Saturday, January 31, 2009

Social networking, Twitter - Tweet Thoughts about Twitter

Preface: Some of you out there may not be aware of the latest twists and twaddle in rapid communication on the Internet. It’s Twitter. Twitter is two years now, and it’ s the rage in the social networking world. Twitter messages are restricted to 140 characters, and answer the question, “What are you doing?” The messages on Twitter are called “Tweeties, “ or “Tweets,” and applications go by names of Twinkles, Twitterricks, Twidgets, or Twaddles, Twickie. or Tweedles.

Why this blog? Well, it’s Saturday night, a time for rest from the usual routine. And frankly, I’m weary of constant chatter about health innovations and health reform. Health reform is a serious business, but keep in mind only 15% of any nation’s health is due to its health system. The other 85% of factors contributing to health come from its culture, its literacy rate, its hygiene systems, and its socioeconomic levels.

The inspiration for Twitter may have come from Lewis Carroll’s “Through a Looking Glass, in chapter called Tweedle Dee and Tweedle Dum.

The following is from Through a Looking Glass. Alice in Wonderland.

THEY were standing under a tree, each with an arm round the other's neck, and Alice knew which was which in a moment, because one of them had “DUM” embroidered on his collar, and the other “DUM". `I suppose they've each got “ TWEEDLE”round at the back of the collar,' she said to herself.

They stood so still that she quite forgot they were alive, and she was just going round to see if the word “TTWEEDLE " was written at the back of each collar, when she was startled by a voice coming from the one marked "DUM.”

I'm sure I'm very sorry,' was all Alice could say; for the words of the old song kept ringing through her head like the ticking of a clock, and she could hardly help saying them out loud:

Tweedledum and Tweedledee
Agreed to have a battle!
For Tweedledum said Tweedledee
Had spoiled his nice new rattle.

Here’s a Tweet for You.

There once was a young blogger seeking absolute brevity

He feared anything reeking of resolute longevity.

So he became all a’twitter about sending Tweeties on Twitter,

In 140 characters or less he could be a regular Web transmitter,

He could micro-blog pith to all in the social networking vicinity.

Oops! That’s no Tweetie. It has 292 characters, as a Tweet it twas not to be and
twill not do.

I try again.

A blogger seeking brevity,

Resisted longevity.

He sent Tweeties on Twitter,

He’s now a Web transmitter,

For others in his cyber-vicinity.

Now that’s better, 135 characters. How tweet it is. I’m no quitter when it comes to Twitter.

Health Savings Accounts: Skeptics and Believers

I’ve been following the dialogue between non-believers and believers in Health Savings Accounts and Consumer Driven Care since HSAs were made widely available to Americans in the Medicare Modernization Act of December 8. 2003. HSAs are five years old, and about 20 percent of non-Medicare employees belong to these plans. Have HSAs succeeded or failed? It depends on to whom you talk.

HSA followers fall into two camps:

• Skeptics often are members of health-policy think tanks and academic institutions. They tend to think patients should be “managed” by top-down authorities who know what’s wise for patients. They focus on quality, outcomes, and value. They believe traditional HMOs and PPOs with no or low co-pays but with higher premiums are preferable to Health Savings Accounts with lower premiums but in which patients must pay a high deductible and are responsible for their care in tandem with physicians but often outside the realm of third parties.

Paul Ginsberg, President of the Center for Studying Health System Change, and Professor James Robinson of School of Public Health at the University of California in Berkley expressed this point of view in a Health Affairs January 27 online article, “Consumer-Driven Care: Promises and Performance.”

“The market is generating product designs that combine elements of consumerism and elements of managed care, but the trend is always towards a stronger role of consumer choice and a weaker role for management of these choices by physicians, insurers, employers, and regulators.”

As I read their article, I gathered the authors felt that “a stronger role for consumer choice” was not wise. “Stronger consumer choices” may result in delay of needed care because of high deductibles, and favors the healthy and the wealthy more than those with chronic disease and less wealth or those at high risk who need more preventive care. I gained the sense that the writers thought patients were ill-equipped to judge proper care, and concluded these were just a few of the reasons growth of consumer-driven care was “anemic.”

• A believer took only three days to offer a rejoinder to the Ginsburg-Robinson article. Here is how Greg Scandlen, President of the Center for Healthcare Consumer Choice, responded to the Ginsberg-Robinson piece,

My bigger objection to the article is the way the authors cherry-pick and mischaracterize the available evidence.

They try to make the case that CDHC adoption has been "anemic," but they do so by purposefully overlooking the available data. They acknowledge that, "The HDHP represents the most important product innovation in health insurance since the point-of-service (POS) product, (but) the HDHP has been a disappointment in terms of actual sales."

To support that idea they cite AHIP's census of HSA-qualified health plans. But AHIP counts ONLY plans that are HSA-qualified. It does not count HRA plans or stand-alone HDHPs. In fact, the CDC's annual NHIS survey found that over 20% of the under-65 population were enrolled in HDHPs as of the middle of 2008.

Ain't nuthin "anemic" about that. This finding was confirmed by the KFF/HRET annual survey of employers that found 18% of workers are in HDHPs. The authors had the KFF/HRET survey right in front of them and cited it in arguing that only 8% of workers are in "HDHPs with a savings option!" But they didn't say that "savings options" are "the most important product innovation," they said HDHPs are. As critics have rightly pointed out, there is no advantage in having a tax-favored savings account for a person who pays no taxes. But the behavioral impact of the HDHP applies with or without the savings option.

Even more astonishing is the authors' complete disregard of those behavioral changes, which have been well documented by the parties best positioned to measure it. Just in the past few months reports have been released by the Mercer Company, WellPoint, CIGNA, the Blue Cross Blue Shield Association, United Healthcare, Aon Consulting, and even the chronically skeptical EBRI, all showing that people in CDHPs pay more attention, seek out information, participate in wellness and prevention programs, choose lower-cost treatments, and save substantial amounts of money for themselves and their employers.”

Strong Criticism

This is strong criticism. I shall not join the debate, but I would like to cite another physician’s point of view. William West, MD, of Reading, Pennsylvania, who is president of First HSA, Inc, has this to say,

“Health Savings Accounts reconnect the patient and provider by revealing the true costs of health care services. What we have seen so far is 20 percent to 50 percent decrease in cost utilization. This is because of consumerism – people being alert to true costs. Consumers now shop for health care services, they increasingly use generic drugs, and they ask questions about the necessity of additional testing.”

Questions to Ponder

As I pondered these divergent comments on HSAs and High Deductible Plans, my mind drifted to two phrases being bandied about these days.

• First was President Obama expression that we must now live in the “Age of Responsibility.” Who should be responsible for costs of patient care? Government? Employers? Health plans? Regulators? Physicians? Patients themselves? Ponder that. It is not an easy question to answer.

• Second, was that phrase that so easily trips off the tongue – “Patientcentered care.” We all should focus on patients, of course. And patirnyd themselves should focus on their own health. Should they pay for a greater portion of their care? who takes the lead? And what form should patient-centered take? Again, that’s something to ponder.

I know only one thing. As long as someone else pays the bill, and costs remain invisible to patients, costs will continue to surge.

Friday, January 30, 2009

bundled payments - To Control Hospital-Doctor Procedural Fees, Bundle Them

So say Congressional leaders, Obamanites, and Medicare officials. The idea is to bundle hospital and specialists fees into one pay packet, and to pay a single Medicare fee into a combined hospital-physician entity. This approach is kind of a hospital DRG in drag, namely dragging in the doctors in and putting a ceiling on the fee on the hospital-related fee.

As one who has been there and done that in a community hospital setting, I would like to point out that certain obstacles must be overcome.

• Changing Stark and other laws so doctors in a given bundled specialty can set a fee without being accused of collusion.
• Getting specialists who are skeptical of being controlled by the hospital to go along.
• Setting an equitable agreed upon fee on the part of both the hospital and the doctor group.
• Establishing a fee schedule for other specialists should complications develop and other specialists be called in for consultation.
• Acquiring re-insurance in case the bundled fee is overshot.

To read more on bundling, see January 29 Wall Street Journal “Medical-Payment Fix Weighed” and the January 30 Wall Street Journal Health Blog, which I attach for your enlightment.

January 30, 2009, 8:50 am

Beyond Fee-for-Service: Paying Doctors for ‘Episodes of Care’

Posted by Jacob Goldstein

When you pay doctors for every procedure they do, there’s an incentive for unnecessary treatments. There’s a financial reward for fixing problems that better care might have prevented. And there’s no incentive for doctors to prevent complications.

On the other hand, few people want to go back to capitation — paying a single, annual fee for all of a patient’s care. That’s been criticized for leading to undertreatment.

So a lot of powerful people are looking toward a middle road: Paying a single, bundled fee for an “episode of care” such as a hip implant or a few months of treatment for cancer or a chronic disease.

As a story in this morning’s WSJ notes, Tom Daschle, the man Obama’s picked to lead the health reform push, is a backer of episode-based payments. Max Baucus, a key senator in the health reform puzzle, likes them as well.

Medicare’s piloting a program that pays a lump-sum to be split by the hospital and physicians for acute-care procedures like coronary bypass. Of course, the prospect of the hospital handling a lump-sum payment makes a lot of docs nervous. And poorly designed bundles could encourage cherry-picking healthy patients or denying needed care.

But beyond Medicare, several experiments are looking at different ways of bundling payments.

Later this year, UnitedHealth plans to test bundled payments for oncologists. Under the current system, many cancer docs make much of their income from buying and selling the drugs they administer to patients. UnitedHealth wants to pay a single, bundled fee for a few months of cancer treatment. The fee would be worth about what docs make now from fees and from profit on the drugs.

