpatient internal medicine.”

Robert M. Centor, MD, Professor and Director of General Medicine, U. of Alabama, Birmingham. March 20, 2008, Medscape Business of Medicine

An impossible dream? Not to every major industrialized country on the planet. This plan is called single-payer. You might have heard of it, perhaps when it's being disparaged by insurance and pharmaceutical companies. There are many controversial issues related to a single-payer healthcare system, but it is time for all of the stakeholders in medical care to realize that the consequences of our current quagmire of a healthcare anti-system are too important to remain intransigent to change. The work will be hard, and some sacrifices will have to be accepted on all sides. However, in the end, we will have a system that is not only fair and efficient but caring and personal as well.”

Charles Vega, MD, Associate Professor, Department of Family Medicine, U. of California, Irving, March 20, 2008, Medscape Business of Medicine

Wednesday, March 26, 2008

Physician culture, effect of culture Doctor’s Dilemma: A One-on-One or One-on-Many

Traditionally doctors see patients one-on-one. That’s how doctors and patients like it. Medicine, after all, is a personal matter between doctor and patient. Unfortunately, health care managers say having highly trained doctors “process “patients one-by-one is an inherently expensive and inefficient proposition."

After the 1980s, times changed. The managed care mindset and the “corporatization of medicine” brougt a different perspective to the table. Managers sought to restructure medicine, rationalize care, and bring down costs. Surely, managers say, doctors could “manage” more patients more efficiently. The assembly-line metaphor may be apt here.

To make their point, managers refer to books like Reengineering The Corporation(Michael Hammer, 1993). The idea as applied to medicine is to foster productivity by having doctors oversee more patients. In the industrial world, managers note, one manager can effectively supervise 7 to 10 people. Why should medicine differ?

Now experts say a corporate manager can oversee 30 people or more (George Anders, “Overseeing More Employees – with Fewer Managers,”Wall Street Journal, March 24, 2008). This is done by having managers share knowledge, pay employers more, create teams, and communicate frequently through e-mail, the intranet, and web conferences Surely doctors can do the same.

I have never been confident you can equate medicine to industry, or covert it into an industrial mode. Doctors see themselves as doctors, not managers. Nevertheless, there may be options for restructuring medicine to make the use of physician time more efficient and productive.

Here are some options that are proposed, with my predictions of the likelihood of their happening.*

1) Status quo, no basic change, with one-on-one relationship under current third party payment system, 50%

2) One-on-one relationship with new practice designs (concierge, cash only, canceling HMO contracts, physician ownership of fee-for-service facilities), 15%

3) One-on-many relationships with group visits for patients with common problems or diseases, 5%

4) One-on-one relationships with doctors focusing only on complicated patients requiring physician expertise, 5%

5) One-on-one relationship with “Teamlet Model” –the transition from a lone physician to two person team – doctor + coordinating person (nurse, retrained medical assistant), 3%

6) Combination of one-on-one and one-on many relationship with physician being paid as the central coordinator, or quarterback, for care, sometimes called “medical home” model, 5%

7) Combination of one-on-one and one-on-many in larger integrated systems, 7%

8) Combination of one-on-one and one-on-many with enhanced coordination of care between primary care doctors, specialists, hospitalists, ERs, hospitals, families, 5%

9) One-on-one with patients entering complaints, data, or histories by direct email or through physician web sites, sometimes called asynchronous care. 5%

• If either a single-payer system of a consumer-driven dominates over the next five years, all bets are off. I would place the odds of either of these events occurring at about 5% each.

Take your pick. Only one thing is for sure. None of these options are likely to be adopted throughout the physician community.

Monday, March 24, 2008

Interviews - Surprises and Challenges to Conventional Wisdom

I have published about 500 interviews. They never cease to surprise. Last week, I recorded six of them. Here I share with you a few interviewees’ surprising and challenging thoughts. The thoughts don’t always reflect conventional wisdom. They may even strike you as irreverent.

1. Doctors have little to do with outcomes - Pay for performance will likely fizzle because doctors don’t usually determine outcomes. Patients do. A population’s health depends 10% of medical care, 20% on environment, 20% on genetics, and 50% on life style. The key to boosting outcomes is changing patient lifestyles. As every doctor knows, changing patients’ lifestyle daunts, often discourages doctors. Once patients leave the office or hospital, they tend do what they used to do.

2. Primary care doctors don’t need to compete- Hospital systems, high tech specialists, health plans, drug companies, device makers compete, but primary care doctors rarely do. The demand for their services is so great, their supply so limited, that there are more than enough patients to go around. Why compete? You have enough to do, and you don’t have to worry about where the next patient is coming from.

3. Technology doesn’t replace doctors, it spawns demand - Experts say technology will ease doctor shortages. It will cause consumers to treat themselves, to patronize nurse practitioners or physician assistants, or even to replace doctors with sophisticated algorithms. These things rarely happen. Internet websites drive consumers to see doctors for second opinions, to seek the latest technologies offered by doctors, and sets off chains of diagnostic events such as MRIs or CT scans and visits to multiple specialists, if, for not other reason, to assuage lawyers.

4. America has a doctor shortage with no coherent plan to produce more - We’re now 50,000 doctors short, and we have no rational national plan to produce more. The answer isn’t new medical schools, larger enrollments, more primary care doctors, more foreign-trained doctors, but Congress lifting the cap on funding for more residencies. That’s where trained doctors are who are nearly ready to enter practice, yet we’re not filling these slots, so we don’t have enough doctors in the clinical trenches or in the neighborhoods.

5. The gender factor – 50% of medical students now women – will influence doctor supply estimates. Because of their dual roles, women doctors are likely to be salaried, to take maternity leave, to work shorter hours, and to retire earlier because their spouses are usually professionals and they can afford to. These choices are inevitable and understandable, and have nothing to do with quality of care delivered. The choices simply mean we must take gender into account when calculating the number of doctors needed to meet an aging population’s demands.

