Thursday, April 30, 2009

Safety - Attack of Doctors; Hippocratic Oath

April 30, 2009, Investor's Business Daily

Prelude: What follows in an article by Betty McCaughey. McCaughey is a patient advocate and founder of the Committee to Reduce Infection Deaths. She is also a fellow at the Hudson Institute and a former lieutenant governor of New York State. Her point of view directly counters policy makers in the Obama Administration, who believes the government should reserve the right to override doctors’ decisions based on computer evidence of effectiveness.

Patients count on their doctor to do whatever is possible to treat their illness. That is the promise doctors make by taking the Hippocratic Oath.

But President Obama's advisers are looking to save money by interfering with that oath and controlling your doctor's decisions.

Ezekiel Emanuel sees the Hippocratic Oath as one factor driving "overuse" of medical care. He is a policy adviser in the Office of Management and Budget (OMB) and a brother of Rahm Emanuel, the president's chief of staff.

Dr. Emanuel argues that "peer recognition goes to the most thorough and aggressive physicians." He has lamented that doctors regard the "Hippocratic Oath's admonition to 'use my power to help the patient to the best of my ability and judgment' as an imperative to do everything for the patient regardless of the cost or effects on others."

Of course, that is what patients hope their doctor will do.

But President Barack Obama is pledging to rein in the nation's health care spending. The framework for influencing your doctor's decisions was included in the stimulus package, also known as the American Recovery and Reinvestment Act of 2009.

The legislation sets a goal that every individual's treatments will be recorded by computer, and your doctor will be guided by electronically delivered protocols on "appropriate" and "cost-effective" care.

Heading the new system is Dr. David Blumenthal, a Harvard Medical School professor, named national coordinator of health information technology. His writings show he favors limits on how much health care people can get.

"Government controls are a proven strategy for controlling health care expenditures," he argued in the New England Journal of Medicine (NEJM) in March 2001.
Blumenthal conceded there are disadvantages:

"Longer waits for elective procedures and reduced availability of new and expensive treatments and devices."

Yet he called it "debatable" whether the faster care Americans currently have is worth the higher cost.

Now that Blumenthal is in charge, he sees problems ahead.

"If electronic health records are to save money," he writes, doctors will have to take "advantage of embedded clinical decision support" (a euphemism for computers instructing doctors what to do).

"If requirements are set too high, many physicians and hospitals will rebel - petitioning Congress to change the law or just resigning themselves to ... accepting penalties," he wrote in NEJM early this month.

The public applauded the new requirement for electronic records, not foreseeing that it would put faceless bureaucrats in charge of your care.

Patient views - Rising Expectations of the "Near Old" as an Obstacle to Cutting Health Costs

The Revolution of Rising Expectations

Harland Cleveland, title of speech

New drugs ease pain, reduce depression, manage hypertension, control cholesterol, improve sexual function, and generally make life livable for millions of Americans. New technologies quite tremors, replace failed joints, keep diseased hearts beating, and hunt down errant cancer cells. New scanning procedures allow physicians to view the body through incredible imaging technology that much likes magic as science. Every single one of these new and wonder care improvements costs money, and most cost a lot of money.

George Halvorson, George Isham, MD, Epidemic of Care, Jossey-Bass, 2003

Critics of American health costs complain we spend 30% of Medicare dollars on the last illness. What they don't say is: we spend even more restoring function to the “near old.” Someone has grandly divided aging into the very young old (55), young old (65), middle old (75), and old old (85). But most of us naturally think of ourselves as the “near old,” meaning not old yet. As the saying goes, you're only as old as you feel.

We “near old” have high and rising expectations of what health care can do for us. This is America, and we expect quick access to those life-style and youth-restoring half-way technologies that make us feel and function as the near-young again.

I often ponder the rising expectations of aging America as I walk, talk, and balk at the aging process with my male friends each morning at our coffee clutch. All of us are over 60, all of us think of ourselves as high functioning seniors. All of us have experienced American medical care's wonders, and all of us expect to continue to have prompt access to these wonders.

There are 10 of us. As an exercise, I’ve jotted down what wonders the 10 of us have experienced and are experiencing.
• Currently taking statins 8/10

• On hypertensive medications 6/10

• Stent, coronary bypass, 6/10
pacemarker, or other device

• Cataract surgery 3/10

• Drug for hypertension 5/10

• Invasive surgery 8/10

• Joint replacement 3/10


Growing old and infirm used to be very hard. It means faltering parts and a Medicare card. Now, thanks to Medicare and medical technology, along with replacement parts comes a new psychology. When you’re going like sixty again you don't feel like part of the fading old Guard. The rising expectations of the near old for quick access to the wonders of modern technology will make it hard to cut costs as part of the health reform effort. This is America, the land of equal opportunity, and a shot at the best.