“What you used to be making on drugs now becomes a patient-care fee that can be redistributed in whatever way you think is right,” Lee Newcomer, the oncologist-turned-UnitedHealth exec, told us.

And Minnesota is making its own big push into bundles. A big health-reform law that the state passed last year will create “baskets of care” for several conditions, including asthma and diabetes. The basic idea is for hospitals and doctors to define and price a package of care, so that patients and payers can see what they’re getting and comparison shop between providers.

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Comment - January 30, 2009 . 9:39 am

As Chairman of a Physician Hospital Organization, I was involved in putting together a series of 50 or more bundled bills for a community hospital. It was doable, but health plans didn’t like the idea because they preferred to negotiate with doctors and hospitals separately - a divide and conquer strategy. Our approach was to discount hospital fees by 10% and doctor fees by 3%, and to set the doctor fees by having doctors in a given specialty sent in their fees, average them, and send it back for doctor’s approval. This worked well, but it takes more than hospitals and doctors agreeing - private payers must go along, too. Specialists, by the way, had no problem with the bundled concept.

Comment by Richard L. Reece, MD, medinnovationblog

Regional variations, costs - Practice Variations and Patients' Socioeconomic Status

Some, but not all, practice variation between various regions of the country stems from differences in the socioeconomic status of populations served – not necessarily to differences in physician-induced demand or hospital pricing. If you service a population of poor patients with low health literary and high chronic disease risks, your costs will be higher.

Flawed Last Blog

That’s the message I failed to convey in my last blog. Richard “Buz” Cooper, MD, Professor of Medicine at the University of Pennsylvania, corrected me with this comment.

I really don’t think its “unwarranted variation” vs. unbridled entrepreneurism. It’s whether the variation is due to suppliers or patients. The Dartmouth Group fails to adjust for risk (they say they do, but they really don’t) which leaves the variation” unexplained,” and since it’s not explained, it’s” unwarranted” and must be due to physicians and hospitals since no other reason is apparent. The Dartmouth crowd doesn’t want to find another reason. The one they have suits them just fine. But whenever anyone disaggregates the Dartmouth data, most of the variation is explained by clinical risk (high risk = higher use +poorer outcomes) and socioeconomic factors (poor patients used more service).

I don’t think anyone would argue about whether the health care system could function better or whether doctors could function better or whether doctors could be more efficient in their use of resources. Efforts to improve things are widespread, from clinical trials to decision analysis “hints” to system technologies and more – and there’s lots more to do. It’s a constant struggle just to keep up with the “inefficiencies ” that are inherent in caring for more complex patients, dealing with more system pressures (regulations, 80 hour weeks) and more. But this struggle has very little to do with why Mayo is different from hospitals in Newark and Chicago – the patient populations couldn’t be more different- and they will never be the same. It is disingenuous to tell policy makers that there’s 30% of health care spending out there just waiting to be saved by homogenizing the populace.

Lower Health Literary, Higher Risks, Higher Costs

In other words, differences with practice variation can often be traced to the poor socioeconomic status of the population. This view is reinforced in mu mind by a power presentation I was reading by Jerry Reeves, MD, one of the nation’s leading authorities on cost variation and author of “Report Cards, Incentives, and Reminders – Impacts on Health and Costs.” Reeves is president of the Los Vegas Operations for the Culinary Health Fund that provides health benefits for hotel and restaurant workers across the country.

Among other factors, explains Reeves, is that health risks differ in populations with low health literacy. These low health literacy rates are,

• White/Anglo 39%
• Hispanics/Mexicans 79%
• African Americans 75%
• Native Americans 64%
• Asian/Pacific Islanders 61%

These literacy rates could make a tremendous difference if you are at UCLA serving its poor population. Low literacy is the single best predictor of health cost, and leads to,

• More hospitalizations
• More emergency room visits
• Less screening
• Later stages of disease
• Lower treatment adherence
• Proper understanding of treatment
• Higher homicide and suicide
• Higher infant mortality of offspring

Poorer populations have a higher incidence for these measures,

Health Measure Added costs per year
• High blood sugar $1,150
• Overweight $690
• High tobacco use $447
• High cholesterol $428
• High Blood Pressure $390
• High sitting around $339
• No self-care $225

No Mystery

In short, there’s no mystery to why doctors and hospitals serving poor populations have higher costs and why health costs vary with the socioeconomic status of the population.

None of this is to say that variations do not exist in payment and practice patterns of physicians and hospitals. Whether these variations are “warranted” or “unwarranted” is another matter and depends on the judgment of the analyst.

But most fair-minded observers would concede that variability is part of the human and organizational condition. Individual physicians vary in their practices from day to day; physicians in the same practice vary from each other; physicians serving the same socioeconomic populations vary; hospitals vary in their payment policies.
Physicians and hospital administrators are not automats. They may not even be aware of these variations, so it is important to bring variations to their attention. But at the same time, you cannot homogenize humankind, and you cannot homogenize doctors and hospitals.

Thursday, January 29, 2009

Physician mindsets - Mindsets about Physicians

Judgments in almost every area are driven by mindsets, from worldviews to personal relationships. If a wife’s mindset is that she has a faithful husband, she receives all information as fitting into that picture. It defines what she hears beyond words and her reaction to it. If a wife’s mindset is that she has a faithful husband, she views the world differently. That’s at the micro level.
At the macro level, there are those whose mindset is that the world is in a “clash of civilizations,” and they see everything within this frame.
Of course we all have mindsets, like politicians are a bunch of crooks, outsourcing to India is stealing American jobs, cats are the cleanest animals you have, global warming is a threat to the sustainability of mankind.

John Naisbitt, Mind Set!, Collins, 2006

Two Doctor Mindsets

Why should mindsets about American physicians be any different?

• One prevalent mindset in this age of reform is reflected in the views of the Dartmouth Institute. It says doctors don’t heed evidence-based care and go their merry way, doing what they want to do. The Institute is most famous for its work on “unwarranted practice variation” which they have shown exists among doctors, especially between specialists, hospitals, and academic institutions. Consequently, costs and outcomes vary enormously in individual cities, contiguous states, and different urban and rural regions. The Institute claims this wide variability comes at the cost of quality, outcomes, rationality, and price without rhyme or reason, other than padding one’s pocketbook and charging what the traffic will bear. Variability also reigns because of lack of monitoring so measure amd subdue it. Overall, says Dartmouth, these variations produce a 30% “waste” in the system. If only one could reduce variation, one could boost quality, make care more uniform , and reduce waste. For this insight, John Wennberg and his Dartmouth colleagues have received honorary degrees and a string of kudos from the health reform establishment, including some who think Wennberg should receive a Noble Prize for Medicine or for Economics.

• Another less visible mindset is that health care is a vast, individualistic, entrepreneurial, innovative , unmanageable, ungovernable enterprise known as the health care industry.. This industry, it is said, is the product of unhampered choices made by patients and physicians in free markets. Leave the markets alone, say its advocates, and the checks and balances and reasoned judgments of everybody participating will work themselves out. This is the view of the market-driven crowd who believe Americans should be left to their own devices, wishes, and choices. It is not the view of third parties who pay for care – Medicare, Medicaid, and health plans.

Mindset of Policy Reform Sector

The mindset of the reform sector staunchly advocate accumulating and applying “data” to more tightly manage care and to bring rationality to the table. This sector tends to push their agenda in certain publications and media outlets. The New York Times, Health Affairs, other health policy journals, the New England Journal of Medicine, growing numbers of liberal blogs, think tanks like the Commonwealth Fund, the Robert Wood Johnson Foundation, the Urban Institute come to mind. The leading lights of this mindset are sometimes called “Policy Works, “ defined as persons who develop strategies and policies , especially those who have a keen interest in and an aptitude for technical details and a rapt attention to data supporting their point of view.

Mindset of Free Market Sector

On the other side of mindset aisle are free-market supporters, who tend to be politically conservative and capitalistic in their world views. They believe health care market details will work themselves out in the push and pull, tug and counter-tug, competitive battles of the marketplace. In the end, society will squelch the outliers. In this group are think tanks like the Manhattan Institute, the Cato Institute, the Hudson Institute , the Heartland Institute, the Heritage Foundation, the Hoover Institute, the Galen Institute, the American Enterprise Foundation, Consumers for Health Care Choice, Fox News, the Wall Street Journal, and, of course, Talk Radio. Champions of this sector may look upon their ideological opponents as eccentrics, “kooks”who are paving the way to socialism through data-mongering.

Mindset Actions and Reactions

Those enraptured with these respective mindsets tend to ridicule their ideological adversaries, to gather data to support preconceived notions, to exclude dissenting points of view from their news and information outlets. They often practice a form of censorship by muting the opposition by being dismissive or not airing opposing points of view, and by filtering and editing material to match their mindset.

The mindset is both cases is not what the news is or what the facts are. It is how you receive and process the information, how you view the world through your respective lens. Each mindset sector, if you will pardon a pun, “doctors” the data and supporting information to fit their world view. In America, we call this “Debating the issues, “ “We win, You lose,” “Our Guy is smarter than your Guy,” or “Democracy in action. ”

Politically, mindset differences have manifested themselves in calls for bipartisanship, in why we can’t just get along for the common good. Yesterday’s vote on the $819 billion economic stimulus in the House of Representatives – “Yes,” 244 Democrats, “No, ” 178 Republicans – though not focused on physician issues other than calling for $20 billion for electronic medical recors, shows the power of partisan mindsets.