6. Consumer-driven care allows people to make mistakes and to learn from those mistakes - In federal and private bureaucracies, paternalistic attitudes reign. Bureaucrats believe they possess superior wisdom and are smarter than patients, who need to be protected from bad decisions and greedy caregivers. In a consumer-driven system, attitudes differ. Intelligent informed consumers will make mistakes, but they will learn. Markets, in other words, have their own wisdom, and it generally surpasses the wisdom of bureaucrats and technocrats.

7. EMRs will not lead to “paperless” offices - Paper will not disappear. It will proliferate, as doctors download more, keep permanent records of evanescent cyber documents, process paper from others, and preserve a more secure l private corner of their universe. Most of the outside health care world still deals in paper, and that paper never seems to go away. And remember, the Canadian and American pulp industries thought computers would be their ruination. Instead, with downloading of Internet documents, the pulp industries are booming as people download to keep something of permanence. Paper is more real than what one sees on the screen. Unintended consequences strike again.

Sunday, March 23, 2008

Internet. ,Health Information Technologies -, An Internet Startup

I opened today’s March 23 Sunday New York Times Magazine to find “Practicing Patients.” It bears these subtitles “an Internet Startup, “ “Creates information-rich communities,” “It is the next step forward in medical science – or just a MySpace for the afflicted?’

Thomas Goetz, deputy editor of Wire Magazine,” wrote the piece. He describes how patients with degenerative neurological diseases – multiple sclerosis, amyotrophic lateral sclerosis, Parkinson’s Disease , AIDS– can talk to each other, compare notes, and regularly share information on dosage and treatments.

This article highlights the latest crazes on the Internet – easily accessible social networking websites for people with common concerns. MySpace and MyFace are other examples in the public domain, and in medicine, occupies a prominent spot.

The idea is to create structured communities, to build databases, to churn personal experiences into hard numbers, and to create personal exchanges, to be open, to accelerate research by gathering hard data to solve problems.

Thomas Goetz waxes enthusiastically on the power of information. So am I. These sites can build solid information bases quicker and earlier than traditional sources. The sites build hope. Yes, there may be privacy issues, but when you’re desperately ill, you may figure you don’t have anything to lose. Besides, when bundled into databases, private information can result in immediate and long term benefits and returns. And, for the drug industry, social networking sites for patients and doctors may a powerful shortcut to find what varying drug doses do for a larger population.

Of course, sites like PatientsLikeMe. com may build false confidence and hopes , produce unreliable information, and create a mistake-prone environment. It isn’t scientifically evidence-based double –blind controlled clinical trials. But it ‘s fast, understandable, and personal – and sometimes produces gratifying and constructive results.

On the other hand, chronic diseases tend to be incurable, none of us are going to get out of this alive, and there’s always gloom for improvement, even for DoctorsLikeMe.

Friday, March 21, 2008

Medicare - Riding the Medicare Tiger

He who rides the Tiger can never dismount

Chinese Proverb

What - The MGMA, whose 21,500 members lead and manage 13,500 groups with 270,000 physicians, say 46% of physicians will either limit or stop accepting new Medicare patients in light of anticipated 10.6% reduction scheduled for June 2008 and 5.4% in 2009.

Why – Over last 9 years, overall Medicare payments have fallen 1.5% while Consumer Price Index is up 25.1% and operating costs of running practice is up 43,1%.This is important because it is certain to cause political outrage if doctors stop seeing new Medicare patients. New Medicare patients who expect to be covered after paying in over their lifetime. Medicare cuts will exaggerate physician shortage. In Medicare’s eyes, the cuts are necessary to keep its costs from devouring the federal budget.

- 10.6% cuts are scheduled for June 2008, with another 5.4% to follow in 2009.

How - It will probably take heavy lobbying by physician organizations, AARP, and other consumer groups tied to Medicare to reduce cuts.

Where – Everywhere.

Who - Will effect all physicians serving Medicare patients. According to MGMA, more than half are already reducing administrative and clinical staff and limiting hiring, and two-thirds will sacrifice or postpone Information Technology (IT) and equipment purchases. They may choose not to see new Medicare patients, But those sitting atop the old Medicare tiger will have a hard time dismounting. These patients need care and cannot be abandoned.

Thursday, March 20, 2008

Doctor shortage - Part-Time Older Doctors and the Doctor Shortage

What - A 2006 survey by the Association of American Medical Colleges Center for Workforce Studies indicates two of three doctors over 50 work part time or are interested in doing so.

Why – Older doctors want a balanced life style, but need to work part time to supplement income or to keep their skills and knowledge current. At same time, part-time doctors are needed to ease looming doctor shortage which experts say will be in 85,000 to 200,000 range by 2020.

When - According to James Merritt, Joseph Hawkins, and Philip Miller in Will The Last Physician in America Please Turn Off The Lights (Practice Support Resources, Inc, 2004), the shortage is already upon us.

How - Overwork, hassles, loss of respect, demoralization, declining incomes, and hostility towards health plans and Medicare are causing fewer medical student to choose primary care residencies and more older doctors to retire.

Where – Shortages most intense in primary care and general surgery, in cities of 50,000 or under, and underserved rural areas and in inner cities.

Who – In doctors over 50. 21% already work part time, 22% would like to but can’t because not offered by their practices, 24% are considering part time work, 19% are not interested, and 14% are not interested under any circumstance.

Internet, health information technologies, health 2.0. clinicial innfovations,Twelve Random Observations on Innovation and Information Technologies

“Seek simplicity and distrust it.”

Alfred North Whitehead (1861-1947, English Philosopher

"Complexity. It is a concept that is imposing in its very name. In fact, even the idea of explaining complexity (making complexity simple), is, at its heart, paradoxical.”

Brenda Zimmerman, phD, Curt Lindberg and Paul Plsek, Edgeware, VHA, Inc, 1998

I often talk to people about health care innovation and its main catalyst – health information technology systems. Usually these conversations flow from those who read my book Innovation-Driven Health Care; 34 Key Concepts for Transformation (Jones and Bartlett, 2007) or my blog, with its tag line, “Observations of a Health Care Innovation Watcher.” Out of my conversations with innovation leaders has arisen 12 observations. I present them in no particular order.