Wednesday, April 29, 2009

Physician payment -Congressional SGR (Sustainable Growth Rate) Formula and AMA's RUC (Relative Value Update Committee) Stack Deck Against Primary Care

A large, widening gap exists between the incomes of primary care physicians and many specialists. This disparity is important because noncompetitive primary incomes discourage medical school graduates from choosing primary care careers.

The Resource-Based Relative Value Scale, designed to reduce inequality between fees for office visits and payment for procedures, failed to prevent the widening primary care-specialty income gap for 4 reasons: 1) the volume of diagnostic and imaging procedures has increased far more rapidly than the volume of office visits, which benefits specialist who perform these procedures; 2) the process of updating fees every 5 years is heavily influenced the Relative Value Update Committee, which is composed mainly of specialists; 3) Medicare’s SGR formula for controlling physician payments penalizes primary care physicians; and 4) private insurers tend to pay for procedures, but not for office visits, at higher levels than those paid by Medicare. Payment reform is essential to guarantee a healthy primary care base to the U.S. health system.

Thomas Bodenheimer, MD, Robert Berenson MD, and Paul Rudolf, MD, “The Primary Care –Specialty Income Gap: Why It Matters, Annals of Internal Medicine, 2007; 146, 301-306

This year it’s the same old story. Medicare pay cuts for doctors are imminent. Congress will step in at the last minute to block the cuts.

But this year differa because the Obama administration knows health reform is not possible without more primary care doctors and other specialists (general surgeons, ER doctors, and other specialists). Surveys indicate doctors are unhappy and are refusing to accept new Medicare and Medicaid patients in record numbers because of low reimbursement and bureaucratic regulations taking time away from patient care.

The threatened pay cuts are due to the SGR (Sustainable Growth Rate) formula, adopted by Congress in 1997, which has called for physician pay cuts every year for the last ten years, and coding actions of the AMA/Specialty RVS Update Committee, formed in 1991, which favors specialists over primary care doctors.

This year’s SGR says doctors will receive a 21% Medicare pay cut on January 1, 2010. That will not happen, and the Obama administration knows it. The Obama team and Congress, on the other hand, seem reluctant to change the historically unworkable and inflexible SGR, which, if implemented would cause more doctors not to accept new Medicare and Medicaid patients. Congress, on its part, seems reluctant to enlarge the payment pie for doctors by saying it is “budget neutral,“ a euphemistic phrase which means if we enlarge the slice of the pie for primary care, we will have to reduce the slice for specialists.

This thinking has set up a potential food fight between primary care doctors, 300,000strong, and the Alliance for Specialty Medicine, comprised of 11 national medical societies representing 200,000 specialists. The AMA, the American College of Physicians, and the American College of Surgeons say the solution is simply enlarging the pie, but Obama and the Democratic Congress has suddenly become sensitive about the $6.5 trillion it has proposed to save the economy and the staggeringly large and mounting national debt.

Medicare is considering drastic alternatives, such as ending fee-for-service and replacing it with capped payments for bundled hospital-physician procedures, not paying for doctors and hospitals for individual visits and procedures but for episodes of care, rewarding doctors for joining into “accountable” multispecialty groups, refusing to pay for “avoidable” complications, standardizing payment through the country to stamp out “unwarranted practice variations,” and setting up pay for performance and comparative effectiveness programs requiring doctors to install and use “certified” EHRS for “meaningful purposes.” What that means nobody seems to know.

As you consider ramifications of SGR and RUC, remember they’re designed to save a buck. Yes, SGR and RUC may lack flexibility, but they’re fundamentally escapes from hard reality. It takes doctors to give care. That SRG and RUC can’t duck.

Tuesday, April 28, 2009

Heart disease, prevention - How to Contain the Coronary Disease Pandemic

As everybody knows, the Swine Flu epidemic may turn into a pandemic.

As everybody also knows, or should know, the coronary artery disease epidemic kills more Americans than any other disease, 400,000 each year, dwarfing the number likely to die from the Swine Flu virus.

Preventive Steps

The usual preventive stops suggested to prevent coronary disease are.

• Stop smoking.

• Lose weight.

• Identify and Treat hypertension.

• Lower LDL cholesterol.

• Exercise.

Spot it Early

There is another approach: spot heart disease early through a low-stress stress test administered at a doctor’s office or a fitness facility using a new alternative for the current high-risk coronary treadmill stress test that does not require a doctor in attendance should something go wrong, like a patient dropping dead on the treadmill.


The new low-stress coronary stress test is called SHAPE (System of Health and Pulmonary Evaluation). SHAPE is a fifth generation device evolving out of what’s been learned from past coronary testing. SHAPE has been exhaustively evaluated at the Mayo Clinic.

It may become the gold standard of alerting people to the presence of the risks of that dreaded killer. One other thing, while evaluating for the presence of coronary disease, SHAPE also evaluates lung function, which may be associated with coronary disease, e.g., smoking causes both coronary disease and chronic obstructive lung disease.