Wednesday, January 28, 2009

Hospice - Of Books and Men

In this blog, I shall deviate from my usual practice of talking about health care innovation and reform.

I shall talk of books and men. I am selling part of my personal library of 5000 books on It is a surprisingly gratifying experience. I can review where I’ve been and where I am intellectually, I can talk to buyers, and I can see what interests the book-buying public.

Today I received two requests for books.

Self-Consciousness: Memoirs, 1989, by John Updike. Updike died on January 27 at age 76 of lung cancer in a hospice. He was an American novelist, poet, short story writer, art critic, and literary critic. He received two Pulitzer Prizes for his Rabbit series (Run Rabbit, Run, Rabbit Redux, Rabbit Is Rich, Rabbit at Rest, and Rabbit Remembered.) He described his subject matter as “the American small town, Protestant middle class.” He described the foibles and pressures of the middle class. I have always found his writing too clever by half and too cryptic. That is undoubtedly due to my intellectual deficit, not Updike’s. He was tremendously productive, extremely learned and creative in many fields, and widely admired for his more than 25 novels, countless short stories and reviews. His passing reminds me the American middle class is under extreme stress to pay for health care. How we are going to make health care affordable and still fit within the confines of America’s culture continues to elude me, as well as practically everybody else.

The Soul of Capitalism: Opening Paths to a Moral Economy, 2003, by William Greider. Greider is based in Washington, D.C., and writes mostly about economics. He is national correspondent for The Nation, a liberal political weekly. He is unabashedly pro-government. He maintains unfettered American capitalism lacks a soul and is designed to crush the middle and lower classes. He is for national health insurance and says the U.S. has plenty of money to finance comfortable retirements and high-quality health care for all citizens. He a former reporter and editor for the Washington Post. He asserts the current bailout is a sham, rewarding only the capitalists, and is critical of politicians of all stripes. His belief can be summed up with this quote,” The world system, led by the U.S., has pursued what is really a utopian idea – the idea that self-regulating markets, cut free from any moderating controls and regulations, will always correct themselves. “ He believes in “socially responsible investing” and believes that must occur within capitalism. How this differs from socialism escapes me. Nevertheless, this is a timely book on a burning issue.

Interviews, personal physician - Interview with Donald Copeland, MD, a North Carolina Famil Physician Who is Skeptical About Organizational Overkill

Prelude: Dr. Donald Copeland and I go back a way. We were among the early organizers of the High Performance Physician Institute. We were dedicated to the proposition that information technologies could be a boon to medical practice. Now Don is not so sure, nor am I, nor is he confident that bigger organizations or tighter management are the answers to the doctor shortage, and to addressing the problems of primary care. One answer may be to train more family physicians to be personal physicians for physicians and their families and to train more nurses with patient care skills.

Q: You are a family physician with vast experience. Share with me your background.

A: I graduated from Davidson College and the University of North Carolina Medical School. I did a mixed internship in Peds/Med at The Medical College of Georgia and a residency in family medicine at Macon Hospital in Macon Ga. In 1965 I started a solo practice in Mooresville, NC, later moved into a rural group practice with six doctors in Clinton, North Carolina. In 1975 I went to the Bowman Gray School of Medicine to help start a successful family practice program. In 1981 I went back to my hometown area of Davidson, North Carolina, which is 20 miles from Charlotte. The solo practice that I started grew into a large family practice group of eight doctors in three sites. Now there are about 25 doctors in 10 or more sites. Novant hospital system acquired the practice. It is now a major source of family medicine in counties in and around Charlotte.

Q: And what is your take on hospital systems acquiring and hiring physicians?

A: I don’t think it is a good concept. It seems to me physicians are handing over their license to practice medicine to the hospitals. We ought to be paying primary care doctors more so they can exercise their professional independence. But directly or indirectly a family physician generates $ 1 million for the hospital. Also if you’re working for a hospital, you feel obligated to order all tests and procedures from the hospital. That can be exorbitantly expensive and drive up the cost of care.

Q; What are you doing now that you’ve retired?

A: After I retired I started working two days a week for the Public Health Department of Lincoln County, and I worked as medical director of TIAA-CREF for 4 or 5 years until my job there was outsourced to Walgreens. Now I’m just practicing two days a week. I forget to tell you that before I attended medical school I was a medic in the Army for two years, and the GI Bill paid for my education.

Strong Views Backed by Experience

Q: I know you have strong views on primary care. For example, you think people are making it more complicated than it needs to be.

A: When I first started practice 1965, the main thing was to have a doctor and a nurse. We took care of everything, we managed our practice, admitted and discharged patients from the hospital, and referred them to the proper specialists.

Q: I have heard you say you think the medical home is nothing more complicated than the nurse and the doctor.

A: Not exactly. There are other people needed to support a practice. It depends on the economics. It’s expensive to hire a lot of people. In my other practice, I had a lab girl, a radiology girl, and a business office.

But the key person is a personal nurse to communicate with my patients, get the chief complaint, to set up the room, take vital signs. The idea of a team approach in the practice of medicine is not something new to " the medical home."

Q: The medical home people say you need to hire a chronic care coordinator to put the team together.

A; That’s a nurse. I conduct a chronic care clinic over at Lincoln County, I have a nurse, and that’s it. I have a great lab, but not a lot of other people and a receptionist. That’s the team. You don’t need a patient coach, a nurse educator, and a nutritionist. The people following up patients on the outside don’t need to be in my office. The social service people can do that.

Rural Physicians, Urban Internists, and=2 0Health Savings Accounts

Q; I was speaking recently to a Professor of Medicine, and he was saying the roles of a rural family physicians and an urban internist were different.

A; The urban internist that I know seem to have limited themselves to adult physicals, diagnosing and treating chronic diseases with many of their patients on Medicare. The hospitalist and sub-speciality internest has taken much of their practice. They do female physicals, but they don’t do pelvic exams. In Winston Salem, the internist did the a physical and the Ob-Gyn doctor did the breast and pelvic exam. So every woman required two doctors. When I went to Bowman Gray we stopped that practice on our patients.

Q: I understand you think health savings accounts and high deductible plans would help restore the doctor-patient relationships, and you’ve been working with community banks to make that happen.

A: I think the patient should manage their own finances HSAs are catching on. My daughter has a health savings account. But she has to be careful about hospital charges, which are outrageously high. The data is showing that people with HSAs are more careful about the fees they are being charged. When I was at TIAA-CREF employees with HSAs would ask for a generic drug because the prescription cost was coming out of their pocket. HSAs are the easiest way to get insurance companies out of the office. It then comes down to the doctor and the patient.

Q: So you believe getting the third party out of the equation is important.

A: Absolutely. Including the Federal Goverment. The insurance company has no right to tell the patient what kind of care they get. The Aetna Partners in Care concept is to implement a medical homes model with the patient’s personal physician in charge for all care the patient needs. In turn, Aetna will provide the physician with detailed clinical data to assure patients receive the right care, at the right time, at the right place. That sounds like insurence company directed care to me.

Increasing Primary Care Visit Codes

Q: I’ve heard you say, the solution to the primary care dilemma is quite simple. You just double the coding rate for office visits.

A: I was talking about Medicare rates. Those rates are too low, and barely cover overhead. The overhead rate is about 60%. I’m a firm believer that everybody who graduates from medical school should make at least $200,000 a year. I think that figure is fair when I’m paying my lawyer $300 an hour when I make a 10 minute phone call. He charges a minimal hourly rate. It’s ridiculous. A hospital CEO in Charlotte makes $4 million a year. That’s outrageous. Personel that are not directly related to patient care should not be the highest paid people in the hospital. I think most physicians do fine economically, but I think a lot of money in health care is going to the wrong people. I read a statement recently where someone was complaining that their 900 bed hospital had 900 employees in the billing department, but did not have a nurse for every bed. My wife had some lab work done at a local hospital, and the charge was $1700. I can get the same tests done for $42 at a commercial lab. That’s outrageous.

Providing Comprehensive Care for Medicaid Patients in North Carolina

Q; Just to switch the subject, I read that in North Carolina, a system for taking care of Medicaid patients has been developed whereby doctors are paid a monthly fee for taking care of a panel of patients, and it’s been quite successful.

A: Doctors in rural North Carolina, and we are a rural state, have joined in with the Social Service people to coordinate care of Medicaid patients. They are paying doctors about $2.50 per member per month. It is successful in that it is saving money for the state. I m not sure it’s making the doctors any money, but they embrace the concept because they have to take care of those patients anyhow, and it helps to have somebody helping manage these people outside of their offices.

$50 Billion for Electronic Medical Records

Q; President Obama has recommended the government spend $50 billion over the next five years to make electronic medical records mandatory, and there is underlying threat to restrict payment only to those doctors with electronic records. What do you think?

A: I think it’s ludicrous. You and I know that I know enough about electronic records to know that all EMRs are just a way to keep records. How can EMRs transform medicine? EMRs advocates say EMRs are a way of teaching or telling us how to practice medicine, but most of the people promoting them have never practiced medicine.

Organization Overkill

The President of Duke University Health System is saying we need electronic records and medical homes to take care of more patients and address the issue of the dwindling supply of primary care doctors. He doesn’t have a clue to what he is talking about. He says, and I quote , “ An immediate and serious commitment must be made to actively explore new patient-centered primary care centers that more effectively apply to the skills of extenders – nurse practitioners, physician assistants, managers, and even health coaches as part of integrated physician care.” That’s nonsense.

Q; And you regard the Duke President’s words as mumbo jumbo – a symptom of organizational overkill.