1. No single EMR fits all specialties – Indeed, in multispecialty and hospital settings, an EMR commonly clogs work flow, confounds physicians, and angers them because it distracts from practicing medicine. More often than admitted or publicized , EMR systems are jettisoned or reconstructed into simpler pieces to fit individual specialty needs.

2. Innovation means different things to different specialists -- For cardiologists, innovation may mean pumps, implantable devices, left ventricular assists, atrial ablation; for orthopedic surgeons, it may mean mechanical devices, rods, screws, artificial discs, joint prostheses; for oncologists, it may mean infusion techniques, off- label use of chemotherapeutic agents, new protocols. For technophiles in other disciplines, innovation often means different key strokes for different folks.

3. Young doctors tend to be enamored with the magic and promise of new technologies: older doctors tend to more impressed with the impact of technologies on practice work flow and quality improvement. These differences may exist because young doctors have nothing in the past to compare with; older doctors do, and they can see new technologies do not automatically improve care or outcomes.

4. Innovation is the current rage, and innovation centers and programs are popping up all over the country in major medical and academic centers - Kaiser, Group Health, Virginia Mason, U. of Kansas Medical Center, Northwestern, Johns Hopkins, U. of Pittsburgh Medical Center, and Partners in Boston, to mention just a few. Some innovation meetings convene innovation summits, others address the latest fad; still others introduce new information technology products.

5. Doctors do not make good or willing documentalists - Clinicians often view documentation as something done for the benefit of payers, not themselves, as time consuming, and as a “hassle,” which in my dictionary is defined as “as a source or the experience of aggravation or annoying difficulty,” and something that slows productivity without any particular benefit accruing to patients or their caregivers. .

6. Data entry is an expensive , distracting, and sometimes degrading proposition, best left to others – patients themselves, scribes, nurses, or other staff members. The doctor should be thought as the final arbiter, the Vice-President , the Commander-in-Chief, of the office or group information system, not a data-monger. Data may be superior for tracking population health improvement, but in doctors’ minds, doesn’t improve individual quality of care at ground zero.

7. “Chunking” should be the order of the day in building information systems. Allowing complex systems to emerge out of the links between simple systems that work well and are capable of operating independently and efficiency is the way to go. For example, patient e-mail is a form of chunking; so is an email from doctors to the emergency room telling them what ticks or what’s sick about an incoming patient.

8. Innovation is never done: it is complex, ongoing, frequent interaction between caregivers to tweak, improve, and re-invent some care process. This process is the essential building bloc of workable evolving information systems and of constantly “learning” organizations. The idea is dawning that constant, constructive, and synergistic learning between doctors is the only way to fix the system and pull practices up by the bootstraps.

9. Anything that adds “hassle” to an overworked clinician and distracts from the primary mission of seeing patients, even if presented in code language speaking of “financial incentives, “” pay-for -performance,” or the more homey “medical home,” is likely to fail if it is too complex or time consuming. It is also likely to be expensive with indifferent outcomes, as the British Health Service has learned from its cash for data program.

10. “Informed” health care consumers, acting alone without doctor advice. Or, on basis of consumer Internet information , cannot be counted on to make consistently good decisions. There is some truth to the old maxim, “He who treats himself has a fool for a doctor.” Patients acting in concert with their doctor is better. It takes two to tango. A third party instructor does not customarily advance the tango, give it a more measured cadence, or make it more rhythmic.

11. Retail clinics, even though run by nurse practitioners or physician assistants armed with EMRs and protocols, are probably a good thing, even when backed by remote physician advisors and overseers, but harbor dangers stemming from inadequate knowledge of patient history and context. Some observers say malpractice landmines lie ahead for these clinics. Physicians may counter and compete with these clinics by various means – longer hours, lower prices for minor problems, and convenient and paid email communication.

12. The “transparency” movement among doctors, posting prices on websites and in offices, may soon be a wave of the future. The reason is quite simple. If consumer driven care is real, and I just read 24 million Americans now have high-deductible plans with HSAs, and the economy tanks, as some predict, uninsured or uner-insured consumers will want to know in advance what charges to expect and what they can afford.

Wednesday, March 19, 2008

medical students, effect of culture - Medical Students Seek Residencies Leading to Good and Balanced Life

What - Residency matching program results are about to be announced, and medical students are most desirous of being placed in dermatology and plastic surgery residencies. Last year only 61% of students got their first choice in dermatology residences, and only 63% got their first choice in plastic surgery residencies.

Why - The allure of dermatology and plastic surgery careers is obvious – high incomes, a balanced life style, few critically ill patients, and no night or weekend call.

When - The push for matches in dermatology and plastic surgery has been going on for at least five years as the word is out among medical students about low pay, long hours, and a grueling work load in other specialties like family medicine, internal medicine, and pediatrics.

How - Students generally apply for matches in multiple programs. A NYT March 19 article ,”For Top Medical Students , An Attractive Field, “ described a Harvard senior medical couple who applied to 90 dermatology residency programs each, and even though already $330,000 in debt, the couple borrowed $20,000 to travel to two dozen interviews each.

Where - In dermatology and plastic surgery, a limited number of residencies are available, and students will go where they are accepted. At Harvard, six dermatology residencies are available for 330 applicants – not very good odds, especially if you are a couple who want to be placed in the same program.

Who - Who is being matched? The following table tells all.

U.S. Seniors Matched in 2007

% Matched # of Positions Average Salary

Dermatology 61% 320 $390.000

Plastic Surgery 63% 92 $408,000

Orthopedic Surgery 80% 616 $476,000

ENT 82% 270 $369,000

Radiation Oncology 82% 142 $488,000

Ob-Gyn 89% 1146 $297,000

General Surgery 90% 1057 $330,000

Diagnostic Radiology 91% 1035 $450,000

Emergency Medicine 92% 1384 $258,000

Anesthesiology 94% 334 $372,000

Neurology 96% 539 $255,000

Pediatrics 96% 2624 $188,000

Internal Medicine 98% 5517 $192,000

Family Medicine 99% 2603 $179,000

Sources: National Residency Matching Program, Association of American Medical Colleges, Medial Group Management Association

Tuesday, March 18, 2008

Health Plans Seek to Keep a Leg up on Profits

What - Health plans, under the gun for inflating out-of-network consumer expenses and for not paying for pre-existing illnesses, are not under fire for capping prosthetic limb expenses at $2500 to $5000 a year, while costs have risen to $3000 to $15,000, and up to $40,000 for advanced mechanical and computer-assisted prostheses.