You can learn more about SHAPE by going to There you will learn SHAPE can be used for the following purposes.

• Assesses the presence of coronary disease.

• Predicts risk of hospitalization and death.

• Assesses pulmonary capacity.

• Monitors patient’s clinical response to therapy

No Risk, Repeatable

It does theses thing repeatedly without risk to the patient with automated interpretation of results, best judged and acted upon by a cardiologist.

The Shape Device

SHAPE consists of a 1 ½ step staircase, which the patient steps up and down upon and which a substitutes for the treadmill; a snorkel like device which tests for gas exchange in the lungs; and a laptop which interprets gas exchange data , integrates the data with amplified stair step information; and compares resulting data against a large database of patients with known outcomes to determine changes of morbidity and mortality.

One last thing. I am a big fan or clinical innovation and of basing that innovation on existing technology. You can never tell what the benefits will be when clinicians and physiologists are left to their own devices.

Monday, April 27, 2009

Medicare, public option - The Goverment Has a Plan

The government has a plan – a “public plan” to compete with private plans. The public plan will supposedly be more efficient than private plans.

The comparison is worthless. Unlike Medicare, private plans must,

• build private networks;

• negotiate rates;

• combat fraud or fact the consequences of being put out of business.

Medicare doesn’thave to worry about any of these things. The networks are a given. The rates are what Medicare wants them to be. Its record on combating fraud is abysmal. And when it comes to administering its public plan, it will simply contract out that function to private plans as it does now.

And as far as competing, the government now pays its Medicare drug plan recipients 30% below what private plans charges – without assuming any of the marketing and administrative costs. Medicare simply pays the bills and assumes none of the overhead headaches.

If the public plan were to be open to everyone, hospital net revenues would drop $36 billion and physician net revenues would plunge $33 billion. Presumably, medical care would then be “affordable” but your options would be limited. You could consider those options while waiting in line for care and wondering whether that care is now available or rationed.

When the government "competes," guess who wins. It isn't necessarily you - the patient, doctor, or hospital.

1. “The End of Private Health Insurance,” Wall Street Journal, April 12, 2009.

2. “Is Government Health Insurance Cheap?” Wall Street Journal, April 14, 2009.

3. “The Cost and Coverage of a Public Plan: Alternative Design Options, “ The Lewin Group, April 8, 2009

Physicicn shortages, doctor shortages - No Doctors, No Reform

WASHINGTON, — Obama administration officials, alarmed at doctor shortages, are looking for ways to increase the supply of physicians to meet the needs of an aging population and millions of uninsured people who would gain coverage under legislation championed by the president.

Robert Pear, Shortage of Doctors an Obstacle to Health Reform, New York Times, April 26, 2009

Suddenly, it seems, the Obama administration has come to a stunning conclusion: no doctors, no reform.

The administration says it can

-expand coverage;

-make care affordable;

-cut costs of doctors;

-offer incentives to implement a national EMR system;

-form a comparative effectiveness institute;

-create an alternative enrollment plan to compete with private plans;

-cut the profits of drub companies and health plans;

-force doctors and hospitals to bundle fees for high tech procedures;

-compel all businesses to pay for health coverage of employees;

-standardize Medicare payments in every region and hamlet in the land;

-even be able to push through legislation compelling every American to buy insurance.

But the administration admits it cannot cut out of whole cloth 50,000 more doctors now needed to serve the American people, expected to grow to 200,000 by 2019. It is a sad fact but it takes 8 to 10 years to create a new primarr doctor, and even more for specialists who are also in short supply.

To cut the shortage, proposals so far include:

• Increase payments to family physicians and internists.

• Increase enrollment in medical schools and residency training programs.

• Make greater use of nurse practitioners and physician assistants.

• Expand the National Health Service Corps, which help pays the educational debts of doctors and nurses in rural areas and poor neighborhoods.

• Support the medical home concept, which emphasize more primary care physicians providing comprehensive coordinated care.

• Subsidize the education of primary care doctors.

All of these proposals require more federal monies in the face of huge deficits. And they require expanding the federal mindset beyond Medicare and Medicare, which cover about 1/3 of Americans but are not representative of the care delivered by private plans for nonMedicare and nonMedicaid patients.

If the Obama administration is serious about expanding access with the ultimate aim of covering the entire population, it will surely come up with the money. And it had best gets its act together before 78 million baby boomers started entering the Medicare rolls in 2011.

And by the way, along the way, it will have to come to grips with the fact that there is a shortage in multiple specialties – general surgery, emergency room medicine, geriatrics, and obstetrics and gynecology – to name but a few.

In addition to more money, the government might think about letting up on this irritating and timeconsuming regulations that, other than inadquate payments, are the primary reason only 60% of doctors are accepting new Medicare patients and less than 50% take new Medicaid patients.