A: Mumbo-jumbo is not the expression I would use.

Q: Careful now, I’m a Duke Medical School graduate.

A: This reminds of a famous infectious disease specialist, Dr. Robert Peterdorf, a wonderful infectious disease expert, who came to Bowman Gray to give a lecture on primary care. I asked him, “What do you know about primary care?” He did not have a reply.The problem is that people who try to teach us how to practice primary care have never practiced it. I have.

Practicing Primary Care

Q: Yes, you have. You’ve practiced solo, you’ve practiced in large groups, and you’ve trained people to practice it.

A: At Bowman Gray, we trained our doctors to practice in rural areas. The problem with some of these residency programs they are training people to be half-trained internists. You have to train people to deliver babies, perform minor surgeries, sew up lacerations, apply a cast, inject a joint, biopsy a suspicious skin lesion, treat a skin rash, make a tough diagnosis. That goes with the territory. In other words, we should teach family physiicans to practice comprehensive medicine

Personal Relationships Paramount

At Bowman Gray, we taught residents to practice in modules as personal doctors with personal patients with a personal nurse to help. Our residents had personal patients, and they took personal care of them. The goal was to teach the resident to work with their patient to practice good health habits, prevent illnesses, seek proper medical care when needed, and when necessary help the patient through the medical maze. This concept was not only for the individual but the family as well.

The way to improve health care in America is to train more Family Physicians as we did in 1975 to be personal physicians,and train nurses with patient care skills as they were taught in the three year diploma schools that existed when I began practice. The method of payment should be between the doctor and the patient, ideally from an HSA account and a major medical insurance policy not tied to the place of employment

Q; So you think personal relationships are fundamental to it all.

A: Of course. Who would think otherwise? The problem with outpatient clinics in academic medical centers is that they’re impersonal. That’s a terrible way to teach doctors how to practice medicine. I want medicine to be personal - between the doctor and the patient – not some third party. Besides, my granddaughter is going to medical school, and I want to do what I can to preserve the personal element. That is what makes medicine such a great profession, and the lack of the personal element is what’s wrong with corporate medicine and third party care.

Tuesday, January 27, 2009

L:imits of technology, Limits of intervention, EMRs, EHRs -Mr. President, Beware of Blind Belief in Information Technologies to Transform Medicine

The $825 billion stimulus plan presented this month by House Democrats called for $37billion in spending in three high-tech areas: $20 billion to computerize medical records, $11 billion to create smarter electrical grids and $6 billion to expand high-speed Internet access in rural and underserved communities.
The computerized records, when used properly, are an indispensable tool for measuring, tracking and improving patient care — yet only about 17 percent of the nation’s doctors are using them. They are commonplace at large medical groups, but 75percent of doctors practice in small offices of 10 physicians or fewer.

Steve Lohr, “Technology Gets A Piece of the Stimulus,” New York Times, January 25, 2008

Mr. President.

Yes, I know your advisors. like Dr. Robert Blumenthal of Partners Health, your unpaid health care advisor during your brilliant campaign, staunchly believes in the power of electronic health records to transform medicine.

Yes, I know your campaign succeeded in large part to your adroit use of the Internet to raise funds and mobilize support.

Yes, I know this is the Internet age, and you have been called the first Internet president.
But don’t let you and your advisors love affair with the Internet blinds you to these realities.

One, beware that too much unedited and undifferentiated information can be a bad thing. What doctors need is the right information. I was reading Malcolm Gladwell’s book Blink. He cites the ER Cook County Hospital in Chicago, where many go to the ER with chest pain. Doctors there who had too much information made the right diagnosis of a heart attack only 75% of the time, while those focusing on the presence of three symptoms – history of unstable angina, chest rales, and systolic pressure under 100 - - made the right diagnosis 95% of the time. Using less information to zero in on the odds of a heart attack is better than 40 ro 50 pieces of information.

Two, beware of information coming out of large institutions like Partners Health in Boston, a huge health system made up of many hospitals and thousands of employed doctors, as the sole guideline to the future of EHRs. These institutions have the money, technical infrastructure, and sophisticated personnel, to use EHRs, but they are not representative of health care as a whole, where 75% of care is delivered by private doctors in small practices. Small practices are a different breed of cat than institutional practices. For big institutions, IT can be useful in judging and managing population health of a subset of people with a given problem, like obesity and diabetes. But small practices may not have enough on any given disorder to judge performance.

Three , beware of the encroachment of information technologies on the privacy of patients and doctors, the use of IT to judge doctor performance, and its misuse in excluding doctors from large networks. The psychological and personal element in medicine, i.e, whether a patient likes and trusts a doctor are underestimated ; the “gray’ areas in diagnosis and treatment are often individualistic; and the Art of Medicine is often more important than the Science of Medicine. One cannot use compute to categorize all patient encounters, because these encounters do not fall neatly into diagnostic bins.

Four, beware of those who say computerized records are ready for prime time. As a means of communicating with patients or hospitals or other doctors, most EHRs are cumbersome, time-consuming, and worthless. Furthermore, they hinder productivity, cost too much, and have a mixed record in improving quality and preventing mistakes. As things now stand, EHRs are more of a giant invoice rather than a patient and doctor flexible device for improving care. Most doctors find implementing them is an overwhelming and unrewarding task, distracting from the important job of taking care of patients. Finally, most of these EHRs don’t even talk to one another, and writing software to overcome this illiteracy is an expensive and daunting proposition, with not enough programmers around to do the job. I’m sure standardization and certification may overcome these obstacles.

In implementing a vast national electronic network , keep in mind that a rifle is sometimes preferable to to a shotgun, that some things do not lend themselves to computerization, and that seeking help from physicians themselves would help make the computer systems workable, useful, and usable. I am keenly aware implementing EHRs may generate more knowledge workers’ jobs, but beware of unintended consequences.

On the other hand, Mr. President,

Beware of the vibes of this health IT skeptic,

Who is wary of IT as a health system antiseptic,

You may prefer to listen to your advisor CEO Eric Schmidt of Google,

When he tells you IT is one answer to the jobs creation struggle,

Or when he and others say health IT the final quality metric.

Monday, January 26, 2009

Costs, Culutre, effect of - Pogo Speaks Out on U.S. Health Costs

We have met the enemy, and he is us.


According to the McKinsey Global Institute, the U.S. per capita use of,

• CAT scans is 72% higher than in Germany.

• CAT scan reimbursement rates are 4 times higher than Germany.

• Knee replacements are 90% more frequent than in other countries.

And that is just the tip of U.S. health cost iceberg.

The message?

When it comes to health costs, we have met the enemy, and he is us – the U.S. culture.

We are a highly individualistic, entrepreneurial, legalistic nation suspicious of centralized supervision, and believers in perfect care delivered by perfect physicians offering the very best in drugs, advanced surgeries, and diagnostic tests that assure us of perpetual youth and optimal function – as long as someone else pays.

Since most of us don’t pay directly but through 3rd parties, cost is not a factor. Patients, doctors, hospitals, and drug companies have no interest in limiting care.

So, as Alfred E. Newman says, “Why worry?”

Blame high administrative costs for health costs, even though the Institute estimates administrative costs account for only 7.5% of health costs.

Blame emergency room visits for the uninsured, even though The Institute calculates that accounts for 3.5% of total costs, and probably less.

But don’t blame our culture. Don’t accept the fact that that’s the way we like it.

Yes, we could change our culture. We could remove tax advantages for corporations for providing care for employers. We could means test Medicare patients, and have those with higher incomes paid more. We could create a federal tax to cover all government health costs. We could make routine and mandatory health savings accounts and high deductible plans to make consumers partially responsible for costs of their care.

But these things would be politically unpopular, destroy entitlement illusions, threaten re-elections of politicians, and upset the status quo. Why do these things now, when you can blame someone else and continue to kick the can down the road?

There was a creature named Pogo.
An expert in U.S. healthcare cost Polo,
Pogo said it was the U.S. culture,
That was the real cost vulture.
Which made it hard for us to say No.

Medical homes, Paul Grundy - IBM and Health Care

I don’t know what impact IBM will have on health reform.

I do know IBM is a big buyer ($2 billion) of health care for its employees worldwide. I do know Paul Grundy, MD, IBM’s Director of Healthcare Transformation, envisions the medical home as a powerful instrument for reviving primary care. I do know IBM is a powerful and decisive leader among corporations in making health care more rational and less costly.

And I do know an IBM team has published a white paper on its vision of what health care is likely to look like in 2015. Visit if you’d like to read the white paper.

Reading a summary of the white paper reminds of the story of the mother and father watching their children play in the newly laid concrete in front of their home.
The father is furious. The mother turns to her irate husband and says, “But, Dear, I thought you loved children.” He replies, “In the abstract, not in the concrete.”

In the abstract, IBM envisions four generic delivery models.

Community health networks offering access across a defined geography (in the concrete, this is the environment in which most physicians practice).

• Centers of excellence, emphasizing quality and safety (in the concrete, these are usually academic or health systems experienced in treating or evaluating major high ticket disorders).

Medical concierges (In the concrete, these are generally private practices focusing patient-centered care with more time and assiduous attention to patient needs).

Price leaders (In the concrete, these are practices, organizations, or new business models stressing productivity, greater patient throughput, and greater and more predictable economic value for consumers)

In the abstract, IBM foresees a number and variety of competencies will be required to sustain these delivery models.

Empowering and activating consumers (in the concrete, I suppose this means forming “partnerships” with patients, informing them, and strengthening patient bonds).

Collaborating and integrating (In the concrete, this is most important in centers of excellence and in concierge practices).