Why - Plans say they want to keep premium costs down, but critics assert plans dupe consumers by burying caps language in small print. Health plans are struggling to maintain profits at a high level to keep their stock prices up. As of March 13, stock prices of health prices had fallen this far in month of March: Humana -40.2%, WellPoint -33.7%, UnitedHealth -21.1%, Cigna -10.4%, and Aetna -10.2%. Health plans problems include climbing medical costs, cumbersome government programs, and consumers delaying co-pays.

When - Amputees and prosthetic makers are lobbying state legislatures to mandate coverage comparable to Medicare, which pays 80% of costs.

How - Amputee proponents argue only 2 million Americans have prostheses, so overall premiums would only rise by pennies if prostheses were generously paid for, and prostheses make people more productive, active, and healthy, lowering premium costs.

Where – Eight states have passed laws mandating coverage.

Who - The Amputee Coalition of America, an advocacy group of amputees and prostheses makers, are pushing for law in Congress to mandate coverage, and Hanger Orthopedic Group, Inc., the biggest prosthetic maker in $2.5 billion industry, is big backer of lobbying effort.

Monday, March 17, 2008

Clinical innovations, systems thinking - Short Take on Disseminating Innovation

What - Dr. Lyle Berkowitz, a practicing internist, chief medical information office of 120 person primary care group at Northwestern Memorial Hospital in Chicago, and program director at Szollus Innovation at Northwestern, called to discuss status of medical innovation in the U.S. – how to spot it, encourage it, spread it, teach it, embed it.

Why – If U.S. health care is to improve, cost less, and get better outcomes, it must innovate to crawl out of its present rut and fixed ways of looking at things.

When - It’s happening fast now as we seek ways and as innovation centers spring up to “fix” the “broken system,” or “mess,” whichever term you prefer.

How – To spread, innovations must be perceived as benefit with risks outweighing risks; must be compatible with values, beliefs, past histories, and current needs of doctors; must be relatively simple; must find ways to test validity; and be observed and tried out by early adopters.

Where -. Innovation centers have been set up at Kaiser, Virginia Mason, Northwestern, Cleveland Clinic, Minnesota state government, Mayo, and University of Pittsburgh – and no doubt others.

Who – Personalities who spread the word and make it stick include : 1) innovators (venturesome, risk tolerant, novelty seekers, who are willing to venture outside to learn); 2) early adopters (those who see the opportunity and seize it early); 3) the early majority (who see the light shed by innovators and early adopters and climb on the bandwagon); 4) the late majority (who see the success stories and view change as inevitable); 5) the laggards (who refuse to change under any circumstances and are chained to the past by social, organizational, or political constraints)

To make innovation work , rules are:

1) Find a sound innovation.

2) Support innovation.

3) Invest in early adopters.

4) Make early adopters’ activities observable.

5) Trust and enable those who want to modify or reinvent original innovation.

6) Give those who fail some slack time to re-energize their risk-taking zeal.

7) Lead by example,

8) Read Donald Berwick, MD, MPP, “Disseminating Innovation in Health Care,” JAMA, volume 289, pages 1969 -1975, 2003, for details.

9. Never, never, never give up.

Mayo Clinic -A Slightly Longer Take on Mayo Clinic’s Six Principles

At a recent meeting in Washington, D.C, the Mayo Clinic announced six principles on national health reform. Mayo arrived at these principles after a systematic year long process. It started with a national forum at Mayo, and a series of regional meeting sounding out the physician community and ended in the nation’s capitol.

The principles are,

• America spends enough on health care.

• Everybody should be required to buy insurance.

• Employers should contribute.

• Government should step in for those who can’t afford to pay.

• Electronic records will be required to better coordinate care.

• Medicare should reform its payment system by paying more for good outcomes and less for bad outcomes.


Mayo’s fundamental principles Mayo deserve further comment. I go back about 25 years with Mayo. I respect Mayo immensely. Over the years, I have interviewed their physician chief executive officers. Last year I wrote a chapter in Innovation-Driven Health Care (Jones and Bartlett, 2007) entitled “The Mayo Clinic Innovates the Mayo Way: Leaving Nothing to Chance.”

Mayo approaches what they do methodically, purposefully, and as a unit. Consensus is the order of the day.Their principles command attention. Hundred years ago Mayo pioneered patient-centered, team-oriented, group practice; over the last 30 years or so have consistently delivered care at 20% to 22% below the health care market at large over the last several decades, and over the last two decades U.S. News and World Report surveys of physicians, regularly ranks Mayo either #1 or #2, with Hopkins, as the top medical institution in multiple specialty categories. Mayo’s opinion are not to be ignored.

Now let’s examine the principles one by one.

1. America already spends enough on health care.

This may be. We spend 40% more than either other nation, about 17% of our GDP, while no other country expends more than 12%. I’m deeply suspicious of national ratings, both on money and health outcome ratings. I don’t know how the statistics are gathered, and those entities that collect them, for example the World Health Organization, has a political ax to grind. National cultures and life style differ profoundly. And, being the biggest immigrant nation, our government has less control over social mores. But we certainly have waste and duplication, which be the price of choice and freedom, our expendable incomes, our individualism, and our capitalistic system. Still, Mayo, through its discipline and execution of its group practice model, its emphasis on ambulatory care, its narrowing of income differences between specialists and generaliss, and its innovative systems, has much to teach us.