Sunday, April 26, 2009

blogging doggerel -Two Physician Friends

After my heart attack, Dr.Cooper of Philadelphia and Dr. Bachet of Seattle,

Gave me two pieces of advice on how with heart disease to do battle.

Cooper, a professor of medicine, said it’s mostly about exercise,

Barchet, former head of naval medicine said to prevent my demise,

Eat the right things and fight a continuous the navel battle.

Cooper advised me to give up my automobile,

To walk everywhere,to be pedestrian mobile,

Brecht said: forego processed foods, go for olive oil,

Add coEnzyme Q10 and vitamin A enriched cod liver oil,

I’ll have to do both, I’m on a banana peel.

Blogging, doggerel - Sacred Cows

Medicare for all, says worshippers of the first Sacred Cow,

All will be well, all will be swell, they don’t say: How?

Of course, if Medicare fails, there’s always Medicaid for all,

Another Sacred Cow entitlement worshippers hold in thrall.

Now in health care we all know what is meant by “Holy Cow!

Physician shortage, doctor shortage, regional variation - HEALTH REFORM CANNOT SUCCEED WITHOUT MORE PHYSICIANS

From: Physicians and Health Care, Commentaries by Buz Cooper, MD

Why are there shortages of physicians? Because health planners in the 1990s thought there were too many specialists and federal legislation was the number passed yearly. But why isn’t anything done about it now? Because voodoo statistics have convinced them (again) that there are too many. This blog will explain more about these statistics and about the damage that is occurring because of the failure to act responsibly on the behalf of citizens of this great damage. HEALTH REFORM CANNOT SUCCEED WITHOUT MORE PHYSICIANS.

Buz Cooper, MD, Prelude to his blog,

Richard (Buz) Cooper, MD is a Professor of Medicine and Senior Fellow in the Leonard Davis Institute of Health Economics at the University of Pennsylvania. During almost 50 years as a physician, he has practiced hematology and oncology, conducted experimental hematology research, directed a cancer center (at Penn), been dean of a medical school (at the Medical College of Wisconsin) and led a health policy institute (also at Wisconsin). Over the past 15 years, his efforts have been focused on critical issues in health care policy related principally to projecting the demand for physicians and other health care professionals and understanding the future dimensions of the health care system.

We bloggers have to stick together to achieve visibility in the sea of more than 2 million bloggers out there. Buz Cooper is one of the best of the physician bloggers because of his unique, strongly held, and well-documented views of the harm of the looming and growing physician shortage among all specialties.

His blog, now 2 months old, is not yet widely read, but it will be, when people realize as they are beginning to in Massachusetts, that universal coverage is meaningless with primary care access.

What Buz is saying is this: The disconnect between national policies based on theoretical assumptions resting on biased data interpretations divorced from reality (There are too many specialists, specialists are bad for quality, regional variations are unwarranted) and practical problems on the ground (I can’t find a primary doctor, there aren’t enough surgeons)CAN BE DANGEROUS TO THE HEALTH OF THE AMERICAN PEOPLE.

Here, to give you a taste for what Buz is saying are the titles and lead paragraphs of six recent blogs.

No One Home in the Medical Home

April 25

The ACP sees Internists as custodians of the “Medical Home,” a broad and inclusive model of care that is more conceptual than practical and only minimally tested among adult populations. Yet even if it proves to be valid, it faces the reality that there won’t be enough Internists, or Family Physicians, to make it happen.

This lack isn’t simply because Internists and FPs aren’t paid enough, although they aren’t. It’s because there won’t be enough physicians overall. There already are too few general surgeons and too few urologists, and the oncologists project a 40% shortfall within ten years. Faced with shortages like these, physicians will have to gravitate to roles that only physicians can play, while most of what goes on in a Medical Home is undertaken by Nurse Practitioners and others.

Let’s Talk About Poverty

April 23, 2009

Did you know that the poorest 15% of our fellow citizens consume more than twice as much health care as the richest? That means that if health care spending for everyone could be the same as it is for individuals at the median, our nation would consume 20% less health care. That’s a sobering reality.

Medicare is Not a Proxy for the Whole

April 20, 2009

The Dartmouth Doubletalker’s continue to insist that “state-level Medicare spending is closely correlated with overall per capita spending,” as it must be, because if Medicare and total expenditures don’t correlate, Dartmouth’s whole house of cards comes tumbling down. But they don’t, as clearly shown below, so watch out for tumbling cards.

A Tale of Two Cities: Birmingham and Grand Junction

April 14, 2009

The quiet of an Easter evening was shattered by a phone call from an irate surgeon saying, “did you see Peter Orszag’s Congressional testimony last year and the one by Elmendorf (his acting replacement at the Congressional Budget Office-CBO) last month?” Yes, I had seen both – they’re fundamentally the same. Both cite a 2002 paper from the Dartmouth group claiming to show that differences in illness rates among regions of the country account for less than 30 percent of the variation in spending. And they claim that differences in the income explain little more.