Innovating (In the concrete, this means stressing the flow of new ideas, taking risks, and thinking outside the box).

Optimizing operational efficiencies (In the concrete, this is all about practice management and paying attention to the bottom-line).

Enabling through IT (In the concrete, this means computerizing your practice and using it efficiently in his myriad forms – EHRs, diagnostic support, encouraging and answering patient emails, population health management).

This is a useful framework for thinking about the future, but for most clinicians, trying to make it through their overloaded day, it will be theoretical. IBM insists the status quo is not an option, and coordinated, collaborative, and value-focused care will be needed. The challenge is turning organizational abstraction into the concrete practices.

Sunday, January 25, 2009

Limits of intervention, emergecny rooms Listen to This ER Doctor

In seeking to fix our health system, we sometimes forget to listen to doctors on the frontlines, where the rubber hits the road. No set of doctors has more experience in the trenches than emergency room doctors.

One ER doctor, Robert L. Martensen, 62, who now directs the NIH office of history, gives his view of health reform in a new book, A Life Worth Living, a Doctor’s Reflects on Illness in a High-Tech Era (Straus and Giroux).

Dr. Martensen doesn’t believe electronic medical records, though valuable in their own right, will repair the system where patients, doctors, and hospital administrators are unhappy. The problem is a people, systems, and cultural problem – not a technology problem.

Martensen comments there is no center anymore in our atomized system of special interest groups, all scrambling for advantage. This jockeying for position and profit is not something technology will fix.

Martensen is down on Americans’ attitudes towards death and dying, lack of palliative care, and excess money spent on high tech on our last illnesses. He thinks doctors, patients, hospitals, nursing homes, and society at large should get real about death. He believes doctors should read more history and literature. We rely too much on machines to ward off the inevitable. We should, in short, consider dismounting from our high tech horses to focus on human comfort.

Reece, personal musings - A Prayer for President Obama

My son, Spencer, a nationally known poet studying to be an Episcopal priest at Yale Divinity School, thinks the prayer the Reverend Gene Robinson, the Episcopalian Bishop from New Hampshire, delivered for President Obama deserves wider exposure.

I told Spencer I would do my part by reprinting it on my blog.

Here it is.

O God of our many understandings, we pray that you will…

Bless us with tears — for a world in which over a billion people exist on less than a dollar a day, where young women from many lands are beaten and raped for wanting an education, and thousands die daily from malnutrition, malaria, and AIDS.

Bless us with anger — at discrimination, at home and abroad, against refugees and immigrants, women, people of color, gay, lesbian, bisexual and transgender people.

Bless us with discomfort — at the easy, simplistic “answers” we’ve preferred to hear from our politicians, instead of the truth, about ourselves and the world, which we need to face if we are going to rise to the challenges of the future.

Bless us with patience — and the knowledge that none of what ails us will be “fixed” anytime soon, and the understanding that our new president is a human being, not a messiah.

Bless us with humility — open to understanding that our own needs must always be balanced with those of the world.

Bless us with freedom from mere tolerance — replacing it with a genuine respect and warm embrace of our differences, and an understanding that in our diversity, we are stronger.

Bless us with compassion and generosity — remembering that every religion’s God judges us by the way we care for the most vulnerable in the human community, whether across town or across the world.

And God, we give you thanks for your child Barack, as he assumes the office of President of the United States.

Give him wisdom beyond his years, and inspire him with Lincoln’s reconciling leadership style, President Kennedy’s ability to enlist our best efforts, and Dr. King’s dream of a nation for ALL the people.

Give him a quiet heart, for our Ship of State needs a steady, calm captain in these times.

Give him stirring words, for we will need to be inspired and motivated to make the personal and common sacrifices necessary to facing the challenges ahead.
Make him color-blind, reminding him of his own words that under his leadership, there will be neither red nor blue states, but the United States.

Help him remember his own oppression as a minority, drawing on that experience of discrimination, that he might seek to change the lives of those who are still its victims.

Give him the strength to find family time and privacy, and help him remember that even though he is president, a father only gets one shot at his daughters’ childhoods.

And please, God, keep him safe. We know we ask too much of our presidents, and we’re asking FAR too much of this one. We know the risk he and his wife are taking for all of us, and we implore you, O good and great God, to keep him safe. Hold him in the palm of your hand – that he might do the work we have called him to do, that he might find joy in this impossible calling, and that in the end, he might lead us as a nation to a place of integrity, prosperity and peace.

Saturday, January 24, 2009

Interviews, physician shortage - Interview with Richard "Buz" Cooper, MD, Prophet of Physician Shortage and Challenger of Policymaker Assumptions

Prelude: In his long and distinguished career, Richard “Buz” Cooper has practiced as a hematologist-oncologist, cancer center director, dean of a medical school and founder of a health policy institute, and he is now a Senior Fellow at the Leonard Davis Institute of Health Economics and Professor of Medicine at the University of Pennsylvania. He also is co-chair of the Council on Physician and Nurse Supply at Penn. Above all, he is an independent thinker who looks at health care from the vantage point of a practicing physician and as a student of economic and demographic trends in the U.S. and the world and how these trends impact physicians. In 2002, he was among the first to predict a growing physician shortage, which may be as great of 200,000 across all specialties by 2020 to 2025.

Setting the Stage

Q: Let me set the stage by quoting a paragraph from your 2004 article in the Archives of Internal Medicine (“Weighing the Evidence for Expanding Physician Supply, 2004, 141: 705-714)

“Taken together, the data, forecasts, and signals indicate that physician shortages are upon us and are likely to worsen over time. The picture that emerges is uncomplicated and unambiguous. In simple numeric terms, the number of physicians is no longer keeping up with population growth. The ability to fully service the population is further compromised by the increasing complexity of the care that physicians provide and the decreasing time commitment that physicians are willing to make. These limitations collide with economic trends that predict a growing demand for physician services.”

Does that reflect your current view?

A: Yes.

Cooper Background

Q: What are your background and your current position?

A: I started out as a hematologist. I trained at Boston City Hospital on the Harvard Medical Service. I went on to Penn more than 35 years ago to develop the Hematology-Oncology Section and later the Cancer Center. Fifteen years later I ended up as dean of the Medical College of Wisconsin in Milwaukee and did that for almost ten years.

Q. When did you become interested in health policy?

A: During the Clinton health reform effort, there was a lot of talk that half the physicians ought to be primary care doctors, and there should be fewer specialists. That didn’t make much sense to me. One thing led to another, and I wound up getting interested in what kind of physicians were needed, and how many should there be. While I was Dean, I began a Health Policy Institute and led that for ten years after leaving my dean’s position. About five years ago, I moved back to Penn to be a Senior Fellow in the Leonard Davis Institute of Health Care Economics and a Professor in the Department of Medicine.

One Foot on the Ground, the Other on the Data

Q: So you’ve had one foot on the ground as a practicing physician and the other foot in the policy arena. Do physicians and policy wonks have different mindsets?

A: For most of my life I was in an academic practice of medicine, and I was head of the Division of Hematology-Oncology, and later a dean, who basically serves as head of a multispecialty group dealing with doctors and hospitals. In the process, I learned how things work and how people think. I came to the health policy world fairly late in life.

What I discovered was a lot of smart people trying to figure out how the health system works from data alone. But you have to live it. You can’t figure out why a baseball team wins or loses from statistics. You have to understand the mind of a baseball player and the dynamics of the game. The same is true a hundred-fold over in health care.

Figuring Out What Works in Health Care

On the policy side, the game doesn’t work the way people think it does. Policy folks get attached to their ideas, and they try to fit everything into those concepts. The whole culture builds up around the defense of the indefensible. You can see that in the health plans as they evolve and in health reform. You can’t figure out how to save money without really knowing how the thing works.

Take prevention. It saves lives, and it adds quality to life. But it doesn’t save money.

Or take the notion that physicians cause too much health care spending. There are a thousand anecdotes where physicians churn the system, but in the main, that’s not how the system works. It’s disease that causes health care spending and it is technology applied to disease that increases much of that spending but, mostly, it’s the state of the economy that allows the spending to occur. Economic growth is the fundamental basis for health care spending.

You can look at health care from either end of the telescope, and it will look different. I see it from the clinical practice end, not from the green-shaded end.

Health Affairs Article Predicting Physician Shortage

Q: I first came across your work in a Health Affairs article in 2002 in which you said economic and demographic trends were signaling an impended physician shortage. It was prophetic, but it ran against the tide of the health policy community’s opinion, which had long forecast a physician surplus, particularly of specialists. Explain how that article came to be and what the reaction was to it.

A: The article grew out of interests I had developed during the Clinton health plan. It started in an innocent way. I was looking at in data from COGME (Council of Graduate Medical Education), which had been constructed by the Bureau of Health Professions. It indicated how many physicians there would be in the future and how many physicians per capita there would be. And it predicted a surplus of about 150,000 physicians.

Well, I am a data wonk because I had done a lot of research in hematology. I have a quantitative mindset. So I did a simple calculation to determine what the population was likely to be in 15 or 20 years. For the COGME model to work, the population had to stay constant. That didn’t make sense, so I called the Census Bureau. They said, oh no, we thought that the before the 1990 Census but we don’t think that way anymore. So they sent me their projections in an envelope – not an email – email hadn’t been invented. I took their numbers and plugged them COGME’s physician supply projections, and sure enough, there was not going to be a surplus of about, but a shortage.

Presentation at AMA Meeting

I presented those data in an AMA meeting, and Phil Lee was on the podium. He was the Undersecretary for Health at the time. That was his first knowledge that the COGME data was fallacious. He called the powers that be and told them they had gotten it wrong.