2. Everybody should be required to buy insurance.

As Massachusetts with its universal coverage model is quickly learning, this is easier said than done. Here Mayo focuses on individual responsibility rather than individual mandates. But for many of the 47 million uninsured Americans, who can afford care but choose not to cough up premium dollars because they prefer to spend money on other things, this may be a tough sell. It is also costly to enforce an individual mandate, particularly among the young, who may regard obligatory payment of premiums, as stacking the deck against the young and healthy to pay for the old and sick. Tracking down non-payers or even getting eligible Medicaid recipients to enroll can be a logistical nightmare. Also, come November, roughly 90% of Americans will be insured, and they may not regard paying federal taxes to support the uninsured as being in their best interests. I do not wish to rain on Mayo’s parade, or to say requiring everyone to buy insurance is not noble or not the right thing to do. It is, but it will cost $110 billion the first year, and that’s just for starters.

3. Employers should contribute.

This is realistic in that it retains our current 60 year old employer-based system, which may prove difficult to dismantle since many employers regard their health plans as potent recruiting tools. The other side, of course, is that health costs make U.S. employers globally non-competitive. It is worth noting that many Republicans favor jettisoning the employer-based system and replacing it with universal tax credits and health care cost deductibility.

4. Government should step in for those who can’t afford to pay.

This is an unarguable point, which everybody agrees upon. With Medicare and Medicaid covering 100 million Americans, government already expends nearly half of all health costs.

5. Electronic records will be required to coordinate care.

No argument here either. But it will be slow sledding. Only 10% to 20% of hospitals and doctors have electronic systems now, and most electronic record systems don’t speak to each other. The personal health rccord is in its infancy, with less than 5% of patients having PHRs. It may be more patients with PHRs will demand doctors have EHRs, and consumer pressures will force doctors to enter the electronic revolution. I am dubious about the pace and practicality of universal coordination via electronic communication. The electronic Holy Grail looks frail at this point. In my opinion, a national health care central nervous system linking all people and all health care entities will require a massive federal subsidization program akin to the 1946 Hill-Burton Act for building hospitals.

6. Medicare should reform its payment system by giving more money for good outcomes and less money for bad outcomes.

This, of course, is the premise under girding the multiple pay-for-performance experiments and programs going on around the country, being pushed by Medicare, Medicaid, and private health plans. I am not all sure P4P will save money or evenly modestly improve care for these reasons;

a) P4P programs to date have shown only modest return on investment in terms of dollars saved or outcomes improved;

b) the administrative burdens and data infrastructure required is expensive and generally exceeds the bonuses given to hospitals and doctors;

c) outcomes depend mostly on lifestyle factors, which are largely outside the reach of doctors, hospitals, and government.

When I think of outcomes, that famous pie-chart showing the percentage impact of various factors influencing health springs to mind: 10% medical care, 20% environment, 20% genetics and DNA, and 50% life-style.

In all of these comments, I may a little too pessimistic about Mayo’s proposals, all of which are noble, and no doubt might work if we had a series of regional Mayo clinics, or their equivalents, dotting the landscape. Another problem, and a big one, is our fee-for-service, which rewards hospitals and doctors for tasks-done rather than for consultations, collaboration, costs-saved, complications-avoided, coordination, or, consensus on what needed to be done. Perhaps consumer-driven care, with consumers gravitating to high-performing physicians, hospitals, or integrated institutions, will solve some of the cost problems.

But as things stand now, Medicare is a big part of the problem, with its 140,000 pages of regulations, its ponderous bureaucracy, its reliance on a fee-for-service systems, its lack of blended payment system rewarding coordination, consultation, and good old fashioned advce, and the very fact that it is the Sheriff of the System, whose marching orders the private system passively follows. Medicare does not reward efficiency or performance, which is one reason Mayo seeks reform. Medicare’s payment system puts downward pressure on Mayo’s $6 billion budget

Concluding Remarks

I conclude this discursive little essay by recalling the words of Oliver Cromwell (1599-1658) to his executioners before he was beheaded,” I beseech you, in the bowels of Christ, think it is possible you may be mistaken.” Mayo is probably mostly right in its ideas about reform, and I are probably mostly wrong. As a widely respected physician-led organization, Mayo has been right too many times in the past. If by some chance, some future historian reads this remarks, it will be said of Mayo, “Right on!” And of my Late Self, “Wrong gone!”

Saturday, March 15, 2008

Reece, Personal musings - Orgism

I believe in words. As Barack Obama said, “Words matter.”

I believe in short words. As Winston Churchill said, “Short words are best.”

I believe in new words. New words express new ideas.

I believe in new ideas, the fount of creativity.

I believe in organisms. We are one of them.

I believe in –isms. –Isms are systems of belief, and to create we must believe.

I believe one short word is good when it combines two ideas – organisms and belief systems.

I believe in word play. Orgism climaxes creative excitement, as orgasm climaxes sexual excitement.

I believe organizations can practice orgism – the bringing together of individuals to combine ideas and beliefs.

I believe some ideas and beliefs are more equal than others, but all must be listened to and weighed.

I believe the Mayo Clinic is an orgistic organization in that it believes the consensus of thousands of doctors means something.

I believe the Mayo consensus on health reform, reached after a year of meetings at Mayo and elsewhere, is worth considering.

Mayo believes,

• We already spend enough money on health care.

• Everybody should be required to buy insurance.

• Employers should contribute.

• Government should support those who can’t afford to pay.

• Electronic records will be required to coordinate care.

• Medicare should give more money for good outcomes and less money for bad outcomes.

Those are Mayo’s beliefs.

Believe them or not, but think about them.

Friday, March 14, 2008

Clinical Innovation, Harvard - Six Myths About Physician Creativity

Today I received the March 2008 Harvard Business School Alumni Bulletin. I spent 8 weeks at HBS once – just enough time to make me dangerous. This issue sports an article, “Innovation, Inc.” The article lists six myths about creativity in organizations. These myths apply to physician groups.

Creativity Comes from Creative Types – Not necessarily. Creativity depends on experience, knowledge, technical skills, talent, and the ability to think in new ways. To encourage creativity in physician groups, appointing a Chief Innovation Officer (a nurse, doctor, practice manager) and holding periodic brain storming sessions may help foster creativity.