The MedPAC Squeeze: What’s at Stake for Rural America

April 10, 2009

Here’s what Tim Skinner, Executive Director of the National Rural Recruitment and Retention Network (3RNet), has to say about MedPAC, the agency that advises Congress on Medicare. MedPAC fully embraces the Dartmouth line that “more is less” (more physicians produce poorer quality) and has failed to promote greater support for graduate medical education (residency programs), which is the only source of new physicians in America.

The Paradox of Outcomes in Hospitals and Regions

April 10, 2009

A very good reporter asked a very good question. I had told him that one of the major problems with the Dartmouth group’s studies of regional variation was that their metric of health care utilization was the average level of Medicare spending in each region. The problem is that quality within regions doesn’t depend on Medicare spending alone – it depends on total revenues from all sources, and total spending doesn’t correlate with Medicare spending. This hangs as a cloud over their studies of outcomes among regions (see “30% Solution – A Treacherous Prescription”).

More Jobs, but not without More Physicians

April 7, 2009

In the month of March, the number of health care jobs increased by 13,500, bringing the total to more than 13 million, 12% of all jobs. At the same time, overall employment fell by 663,000, erasing the meager gains over the past decade and raising the unemployment rate to 8.5%, the highest in 25 years.

The 30% Solution – A Treacherous Prescription for Health Care Reform

April 5, 2009

According to a leader of Dartmouth’s Health Policy group, “if we sent 30% of the doctors in this country to Africa, we might raise the level of health on both continents.” Sadly, the notion that 30% of health care resources are wasted underlies current thinking about health care and serves as a beacon for Peter Orszag (Director of the Office of Management and Budget) and his health care reform team.

Saturday, April 25, 2009

Reece, personal musings - Reform Wishes

Facts are stubborn things, and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence.

John Adams, 1735-1826

This is an exercise in wishful thinking.

• I wish for a heated health care debate in Congress after the publisher releases my book Obama, Health Reform, and Primary Care Shortages. I wish the public reads the book, designed to inform people what’s involved and what’s at stake in this Great Debate. I wish the debate is long, factual, and detailed.

• The Obama administration and the Democrats wish to debate to end in comprehensive reform that requires all residents to purchase health insurance, with premium subsidies for people of modest means , and creation of a government-run insurance plan that would compete with private plans.

• Republicans and many businesses, health-related enterprises, physicians, hospitals, and private “special interests seek more market-based solutions, including high-deductible plans with health savings accounts, retail clinics, worksite clinics, concierge practices, privately run urgicenters, and third-party free clinics.

• Physicians wish for less onerous Medicare relegations, realism on electronic medical records, freedom to contract with patients outside of Medicare, educational support and debt relief for primary care physicians, help in forming medical homes, reforming antiquated physician payment, and lessening of federal “mandates.”

• American people wish for reform, lower costs and greater access, but polls indicate they wish to pay less than $50 a month for these reforms. The Massachusetts universal coverage model show costs will run at least $400 a month. Polls also reveal citizens don’t like the idea of a comparative effectiveness plan in which government officials, not doctors, decide what to pay for.

These are the facts. So much for wishful thinking.

Thursday, April 23, 2009

Health 2.0, Medicine 2.0, and Other Matters Large and Small

I have a friend, Brian Klepper, prominent health care analyst and principal of Health 2.0 Advisors ( To see how his mind works, read the blogs that he and his online running mate, David Kibbe, MD, are currently writing in, open letters to David Blumenthal, MD, the new National Coordinator of Health Information Technology(HIT) for the Obama administration.

As I read it,HIT's objective is to put an electronic health record system in every hospital and every doctor’s office by 2014 by using carrots (increased Medicare payments for “meaningful use” or “certified” EHRs) and sticks (lowered Medicare payments for non-users).

Brian called yesterday from Boston, where he attending and giving a keynote at the Health 2.0 conference from April 19 to April 23.

If you’re unaware of Health 2.0, and its online running mate, Medicine 2.0, collectively sometimes called Web 2.0, I invite you to read their respective website. Health 2.0 and Medicine 2.0 are terms used to describe the massive Internet-sharing of health and medical information among everyone with interest, from health and medical professionals, to patients, to caregivers, to the businesses (pharmaceutical manufacturers, health insurance) which support them.

Health 2.0

Health 2.0 and Medicine 2.0 are separate organizations.

Health 2.0, founded in San Francisco in 2006, is more diverse than Medicine 2.0 and thinks of itself as a social networking site for online user individuals dedicated to restructuring health care using the Internet for providing the tools and framework To give you a “feel” for where Health 2.0 is coming from, here is verbiage promoting their current conference.

“Health 2.0 Conference and the Center for Information Therapy (Ix®) are delighted to announce their first joint conference. The two organizations have been discussing the tensions and synergies between Information Therapy and Health 2.0. And they've been looking for a way to collaborate and integrate all the hundreds of ideas about the role of patients in the transformation of health care. So it makes great sense to put the two organizations together for one great conference.