So they developed new model based on demand. Lo and behold, their new model again showed a surplus of 150,000. They came up with the figure of 150,000 too many physicians no matter how they did it. Like Carnac the Magnificent on the Johnny Carson show – they had the answer – all they needed was the question.

Policymakers have been producing phony numbers all the way back to the GMENAC (Graduate Education National Advisory Committee) in 1981. Now the Dartmouth Group is producing the phony numbers. The root idea is to prove there are too many specialists and to do it in as creative and elusive a way as possible. It was hard to figure out what GMENAC and COGME had done wrong. Dartmouth was an even bigger challenge, but I’ll get to that later.

Coming Up with the Right Numbers

Q: How did you come up with the methodology for projecting the demand for physicians?
A; Well, I was given a contract by COGME to figure out how many specialists would be needed. I thought that there would be something to draw on to build a model from previous workforce studies. But there was nothing. COGME’s way was no good. The Lewin Group’s way was no good. Other consulting groups used variations on those methods and arrive at the same fallacious conclusions. The group that I had assembled was left with a contract, a date to report the findings and no way to proceed.

The First Principle – The Money Available

Q: So how did you figure it out?

A: I went back to first principles. If you look back to chemistry, you ask, what is the limiting factor in a chemical reaction? So, what is the limiting factor in health care? There are infinite ways to take care of patients and more ways invented all the time. And patients have vast needs and even greater desires for health care. So, neither of those is limiting. But money is limiting. Health care is determined by how much money is available. It’s a hard concept for physicians to accept – it was for me. But it’s true.

If you look back over the entire period beginning in 1930s, you find that the growth of health care spending tracked the growth of the economy, but with a lag of about four years. Tom Getzen, an economist who has taught me a lot, showed that relationship. And if the economy slows, health care spending slows – we’re seeing that now.

The number of patients hasn’t changed. The amount of disease hasn’t changed. The number of doctors hasn’t changed. But there’s been a decline in hospital utilization of about 8%. The effect of economic growth on health care spending is slower. It plays out over 3-4 years, as benefits plans chance, hospital staffing changes and patients feel more comfortable committing more to health care. More is available to treat disorders that were previously untreatable, or if treatable, unattended. And innovation builds in the wake of economic growth.

As a rich nation, we tend to think we can have as much health care as we want. But we can’t, and we’re seeing that right now. We’re no different than Sub-Saharan Africa. They have an AIDS epidemic but they don’t have sufficient funds to do all that is needed. We have more money, so we do more. But we still can’t do all that is needed.

So, ultimately, it isn’t how much patients need, or how much they want, or how much technology is available to care for them, or what doctors might want to do for them. It’s what society is able to purchase. That’s the discussion that is going on now.

Health reform is about assuring that everyone is covered by some health plan, but after that, it is about how to rein in spending to what the nation can afford. Not what is needed clinically or desirable personally – it is what is affordable collectively. The struggle in the political arena is whether more will go to those with lower income or not – how much will we as a society share? Just today, the Wall Street Journal had an editorial on SCHIP, the children’s coverage bill, and said it would lead to single payer system, the ultimate sharing, and they opposed it. Our country is divided over how much to spend but even more over how much to share.

Over long periods of time, the total amount spent on health care has increased about 1.5 times as fast as the growth of the economy overall, as measured by GDP on a per capita basis. That makes sense. Health care is a growing part of the economy, and many other things are not growing. Food, clothing, transportation, household goods are not growing parts of the economy, so how does a nation grow its economy? Growth is in electronics and in leisure and travel. It is in new inventions. And health care. Not more of yesterday’s health care. The growth is in new health care – stents, MRIs, and other things that were not in our vocabulary 20 years ago.

Another important thing is that the US is not a homogeneous country. It is large and economically diverse. Health care spending is distributed in odd but predictable ways. Since growth is driven by economic growth. It should not be surprising that growth in health care spending is greatest in areas of the country with greater wealth. But the oddity is that those same areas tend to have a lot of poverty – think of dense urban centers – affluence and poverty side-by-side. Wealth creates the capacity for health care. But it is low-income individuals who use the most health care resources. Wealth is a source of health care creation; poverty is a source of health care consumption.

Two Fixed Beliefs

Q: Two of the fixed beliefs of the policy community are supply-induced demand, meaning doctors drive demand and costs, and another is that there ought to be equal distribution of services without regional differences. Comment please.

A: There’s no question, those are the dominant views. I tremble every morning when I open the newspaper, because some reporter or editorial writer will voice and reinforce those views. The New York Times buys in 100 percent – doctors are at fault, and we ought to make health care uniform everywhere for everyone, and if we do we will save 30% -- the 30% solution. Easy money -- sounds like Madoff. Well, it is not much different. A lot of people have bought it. But it’s not there.

The supplier-induced demand theory was spawned in the late 1950s with the notion that the number of hospital beds relates to the amount of utilization and the number of surgeons relates to the number of surgeries. So the notion was the surgeons cause the surgery and beds cause the utilization. Not long after, David Dranove, an economist at then at Northwestern, published a paper showing the number of births was directly related to the number of obstetricians. If you looked only at the data, you might conclude obstetricians cause pregnancies. The cart was before the horse.

Where Doctors Go to Practice

Doctors tend to practice where there are resources to support medical care. Physicians go where there is demand. That’s where they are recruited to. Few just hang up a shingle. Do they induce demand? Undoubtedly examples exist of physicians who churn the system. But in the main, they go to where there are resources to pay for care – that is, where there is demand for care.

By the late 1990s, most people gave up on the idea of supplier-induced demand. When people looked at Medicare data, they found that there was little increase in service with decreases in fees. It surprised the Medicare people that the volume adjustments they built into their models did not materialize as they expected.

Target Income

The notion of supplier-induced demand is associated with another notion called “target income,” the income that physicians expect to achieve. The thought was that if physicians were not earning enough, they would have patients come back more often or do unnecessary procedures so that they could reach their target. That undoubtedly happens to some extent.
Somewhere, sometime, some place, some doctor is doing something to make an extra buck. But it tends to be evanescent and it is not pervasive. There is a moral imperative. And there is peer pressure. And there are watch-dog activities through insurance claims. Or the opportunity to do so disappears. More often than not, it isn’t the target but the unconscious enthusiasm that physicians have for what they believe is good for their patients.

Medical effectiveness studies sometimes prove them right, and sometimes wrong, and the system changes. There is a lot of uncertainty and a lot of pressure for more uniformity. It is a dynamic process. The system is imperfect, but it strives to be more perfect. Information technology will certainly help to smooth the unevenness.

In an interesting study of target income, folks at Thomas Jefferson University Medical School did a follow-up study of all of their graduates, and what they found was that most doctors achieved their target income – some a high target and some a lower target. Among those who did not, three things changed: 1) they provided less charity care; 2) they did less teaching; 3) and they changed specialties. That’s what doctors do. Churning the system isn’t a very popular avenue.

Regional Variations

Ever since Wennberg and his colleague published their now famous article in Science in 1973 on small area variation in Medicare services, people have asking: Why is the level of care different in different parts of the country?

The singular answer is that it’s because there are different numbers of physicians in different areas and physicians induce the demand for what Wennberg and his minions call “supply-sensitive services.” But after studying this for almost two years, it’s very clear to me that the underlying phenomenon is not caused by physicians – it’s caused by economic dynamics like those that we have already discussed.

Regional variation is a product of regional differences in wealth, overlaid with differences in poverty. It’s not generally appreciated that health care expenditures for people in the lowest 15% of income are 50% to 100% greater than for people of average income. There’s also a difference at the high end. The wealthiest 15% also consume more, but only about 20% more. So there’s greater utilization at both ends of the income spectrum, but for different reasons and with different outcomes.

More spending at the high end improves outcomes, not simply for a specific condition but across the board, because the care consists of a broader spectrum of beneficial services. More yields more. But among the low-income patients, outcomes are poor despite the added spending. In fact, the added spending is because of poor outcomes – more readmissions, more care for disease that’s out of control.

And these differences are exaggerated in dense urban environments, like Detroit, Chicago and Philadelphia. Now, when you blend all of this into “regional” studies, which average rich and poor, urban density and ex-urban comfort, racial and ethnic groups, you get just what you’d expect. High costs with average outcomes in urban areas (the average of excellent and poor outcomes at different ends of the income spectrum).

A good example is the Dartmouth study of academic medical centers. You find that one group of academic hospitals provide more care than another group. The Dartmouth folks say that Mayo is more “efficient” in resources used per patient or in number of doctors devoted per unit of patient care than in LA, Philadelphia, Miami, Chicago, and New York City.

But the so-called “inefficient” hospitals are all in dense urban centers, while “efficient” hospitals are all in smaller cities, often college towns liked Madison, Wisconsin or Columbia, Missouri, or in places like Rochester, Minnesota, where Mayo is located. Rochester is 90% Caucasian with low poverty. But in fact, Mayo is the most resource intensive center in the upper Midwest. Among peer institutions in similar socio-demographic environments, Mayo actually uses more resources. But you can’t compare Mayo to Los Angeles, where only 30% of the population is non-Hispanic white and where you have tremendous pockets of poverty.

The Dartmouth group doesn’t acknowledge the fact that there are enormous social differences between populations served by academic hospitals in various cities and even in the same city, where patients distribute in a non-random way. If you ignore these fundamental considerations, you can make the numbers fit the preconceived notion that there is more spending where there are more doctors and doctors cause the spending. You can “prove” that it’s the fault of specialists. But in the movie of “The King and I,” Yul Brynner, the King of Siam, tells his son to watch out for “people who try to prove that what is not so is so.” And they do. But that’s because they ignore the complexities of social structure and get it backwards. Doctors go to where they are needed, and the needs in urban centers are huge.