Money is a Creativity Motivator - Money isn’t everything. Most doctors don’t think about money on a day-to-day basis, and it doesn’t drive new ideas.

Time Pressure Forces Creativity - Actually creativity goes down under pressure. Creativity requires time to think, concentrate on a problem, and let the ideas bubble up.

• Fear Forces Breakthroughs – Not so. Creativity comes when people are excited about their work. Often creativity strikes overnight after an exciting day at the office. One day’s excitement predicts the next day’s creativity.

• Competition Beats Collaboration - Nonsense. The most creative groups are those that share ideas and don’t compete for recognition.

A Streamlined Organization is a Creative Organization - Not in the opinion of HBS. They say a stable work environment in a group that is doing well fosters a sense of freedom and autonomy and lets ideas flourish.

Wednesday, March 12, 2008

Coordination - Short Take on Coordinating Care

What – Article by Thomas Bodenheimer, MD, West Coast managed care expert – “Coordinating Care – A Perilous Journey through the Health Care System, “ New England Journal of Medicine, March 6, 2008

Why - Because more and more Americans are falling through the cracks, shuttling back and forth between specialists. Bodenheim says barriers to “seamless coordination” are – overstressed primary care physicians, shortage of primary care doctors, lack of interoperable computer systems, low primary care pay, no payment for coordination, and paucity of integrated systems.

When – Poor coordination has been a problem for at least 20 years, and has grown more intense over the last decade with physician shortages, widening income gaps between primary care doctors and specialists, and lack of incentives to coordinate care.

– To correct coordination deficiencies, Bodenheimer suggests electronic referrals by primary care doctors to specialists, referral agreements between the two, hospitalist-initiated agreements with practitioners, advanced practice nursing, care transition programs, and assisting primary care clinicians through: 1) transforming solo practices into “teamlets” – two person teams with a physician and non-physician coordinator in each practice; 2) payments for coordination; 3) creating “medical homes,” 4) adopting and subsidizing EMRs and interoperable records; 5) moving primary care into larger integrated systems.

Where - Wherever different health care entities choose to work together or to integrate into organizations..

Who – As a practical matter, coordinating care is most talked about and acted up by leaders of large integrated systems, which involve about 12% of American physicians, some of which are physician-led and others hospital-led. American Academy of Family Practice, American College of Physicians, and American Academy of Pediatrics support the concept of medical homes, which visualize primary care physicians as coordinating quarterbacks for care.

Universal coverage - Short Take on Universal Coverage

What – Universal coverage for all.

Why - Because it’s hot issue, after the economy, in this year’s presidential campaign. Come November, Democrats may regret they carried on about universal coverage. Nine of ten Americans will be covered, and calls for individual mandates and higher taxes to enforce mandates may not sound so good. Besides, universal coverage will not snuff out rampant inefficiencies and perverse incentives that lead to skyrocketing costs.

When – When will reform occur? Not this year or next, maybe not even in the next decade. After all, Americans been debating reform since 1912. Health reform is evolutionary.. It will not occur in one swoop in response to pleading from a single political party. When will absolute universal coverage occur? Maybe never. Millions of young people will continue choose to spend their money elsewhere and will evade paying individual mandates; and perhaps 10 million eligible for Medicaid, will not show up or enroll.

How – Reform and coverage may take a world depression, a world war, or an unprecedented natural disaster.. Americans may not be ready for a universally mandated system requiring every citizen to pay individually or face fines, garnished wages, tracking down non-payers, and higher federal taxes.

Where - Most likely in D.C . since state experiments have failed or are beset by unexpected costs. Imposing top-down command and control reform on the present system will be expensive. Universal mandates may be alien to our individualistic, government-distrusting culture. Most likely reform will be spotty and will be accompanied by market innovations offering wider choice and quicker access.

Who - A charismatic bullet-proof president with a veto-proof, lobby-proof Congress, a promise of no tax raises, no goring of special interest oxen, and cooperation from physicians to deliver the goods.

Tuesday, March 11, 2008

Spirituality - Short Take in Spirituality in Medicine

What - Noticeable return of spirituality to medicine (renewed stress on soul, spirit, and compassion in contrast to strict emphasis on science and technology)

Why - Chain of events is complex. But these beliefs and events seem to be occurring Science and technology have limits, end-of-life care has spiritual side, hospice movement surging, managed care does not offer solace, public is switching from strict disease-centered to holistic medicine models, and patients and doctors are seeking refuge from harsh costs, rules, and exclusions of coverage. This sequence of happenings may be part of maturity of American people towards aging, disease, and death.

When - Movement toward spirituality, though subtle, are growing as Americans confront aging population, realities of chronic and incurable disease, and this hard truth : none of us will get out of this alive.

How - About 100 of 150 U.S. medical schools are now integrating spirituality into curriculum as part of required course, and some medical schools and residency programs are offering hospice rotations as part of training .

Where - Everywhere. Part of generalized social trend away from strictly disease-oriented and scientifically-based models towards more realistic holistic approach. Public may be ahead of doctors on holistic curve.

Who - Those who believe spiritual practices, as well as meditation, prayer, humor, the arts, and alternative medicine, have roles to play in healing and dying.. Controversial in some quarters. Some think spirituality crosses the line, ignores science, and smacks of born-again or evangelical beliefs. Beside, they may add: hard science trumps everything.. It’s worth noting that physicians are more likely to attend religious services than rest of U.S. population and that 76% believe in God and 59% in an afterlife

Sunday, March 9, 2008

Goverment vs Market Reform - Short Take on Clinton, Obama, and McCain Proposals

What - Health reform policies of the three presidential candidates still standing

Why – Because their policies may determine the future state of health care and your practice.

When – The winning candidate’s policies may kick in over the next four years, depending on what president is elected the make-up of Congress and opposition of powerful lobbyists from major sectors whose ox is being gored.

How - Clinton and Obama disagree on one health care matter. Clinton wants universal coverage for all with individual mandates; Obama wants universal coverage of children with decreased costs.

But Senators Clinton and Obama propose and agree upon the following actions, all of which will require a much larger federal role with tax increases in $110 to $120 billion to start with.