" That conference will be April 22-23, 2009 at the Boston Park Plaza Hotel.

The theme: ‘The Great Debates on the Next Generation of U.S. Healthcare.’
• Health 2.0 & Ix: Tensions & Synergies
• Knowledge creation: Experts vs User-Generated Care
• Navigating the health care system: Human intermediaries vs. automation & algorithms
• How do you build Health 2.0 into the delivery system?
• What is the future role of the doctor?
• What are the incentives for Health 2.0 and Ix?”

“There'll be a stellar line-up of cutting-edge demos, compelling speakers and lots of surprises. Confirmed speakers include Don Kemper (Healthwise), John Halamka (Beth Israel), Rob Kolodner (ONC), Dan Hoch (BrainTalk), Esther Dyson (EDVenture), Paul Wallace (Kaiser Permanente), Jamie Heywood (PatientsLikeMe), and many, many more. In addition Health Affairs Editor and America's leading health care journalist Susan Dentzer will moderate a debate about the future of incentives for Health 2.0 and Information Therapy.”

In Boston will be small players- consumer groups, entrepreneurs, doctors, health system leaders – and the big Internet boys – Google, Yahoo, Microsoft, Cisco, and WebMD – all networking, niche-seeking, and noodling-together – to discern where things are going. In a sense, this is an Internet-based free for all in search of larger mission – reining in the health system, making it more rational and consumer-oriented.

Medicine 2.0

Medicine 2.0, which will hold its annual conference in Toronto in Toronto on September 17 and 18, thinks of itself as a more global and academic than Health 2.
But as you can tell from the following self-definition there is overlap with health 2.0.

“Medicine 2.0 applications, services and tools are Web-based services for health care consumers, caregivers. Patients, health professionals, and biomedical researchers, that use Web 2.0 technologies as well as semantic and virtual realites tools to enable and facilitate specifically social networking, participation, apomediation, collaboration, and openness wtith and between these user groups”
Medicine 2.0 focuses on academics and peer-review and approval , as differentiating points distinguishing it from mere Health 2.0 “tradeshows.” At least, that’s the sense I get from their website language.

“The Congress is organized and co-sponsored by the Journal of Medical Internet Research, the International Medical Informatics Association, the Centre for Global eHealth Innovation, CHIRAD, and a number of other sponsoring organizations.”
“This conference distinguishes itself from ‘Health 2.0’ tradeshows by having an academic form and focus, with an open call for presentations, published proceedings and peer-reviewed abstracts (although there is also a non-peer reviewed practice and business track), and being the only conference in this field which has a global perspective and an international audience (last year there were participants from 18 countries).

An academic approach to the topic also means that we aim to look "beyond the health 2.0 hype", Different “World Views” of Practicing Physicians and Web 2.0 participants
trying to identify the evidence on what works and what doesn't, and have open and honest discussions.”

Different “World Views” of Practicing Physicians and Web 2.0 Participants

As I read the promotional material on the Health 2.0 and Medicine 2.0 websites, one thing that strikes is lack of talk about the tensions between their approaches and the current approach of physicians, so I have decided to create a chart showing these changes in relief and the conflicts

Current Physicians Web 2.0 (health 2.0 and medicine 2.0)

Care based on periodic visits and encounters. Care based on continuous Internet- monitored care.

Doctor using experience and intuition knows Patients and consumers using Internet
best. and system data know best.

Professionals control care. Patients and consumers are the
source of control.

Too much infiltered information can Information is therapy.
be a bad thing.

EHRs are not ready for prime time, EHRs have arrived and simply have
cost too much, and slow and disrupt be tested, debugged, "certified,"
normal practices. subsidized through Medicare rewards.

Patients should betreated individually. Patients are part of populations and
should be treated on the basis of
population-based outcomes.

Decision-making should be based on Decision-making should be evidence
training and experience. based,

Do no harm based on your individual Judgment should be a system
judgment. property.

Secrecy is necessary to protect Transparency in all things is
privacy and to avoid malpractice. necessary, no matter wha.

You can trust doctors to do the right You can trust only data to
thing and charge the right prices. determining the right decisions
and the right prices.

Medical relates to what you can do to and Health applies to the whole
for patients inside your realm of control spectrum of health and can be
and becomes highly uncertain once the patient measured, monitored, and
pateint leaves the hospital or office. quantitated.

The medical system cannot be held A good health system is responsible
responsible for all disease outcomes, for disease prevention, health
which are uncertain and unpredictable. mainteance, and disease outcomes,
and the Internet will make work.

Medicine is an art full of uncertainties. Health care is a management science capable of exactitudes. capable of exactitudes.

Doctors react to patient needs. Health care should anticipate needs.