Fitting Conclusions to Fit Preconceived Theory

Q; Are you telling me Dartmouth comes to conclusions that fit their theory?

A: In my view, they are so committed to the “30% solution” that they don’t want to know more. But they must know more. It’s too easy to observe. For example, most of their studies depend on Medicare expenditures, which they assume represent health care spending overall. But it doesn’t. There’s no relationship between Medicare and non-Medicare spending in communities. And Medicare spending doesn’t correlate with the volume of care in a community – or even in a hospital. But total spending – spending from all sources -- does, and it’s the only valid measure. So their famous map of Medicare spending is not representative of health care spending overall. A good example is their well known papers in the Annals of Internal Medicine in 2003 – they are the ones that are quoted the most, even by Daschle and Baucus and folks who are part of the Obama team.

Where the Most and Least is Spent

By slicing and dicing and then mixing and matching, Dartmouth collected areas around the country with high Medicare spending, but some also had high spending overall while others had low spending overall. They then took these and constructed a “high-spending quintile.” It was comprised of most of America’s major cities – Chicago, Detroit, Pittsburgh, Philadelphia, New York, Boston, Houston, Dallas, New Orleans and also Los Angeles.

And then they average everything – north and south, rich and poor, good quality and poor quality, high total spending and low total spending. All these areas had in common was high Medicare spending. So that’s the high-spending quintile. You’ll never guess what it was compared with. The comparison group was the entire area extending from Alaska through Washington and Oregon to Wyoming, Montana, , Kansas, Nebraska, South Dakota, Minnesota exclusive of Minneapolis, Wisconsin exclusive of Milwaukee, and then across to Maine, Vermont, and New Hampshire. The northern tier. Sparsely populated. White. Non-urban. And cheap.

And you would expect that things would be very different in these vastly different “regions.” But everything was the same. Quality, access, satisfaction, even mortality. When things were average in each of these heterogeneous groups, it was all the same. Differences were not discerned because differences were not discernable. But, then, if they had, what could be made of it. Why would anyone want to know how Newark compares with Nebraska?

Most people I went to school with would have said, “Oh gee, there are no differences, I must have done something wrong.” But not the Dartmouth crowd. They said that because differences were not found despite all of that extra spending, the extra money must have been wasted. And if health care could be the same in both regions, the US could spend 30% less. And everyone believed them! Remarkable! They did it! They proved that what is not so is so. And so, as the sun sets on America, we can all sleep comfortably, knowing that if only Manhattan could be like Montana, all would be well for health care – and we’d save 30% in the process, enough to pay for all of the promises of health care reform. Dream on.

Specialists and Quality of Care

But even worse than Dartmouth’s 30% solution are the studies in states that were carried out by some of their associates at Harvard. The famous one liner that came from that is that “states with more spending and more specialists have poorer quality health care.” It’s quoted everywhere – twice in the current issue of Health Affairs. But if you look at their study in Health Affairs a few years ago, you’ll find that the state with the most specialists and the most Medicare spending, and also the poorest quality, is Mississippi.

Q: Mississippi?

A: Yes, it’s Mississippi, the poorest state in the nation. It does, indeed, have poor quality, but how could it have the highest spending and the most specialists? The answer is it doesn’t. Mississippi, as you know, has the fewest specialists, and although it does have high Medicare spending, it has very low health care spending overall. It’s not surprising that low total spending and few specialists are associated with poor quality. In fact, when all of the states are examined, more total spending and more specialists are associated with better quality – just the opposite of the Dartmouth-Harvard message but just what you would expect.

You might wonder how they arrived at the opposite conclusion. Well, they never really measured how many specialists were in Mississippi or anywhere else. They did some statistical maneuver where everything was converted into residuals, and I guess that Mississippi has a lot of residuals. It just doesn’t have a lot of doctors.

I published my observations about these studies in two papers in the December 2008 issue of Health Affairs online. But much to my surprise, they were accompanied by two rebuttals from the Dartmouth crowd, each with summary statements by the editor that said I had simply reconfirmed the Dartmouth work.

But it all made sense when I learned that the new editor of Health Affairs, Susan Dentzer, is a Member of the Board of Overseers of Dartmouth Medical School, the former Chair of the Board of Dartmouth College, a former Trustee of Dartmouth-Hitchcock Medical Center and winner of the alumnus of the year award from Dartmouth. She has a profound conflict of interest which she failed to reveal in her editorial – an egregious ethical breach. So, it all made sense. And it all is rather remarkable. Fortunately, truth has a way of surviving, and the truth is that states with more health care spending and more specialists have better quality health care.

The $640 Billion Dollar Question

Q: I’d like to finish up with a few concluding questions. The first is a $640 billion question. How will this deep recession we are in influence the physician shortage?

A: Well, it won’t influence the shortage long term unless the recession continues for years. If it does go on for many years, it will influence everything, and we’ll have a country that we won’t recognize. The assumption is that growth will pick up again in 6 or 12 or 18 months. After that, we’ll be back on track of GDP growth of about two percent a year. Averaged over a decade, growth will be at the historic rates, and it is these broad averages that determine the needed supply of physicians. Not that the short term changes don’t matter. Physicians will be busier if the economy has a spurt, just as some are now becoming a little less busy as the economy sags. But it takes a long time to train physicians, and the training decisions have to be based on long term trends.

Q; You have highlighted other factors that aggravate the physician shortage. For example, you point out that by 2020, 60% of medical students will be women, and women spend 20% to 25% less time in practice than men.

A; Yes, and the figure of 20% to 25% may be overly optimistic. Women physicians these days are increasingly dropping out of practice altogether in their 40s or early 50s. And men are seeking better lifestyle arrangements, too.

Q: You also have pointed out the physician shortage involves all physicians – not just primary care doctors.

Primary Care – Yesterday’s Concept

A; Yes, but I think “primary care physician” is yesterday’s concept. Primary care is something that many providers engage in. Generalist physicians, as I prefer to call them, have special roles in primary care, and these roles are still being defined. Some generalists are hospitalists. Some are rural practitioners. Some supervise teams of non-physician clinicians who provide much of the uncomplicated care, like treating upper respiratory infections, following mild hypertensives and stable diabetics, doing well baby exams and dealing with a lot of acute, usually self-limited disease.

A minority of what generalist physicians in urban settings now do is chronic disease management, but I believe that aspect will grow and that generalists of the future will be dealing with panels of patients who are sicker and more demanding. What I’m not sure of is how many will be needed. The problem is that there will be too few of all specialists who take care of chronic illness – oncologists, cardiologists, urologists, and many others. And we’re all interdependent.

So at this point, I think that the emphasis in generalist medicine should be to define roles for the future and construct training programs around those roles. My choice would be a track for rural medicine and a track for urban generalists who focus on chronic disease management and on overseeing teams of non-physician clinicians, but the leaders in the field prefer the model of the “medical home.”

Q: Doctor Paul Grundy, Director of Healthcare Transformation at IBM and champion of the medical home, calls such a doctor a “comprehensivenist,” and specialists sty “partialists.”

A: Whatever you call them, we’re going to need high level generalists – fewer than the number of primary care physicians that we now have but thoroughly trained for challenging practices.

Medical Home Concept

Q: What do you think about the “medical home” concept?

A: I think it’s applicable to children, but probably not to adults. It can probably work for employed groups, but I don’t think it’s applicable to the Medicare population or to low income patients. For some adults with chronic disease, generalists will be home base, but those generalists will be fully occupied with such patients and I don’t think there will be much time for wellness care and other tasks. There just won’t be enough physicians.

For other patients with chronic illness, specialists will be their home base, probably assisted by a high level nurse practitioner who provide much of the general care for the specialty patient. But even if the medical home works, it can’t work for everyone. Physicians are going to be compensated to provide more care per patient and to spend more time with their patients; it’s what I call concierge “lite.”. But those physicians will not be able to care for as many individuals. I can spend more time with you, but then I can’t spend as much time as with your neighbor – or maybe no time at all.

Q: A final question. What direction do you think health reform will take, and do you think government alone can reshape the system?

A: Health care reform will take one of two directions.

One approach, which was the Clinton Health Plan approach, is to do everything possible to restructure everything for everybody and to re-design a theoretical system that won’t work. I hope that doesn’t happen.

Alternatively, government can concentrate on the one thing it can do: create an insurance system that puts everybody under the insurance umbrella and leaves everything else alone. Daschle and Bacchus and others have conceptualized this approach. Each has a similar way to create federal oversight that somehow makes it possible for everybody to be insured. If they can do that, and it will be a Herculean effort, it might work.

But they also have other ideas. They want to impose regulations for medical effectiveness panels, P4P, different kinds of reporting systems and so forth, and that will sink it. Not that there aren’t things that they could do. For example, they could foster electronic medical records and support research in medical effectiveness. But remember, if the new health plan succeeds on the insurance side, it will confront what Massachusetts is confronting – the doctor shortage. Health care reform is absolutely on a collision course with the doctor shortage. Something has to be done about it, and it is spelled GME.

Friday, January 23, 2009

Physician payment, primary care - More Money for Primary Care

Jacob Goldstein of the WSJ Blog on January 22 posted “Where Should the Money for Primary Care Come From?"

The primary care doctors say more money is needed is they are to continue to exist. But where is the money coming from?

Here are Goldstein’s choices.