Government would require, i.e. mandate

• Insurers to charge the same premium to everyone regardless of age, gender, or occupation, called community rating.

• Insurers to cover anyone who applies through guaranteed issue and prohibiting denials for pre-existing conditions.

• Insurers to offer health insurance that is as generous as the comprehensive coverage available to members of Congress

• Employers to contribute to the health coverage for their workers through a "pay or play" mandate, with small business getting added help to offset costs
In addition, government would,
• Repay businesses for some of the catastrophic costs of employees with large medical expenses, providing certain conditions are met.

• Open the Federal Employees Health Benefits Program to millions more workers and setting up other regulated health insurance purchasing exchanges.

• Expand Medicaid and the State Children's Health Insurance Program.

• Allow people to buy in to Medicare, thereby setting up competition between a taxpayer-subsidized program with federal pricing and policing authority and private health plans.

• Curtail private competition in Medicare by scaling back payments for Medicare Advantage and allowing the government, rather than private companies, to negotiate prescription drug prices for the Medicare drug benefit.

• Allow prescription drug importation from abroad, which means importing other countries' systems of price controls (as Sen. McCain also has proposed), and placing new controls on prescription drug prices.

• Promote greater government involvement in determining the comparative effectiveness of medical treatments and requiring doctors and hospitals to practice according to its evidence-based protocols.
McCain proposes: Moving more power and control over health insurance and health care decisions to patients.

Who - Who to vote for? The question for voters this fall will be whether government can create greater efficiency and choice into the health sector or whether the private sector puts doctors and patients in charge, gives incentives competing plans and doctors to offer more affordable care and coverage.

Saturday, March 8, 2008

Access - Short Take on Access

What - In health care, lack of access boils down to waiting – waiting to get an appointment, waiting in the reception room, waiting in the emergency room, waiting for a diagnostic test, waiting for an operation, waiting for test results, waiting for the doctor to come to the phone.

Why – Waiting may be due to inefficient scheduling, over-scheduling, overcrowding in inadequate facilities, doctor shortages, office mismanagement, misinformed patients, or simply sloppy personnel policies. Whatever the cause, people are growing sick and tired of waiting for health care.

When – No one knows. Waiting times and limited access continue to grow.

How – To expand access and limit waiting times, doctors are addressing the problem through open scheduling, wave scheduling, longer hours, greater use of physician assistants and nurse practitioners, scribes accompanying doctors in emergency rooms to take notes and document encounters, patient generated computer histories, and opening of worksite clinics, in-store clinics, urgicenters, multispecialty ambulatory care centers in doctor-short rural areas; and borrowing of Disney World techniques in crowd control.

Where - Everywhere. This would seem to be inefficiency and linkage problems across the health system, but is most noticeable and manifest in emergency rooms, primary care offices, and hospitals operating at overload.

Who - Slow access effects patients in distress, but also overworked, overburdened doctors who can only handle one patient at a time, and only so many in any given day.

Friday, March 7, 2008

A Short Take on Hospital-Physicians

What - Hospital-physician relationships

Why - This is an enormous reform issue because hospitals and physicians spend 75% of all health care dollars. The truth is hospitals and doctors do not always agree because they compete for patients and cannot always decide who should be in control. But hospitals and doctors have a common purpose – to cure patients, alleviate pain, and provide a safe health care haven. In the end, this common purpose may bring them together

When – When will hospitals and doctors cooperate and collaborate? They already do in many respects, but they also compete for patients and payments and for control of patient care. It is a tense tango. Hospitals are open 24 hours a day and insist they offer comprehensive care. Doctors say patients can often be treated more safely and conveniently in their offices and their own facilities. Some hospitals and doctors are working to resolve these issues in the form of joint ventures or common ownership.

How – The question is: integrate or disintegrate? Should hospitals and doctors work together in one system? Or should they pursue their independent paths? It may seem obvious, but elective procedures, are best and more safely performed by physician in settings where the doctor is in total clinical control. Other things are best done in hospitals with 24 hour coverage, where patients are constantly monitored.

Where – Local politics and the statesmanship of hospital and physician leaders can best work out these problems. No solution fits all.

Who – It depends on what is best for the community. The interests of the public, hospitals, and doctors are intertwined. An example is the Walmart decision to align with local hospitals as partners or owners. Hospitals insist they do not want to compete with doctors, but to refer to them when appropriate. Doctors remain dubious about Walmart-hospital alignments

Thursday, March 6, 2008

A Short Take on Health 2.0 and an Even Shorter Take on Health 3.0

Health 2.0

What - Health 2.0 is the next generation Internet with increasingly simple applications and simultaneously more sophisticated software allowing ever widening access and uses of information at the site of care by end-users, namely, patients and doctors.

Why - Google, Wikipedia, and Sermo are friendly end-user search and social networking online engines. These engines allow patients and doctors nearly unlimited access to health information at the click of a mouse. Google uses complex algorithms. Wikipedia features constantly updated and edited text. Sermo makes it easy for doctors to converse online with each other and to compare notes. The three websites are free to users. All require broad band access.

When – Now. All three web sites are currently in use and are growing easier to use and more sophisticated by the day.

How – Type in or in the URL bar space. For Sermo, physicians type in once you have registered and become a member by virtue of being a licensed practicing physician. is a physician-only conversational networking site.

Where – Anytime. Anywhere, By wire or wirelessly.

Who – Anyone who wants to search for health information. Seek and ye shall find.

Health 3.0 – An addendum

An email flyer just arrived to inform me health 2.0 is now kaput. The arrival of Health 3.0 – the convergence of social technology, enlightened consumerism, and globalization – signals an even more radical change in the world’s health marketplace.

I’m not so sure. I’ve seen “perfect storms” blow over before. In any event, Jeff Gruen, MD, MBA, senior advisor to Steve Case, CEO of Revolution Health, says Health 3.0 is here. Maybe he knows. He coined the term.

The flyer stops short in explaining how these forces will come together. But apparently social technologies, internet networking social collaboration sites, will enlighten consumers to find the right care in the right places at the right prices, which will lead to a worldwide marektplace, wherein consumers will seek care anywhere in the world.