New technologies should be directed New technologies should promote
towards saving lives and restoring function, safety, prevent disease, make care
rather than simply saving money. more efficient and should save money.

Health information technologies are one Health information technologies
piece of the clinical puzzle, and often are the missing and biggest piece
a small piece at that. of the clinical puzzle.

Doctors should cooperate but what they Doctors should practice as parts of
do often requires individual decisions at cooperative clinical teams.
the point of care.

Electronic docummenting is not the same Good doctoring requires electronic
as good doctors. documenting.

Practice is poetry with freedom. Practices is prose with discipline.

Practice variation is inevitable and due Practice variations are unwarranted,
to socioeconomic differences. Making can be ended with stardardization
them uniform is futile. and homogenization, and will save
30% of total health costs.

And so the philosophical battle is joined - somewhere between Web 1.0 and Web 2.0, between paper and the Internet, between realism and idealism.

The point of this little chart exercise is that physicians immediately involved in medical care and in diagnosing and treating individual often think very differently form those who seek to restructure health care into a system based on remote Internet-data and its algorithmic components and on information empowered health consumers.

Wednesday, April 22, 2009

Differences between Health Care and Medical Care

I have a confession to make. I am schizophrenic about the health system as distinguished from the medical system.

On the left hand, I feel everybody ought to be covered and health care should bankrupt no one. On the right hand, I don’t feel government should impose these things. I believe government stifles innovation, imposes irrational regulations, limits choice, and drives doctors out of the profession.

In my most recent book, Obama, Health Reform, and Primary Care Shortages: Gloom for Improvement, Glimmers of Hope, now in production at the publishers, I have this passage near the end of the preface,

Difference between Physicians and Reformers

"As you read this book, keep in mind the fundamental differences between physicians and those who would fundamentally reform the system.

• Physicians are trained to treat and to cure disease and to alleviate pain. That’s what they’re paid to do, and from experience, they know it’s hard to persuade patients change unhealthy lifestyles once they leave the office or the hospital. Controlling in-patient and in-office care is one thing; controlling out- of -hospital and out –of-office behaviors are quite another. That’s one reason doctors are reluctant to be judged by outcomes when they know full well that many patients don’t comply with orders or change old habits. Some things are simply beyond the reach of the health system.

• Policymakers, on the other hand, tend to think that prevention should automatically be part of the physicians’ “toolbox, “and that care should be coordinated across the entire health spectrum from womb to tomb, inside and outside hospitals or offices, but physicians shouldn’t necessarily expect to be paid for time spent in discussing prevention or in coordinating or offering comprehensive care outside their realm. It’s part of their work. It goes with the territory.

Policy people often talk of converting our “sickness system” to a “wellness system.” Trouble is, people tend not to go to doctors when they’re well, but when they’re sick.”

This passage cuts to the heart of the issue, viz, health care as perceived by reformers is not the same as medical care as perceived by physicians. But I haven't point out these differences as cogently as Thomas Sowell, the distinguished conservative commentator who had this to say about issue in April 19, 2009 Real Clear Politics.

Words Versus Realities

Thomas Sowell

Much as I hate to be the bearer of bad news, I must report the shocking facts: Medical care is medical care. Nothing more and nothing less.

This may not seem like a breakthrough on the frontiers of knowledge. But it completely contradicts what is being said by many of those who are urging "universal health care" because so many Americans lack health insurance.

Insurance is not medical care. Indeed, health care is not the same as medical care. Countries with universal health care do not have more or better medical care.

The bottom line is medical care. But the rhetoric and the talking points are about insurance. Many people who could afford health insurance do not choose to have it because they know that medical care will be available at the nearest emergency room, whether they have insurance or not.

This is especially true for young people, who do not anticipate long-term medical problems and who can always get a broken leg or an allergy attack taken care of at an emergency room -- and spend their money on a more upscale lifestyle.

This may not be a wise decision but it is their decision, and there is no reason why other people should lose the right to make decisions for themselves because some people make questionable decisions.

If you don't think government bureaucrats can make questionable decisions, then you haven't dealt with many government bureaucrats.

It is one thing to deal with bureaucrats when you are at the Department of Motor Vehicles and in good health. It is something else when you have to deal with bureaucrats when you are lying on a gurney and bleeding or are doubled over in pain on a hospital bed.

People who believe in "universal health care" show remarkably little interest -- usually none -- in finding out what that phrase turns out to mean in practice, in those countries where it already exists, such as Britain, Sweden or Canada.

For one thing, "universal health care" in these countries means months of waiting for surgery that American get in a matter of weeks or even days.

In these and other countries, it means having only a fraction as many MRIs and other high-tech medical devices available per person as in the United States.

In Sweden, it means not only having bureaucrats deciding what medicines the government will and will not pay for, but even preventing you from buying the more expensive medicine for yourself with your own money. That would violate the "equality" that is the magic mantra.