A: Cut subsidies to Medicare Advantage
B. Pay hospitals less for such high-margin services such as radiology.
C. Lower Medicare reimbursements for care and procedures for specialists.
D. The money shouldn’t come out of existing health care spending.
E. Primary care doesn’t need more money.

These choices call for somebody’s oxen being gored. And in the 51 comments to your blog, a lot of these oxen from across the health care fields are bellowing. My favorite ox is Devon Herrick of the National Center for Policy Analysis who says the money should come from patients themselves functioning outside the 3rd party payment system. But, as we all know, this is unlikely. For we already have a U.S. single-payer system – CMS (Center for Medicare and Medicaid Servives )+ The Specialist-dominated RUC (Reimbursement Update Committee) Taken together they set doctor fees, and the health plans meekly follow.

medicaid, physician payment , doctor shortage, access - Medicaid-For-All and Physicians

I could not help but notice the NEJM is pushing its agenda for national health insurance in a new and creative way. In its January 22 edition, in its perspective section, its published “Health Care 2009: Medicaid and the Path to National Health Insurance.” Its author is Dr. Michael Sparer, a PhD and Professor of Health Policy at the Columbia University’s Mailman School of Public Health.

In his article, Dr. Sparer has this paragraph,

More difficult would be convincing physicians to support a Medicaid expansion and participate in the program. Although Medicaid participation is high in some states, it is more typical for office-based physicians to refuse to treat Medicaid patients, citing low reimbursement rates and long administrative delays. Medicaid agencies (or the managed-care plans they rely on) will need to pay higher rates, though increases that are substantial enough to attract physician participation would undermine cost-containment efforts. Medicaid agencies could also rely more heavily on nurse practitioners and physician assistants, but any effort to simply bypass the physician community will fail. Here again, however, the laboratory of federalism could help, since there are states that effectively partner with office-based physicians and have lessons to share.

As I read this paragraph, I could help but wonder, where does Dr. Sparer now go when he gets sick – to his favorite Medicaid physician extender, to the local Medicaid physician, or to a specialist at Columbia?

I expect he finds practitioners or their extenders accepting Medicaid hard if not impossible to find, so he will have to turn to the Columbia specialists.

Perhaps his situation will change in the future. Perhaps government can overcome the fact that many private doctors do not accept Medicaid because of low pay, bureaucratic obstacles, and long waits for reimbursement. Perhaps government can overcome the stigma attached to the name “Medicaid.” But these are Big Perhaps.

Tuesday, January 20, 2009

Electronic medical records, electronic health records . blogging doggerel - What Good are Electronic Health Records (EHRs)

If doctors in small practices, 85% of all physicians,
can’t afford them and distrust them as clinicians;

If all this grandiose talk about information infrastructure,
does nothing but cause massive practice pattern rupture;

If rhetoric about effectiveness and efficiency is mostly theoretical,
not to mention being doctor antithetical and too often hypothetical;

If the 100 EHR systems out there being hawked and sold,
cannot even talk to one another, if God’s truth be told;

If most doctors regard EHRs as nothing but a giant invoice,
and not a desirable communication device of first choice;

If comparative studies of those who don’t use EHRs,
show similar data, results, errors – of quality the 3Rs;

If doctors cannot use EHRs to communicate,
With one other, patients, or hospitals to keep things straight;

If EHRs impede practice productivity, or patient throughput,
where the revenues are, why would doctors up with EHRs put?

What good is this obsession with more and more information,
if you cannot use the data for more effective consultation?

What good are these EHRs if they are not doctor usable,
And geeks develop them to make things more confusable?

Much of what I have said is frightful and tongue-in-cheek,
and may place me squarely among a troglodyte clique.

But when reformers advocate $20 to $50 billion on EHRs spent,
We’re talking real money, even if well meant or by the feds lent.

Limits of technology, limits of intervention - Limits and Power of Health Care Computerization

A Chat with Doctor Gordon Moore

Two months ago, I attended an Health and Human Services’ innovation forum in Washington, D.C. There I chatted with Gordon Moore, MD. Dr. Moore is a family doctor on the Institute of Healthcare Improvement’s faculty in Boston. He specializes in lean and ideal care systems.

In Rochester, New York, he conducted (he has since moved to Seattle) a 24/7 computer-driven solo practice, now called a “micro-practice.” He did so in a small room with no staff and with nothing to aid him but an Internet broadband connection and best practice algorithms. He described his practice as, “A Norman Rockwell practice with a 21st century information technology backbone.”
Dr. Moore told me many overlooked his approach’s true power. That power resided in the promise of constant access and more time spent with patients.. Yes, the computer sped communication and eased open scheduling, but Moore insisted it paled in importance compared to his renewed bond with patients. The human part of the equation, he felt, received far too little attention.

An E-Mail from Doctor Paul Grundy

Yesterday morning I received an email from Paul Grundy, MD, Director of Healthcare Transformation at IBM, and champion of the medical home. With the help of the computer, he feels the computer in a medical home aligns the interests of primary care doctors and patients and creates the basis for a trusting personal relationship.

Among other things, Dr. Grundy wrote,

Dick, the view you have is one that really looks at the world the way it is-- It is no longer that way -- if you just spent a day in a primary care docs office in Denmark or as I did this week in Chuck Kilo's practice in Portland you would see it would be clear.

I talk a lot about the technology, but it is not the technology, it is the doctor and their relationship to his patient that is aligned to use the technology. Honest, we will never go back to the primary care doc of the Norman Rockwell painting.

Something is happening that holds even greater potential. In a word, our planet is becoming smarter. Healthcare is not only getting more integrated it is getting Smarter. This isn’t just
a metaphor. I mean infusing intelligence into the way the world literally works—the systems and processes that enable physical goods to be developed, manufactured, bought and sold, services to be delivered… everything from people and money to oil, water and electrons to move… and billions of people to work and live.

What’s making this possible?

First, our world is becoming instrumented.
Second, our world is becoming interconnected.

Third, healthcare is becoming intelligent.

What this means is that the digital and physical infrastructures of the world are converging. Computational power is being put into things we wouldn’t recognize as computers. Indeed, almost anything—any person, any object, any process or any service, any organization, large or small—can become digitally aware and networked. With so much technology and networking abundantly available at such low cost, what wouldn’t you enhance? What service wouldn’t you provide a patient? What wouldn’t you connect? What information wouldn’t you mine for insight?

Grundy is a brilliant man, he has a noble vision of what medical practice ought to be, and he directs Healthcare Transformation at IBM, perhaps the world’s greatest technology company.

Personal Doubts

I doubt smart machines will ever play in the same emotional intelligence ballpark as human intuition and interaction. Smart machines may “align” the relationship. But all too tempting to overstate their importance. The current massive recession may have occurred because we trusted bundled algorithms more than our gut. And this week a hacker penetrated my firewall and cost me $395 by stealing my identity, so I suffer from personal paranoia. I may not be objective.

New York Times Report

And in the January 17 New York Times, Robert Pear reports,

President-elect Barack Obama’s plan to link up doctors and hospitals with new information technology, as part of an ambitious job-creation program, is imperiled by a bitter, seemingly intractable dispute over how to protect the privacy of electronic medical records.

In a speech outlining his economic recovery plan, Mr. Obama said, “We will make the immediate investments necessary to ensure that within five years all of America’s medical records are computerized.” Digital medical records could prevent medical errors, save lives and create hundreds of thousands of jobs, Mr. Obama has said.

So he says, but we shall see if the pudding puddles or muddles.

Danger of Commercial Exploitation

Health IT without privacy may build a gold mine of information used “ to increase profits, promote expensive drugs, cherry-pick patients who are cheaper to insure, and market directly to consumers,” says Dr. Deborah C. Peel, coordinator of the Coalition for Patient Privacy, which includes the American Civil Liberties Union among its members.

Final Thoughts

Violating patient privacy and exploiting patients and doctors alike are two downsides of electronic medical records. The upsides are transparency and rationality. I fear computer dependency may cause us to overlook health care’s personal sides. We may start to think computers are so smart they can replace or overrule human judgment. That would be a mistake.

Monday, January 19, 2009

Reece, Personal musings - A Doctor's Toast to the New President on the Eve of His Inauguration and on Martin Luther King Day

January 19, 2008

To this day

To this eve

To the fulfillment of your dream

To the content of your character

To hope

To change

To vision

To audacity

To equality

To selflessness

To graciousness

To unity

To fairness

To respect

To idealism

To realism

To coverage for all

To access for all

To more doctors for more access

To the Patient-Centered Primary Care Collaborative

To the Physicians’ Foundation

To hardworking doctors of every specialty

To sick patients in need of care

To affordable care

To health care savings

To better clinical information systems

To workable and affordable systems

To more prevention

To personal responsibility

To the right foods

To more exercise

To no smoking

To less obesity and diabetes

To manageable chronic disease

To better outcomes

To comprehensive care

To coordinated care

To equitable top-down dispensation

To energetic bottom-up innovation

To patient responsibility

To doctor accountability

To financial trasparency

To multicultural fluency

To freedom to chose

To freedom to pay

To freer exercise of judgment

To revamped Medicare doctor pay

To malpractice reform

To MD-to-MD cooperation

To doctor-hospital collaboration

To respect for markets

To less intrusive government

to paying for what's defendable

To not paying for what's expendable

To feasible individualism

To entrepreneurism

To reasonable collectivism

To less regulations and hassles

To fewer unneeded frazzles

To a sustainable health system

To economic recovery

To 2009 and beyond

To doing the right thing

To celebrating what counts most

To you and your family

To your health

To the nation's health