Health 3.0 will be explained at the Health 3.0 summit on May 4-7 in Las Vegas, where the flyer says, the smart money is going. Most busy doctors can’t afford to go, but health 3.0 is something to think about. Most of us will probably stay at home to meet our practice bottom lines. As the saying goes, think global, act local. On the other hand, maybe some of us can afford to take a flyer on the flyer.

Wednesday, March 5, 2008

Short Take on Transparency

What - Transparency in health care entails informing consumers in advance exactly what to expect in terms of quality, comparative costs, complications, and outcomes.

Why - Health care, for various reasons, is opaque, sometimes secretive, and often unknowing as to what care will cost, leading to uncertainties, unpleasant surprises, economic shock, and a litigious environment.

When - Because of multiple factors - unpredictability of diseases; lack of ease of use of information technologies; the fee-for-service system with its billions of billable events; multiple health plans each with different contract arrangements; and the entitlement syndrome, promising consumers comprehensive care incentives with no incentives to ask what costs might be; and ubiquitous third parties who tend to mask or obscure actual costs; and health bills which are impossible to decipher, it is chancy to predict “when” total transparency will be achieved. For hospitals, creating a patient-friendly bill can be a logistical nightmare, retraining of all billing department and data entry personnel.

Where - Experiments are underway everywhere, led by government who says transparency is the way to go, health plans publishing doctor and hospital cost comparisons, and doctors opting out of third party arrangements and forming cash only practices.

How - Multiple approaches are being tried - Internet access to comparative costs and quality; cash only practices with bills posted in offices and offices; retail clinics with fixed prices for minor tests and procedures; bundled bills for hospitals and doctors with prices known in advance; simplified “patient-friendly” notices of what to expect; and “direct care” featuring HSAs, quality and cost comparisons of practitioners conveyed via the Internet.

Who - Those just listed, and assertive consumers, notably baby boomers, many paying co-pays, and other holding HSAs or demanding to know how much is coming out of their accounts.

Tuesday, March 4, 2008

Short Take on Consumer-Driven Care

What - Consumer-Driven Health Care (CDHC), as usually defined, refers to health plans using HSAs, HRAs, and similar plans to pay directly for routine health expenses with minimal interference with patient-physician relationships. These plans feature low premiums, high deductibles, free preventive testing, and catastrophic coverage. Although premiums are significantly less than with PPOs and HMOs, patients pay more upfront.

Why – Proponents say CDHC offers consumers greater choice and freedom, relies on consumers making more intelligent choices when spending their own money, discourages overuse of services for minor problems, allows consumers to interact directly with physicians, minimizes administrative costs, and offers incentives to use tax-free money, to carry over unspent money to following year, and has the benefits of free preventive care. Critics say HSAs are simply cost-shifting and are unaffordable for people with chronic disease or low incomes.

When – CDHC has been evolving since late 1990s. It is designed to engage health consumers more directly and to provide cost and quality information through the Internet. CDHC was articulated in detail in Professor Regina Herzingler’s groundbreaking 892 book Consumer-Driven Health Care: Implications for Providers, Payers, and Policymakers (Jossey-Bass, 2004). CDHCs are works in progress. By April 2007, about 4.5 million Americans were HSA holders, about 5% of covered workers.

How – HSAs were made widely available in December 2003 as part of Medicare Prescription Drug and Modernization Act. The new law renamed Medical Savings Accounts as Health Savings Accounts and encouraged HSA adoption in high deductible plans. Banks may sell HSAs and hold money in escrow until spent for health reasons.

Where - Brokers are vigorously marketing high deductible plans with HSAs to small and medium sized businesses as complete replacement for PPOs and HMOs and as alternatives to HMOs, PPOs, and self-funded plans in large firms. Employers seek to save money for themselves and to offer lower premium plans to previously uninsured workers.One fourth of current HSA holders were previously uninsured.

Who – Thought leaders are John Goodman of National Center for Policy Analysis, Regina Herzlinger of Harvard Business School, Greg Scandlen of the Center of Health Consumer Choice, Grace Marie Turner of the Galen Institute, and President Bush and members of his administration.

Monday, March 3, 2008

Health Plans - Short Take on Health Plans

What – America’s health plans – those HMOs, PPOs, Point of Service Plans, and the newest kid on the block, High Deductible Health Plans. All belong to an organization called AHIP, Association of Health Insurance Plans.

Why – America’s health plans, whose 1500 members or so represent a $450 billion industry, are in political hot water. Critics say their administrative costs are too high, generating profits anywhere from 10% to 30%; they have failed to restrain overall health costs; they anger key constituencies – patients and physicians – through polices that pay less for less care; artificially lower physician fees or deny claims; rescind payment for legitimate claims, turn away those with pre-existing illness, refuse to pay for life-saving procedures; reward their executives outrageous compensation or allow dubious stock option practices ; e.g. the more than $1 billion set aside for Dr. McQuire of United Health; manipulate computer algorithms to lower “usual and customary” fees to punish out-of-network users by making patients pay the difference actual fees and usual and customary fees; and reward Medicare Advantage plans with above market margins – all in the name in profit. Most plans are for-profit organizations with stockholders who are keeping an eagle eye on quarterly profit statements.

When – The fate of health plans, and their reform, rests in the hands of voters, especially those on the left, who say plans ought to be put out of business. Given their powerful lobbies, their high profit margins, and the lack of any government or private organizations to duplicate what they do, transact the more than one billion health care transactions that occur annually, the demise of health plans is not likely to occur soon, if it all.

- How these plans manage their piece of the system (more than 200 million Americans covered), how they generate such generous profits for executives and stockholders (top executives generally earn $10 million or more), and how they use their sophisticated algorithms and vast databases to do what they do, remains a mystery to most.

- Managed care plans are generally strongest in the upper Midwest and the East and West Coast, in metropolitan areas with strong economies, and weakest in the American South and rural America, where there is less money to be earned.

Who – American employers and their human resource departments who use plans as surrogates to manage costs and assure quality and value