Those who think in terms of talking points, instead of trying to understand realities, make much of the fact that some countries with government-controlled medical care have longer life expectancies than that in the United States.

That is where the difference between health care and medical care comes in. Medical care is what doctors can do for you. Health care includes what you do for yourself --such as diet, exercise and lifestyle.

If a doctor arrives on the scene to find you wiped out by a drug overdose or shot through the heart by some of your rougher companions, there may not be much that he can do except sign the death certificate.

Even for things that take longer to do you in -- obesity, alcohol, cholesterol, tobacco -- doctors can tell you what to do or not do, but whether you follow their advice or not is what determines the outcome.

Americans tend to be more obese, consume more drugs and have more homicides. None of that is going to change with "universal health care" because it isn't health care. It is medical care.

When it comes to things where medical care itself makes the biggest difference -- cancer survival rates, for example -- Americans do much better than people in most other countries.

No one who compares medical care in this country with medical care in other countries is likely to want to switch. But those who cannot be bothered with the facts may help destroy the best medical care in the world by falling for political rhetoric.

Electronic Health Records; Pouring $19 Billion Down a Rat Hole?

Even a booster of electronic systems like David Blumenthal, who just started his Washington post as the national coordinator of health IT, points to the myriad of challenges when it comes to digitizing the nation’s medical records.

Sarah Rubenstein, “Are Electronic Health Records Worth The Risks?” Wall Street Journal Health Blog, April 21, 2009

Sometimes you grow so enamored with an idea that you think you can override all barriers. Such is the case with digitizing medical records and having all doctors and hospital data integrated into one massive national electronic health record.
The benefits, we are told, are enormous.

1) Less paperwork for doctors and staff.

2) Tracking prevention, surgical successes, medical morbidity and mortality, and performance of doctors and hospitals.

3) Outcomes research to see what works.

4) Facilitating sending of safe prescriptions to pharmacies.

5) Identifying national security threats.

6) Allowing interstate portability of medical data.

7) Permitting nationwide epidemiological, environmental, and pharmaceutical research.

8) Achieving more efficient, safer, and higher quality care.

9) In short, everything that government had ever wanted to know but has been unable to access.

If you doubt the enormity of these benefits, I invite you to read two recent New England Journal of Medicine pieces: “Stimulating the Adoption of Health Information Technology,” April 9, and “Use of Electronic Health Records in U.S. Hospitals,” April 16.

The only trouble with those who gush about e-health benefits are these:

1) Despite at least five years of government pushing for EMRs, only 1.5 % of hospitals and 4.0% of physician practices have “fully functioning” EMRs, and 10% of hospital and 17% of doctors have even partial EMRs.

2) When it comes down to it, HIT (Health Information Technology) is still only a record for health and medical trackers, not a useful guide for practicing medicine; EMRs are about documenting not doctoring.

3) As these records now stand, with their numerous variations, most systems don’t even talk to one another; an EMR functioning in isolation, said one doctor, is nothing but a giant invoice, and useless as a tool for communication.

4) Independent doc torso resists EMRs for good reasons: most systems are not up to prime time, i.e., as useful, doctor-friendly tools, and they cost a lot with no return on investment.

5) Government, i.e., Medicare payments for “meaningful use” or “certified” EMRs”, is relying on money, up to $44,000 for doctors for 5 years, and $2 million to hospitals plus an add-on fee based on DRGs, to move doctors to use with penalties for non-use: doctors do not necessarily accept Medicare as the gold standard, dislike being bought, and may drop out of Medicare, as 30% already do, rather than use EMRs.

6) Government subsidizing of widespread use of EMRs, with rewards for use, in Great Britain have not lived up to expectations. Here is that story, as told by Greg Scandlen Director for Health Care Choices, in “Research & Commentary: Health Information Technology,

“As part of the federal government's economic stimulus package, Congress has authorized spending about $20 billion on health information technology (health IT) and another $1 billion on comparative effectiveness research. These provisions achieved wide bipartisan support in Congress and in the health care industry, based on the hope that the investment will help improve efficiency, cut costs, and result in better care. The reality is likely to be far different.”

“Proponents of this spending rely heavily on a short RAND Corporation analysis from 2005 that predicted $77 billion in annual savings and improved outcomes. RAND estimated "implementation would cost around $8 billion per year, assuming adoption by 90 percent of hospitals and doctors’ offices over 15 years." It said, "The benefits can include dramatic efficiency savings, greatly increased safety, and health benefits."

“Unfortunately, RAND assumed an error-free system that’s quickly and enthusiastically adopted by virtually the entire health care system. That might happen, but it’s an absolute best-case scenario. Even then, instead of "dramatic savings," the $77 billion hoped-for savings amounted to a mere 4.5 percent of total costs, placed at $1.7 trillion by RAND.”

“Far more likely is that every penny of the $20 billion will be wasted on systems that don't work and can never be implemented. That was the outcome of federal attempts to upgrade technology at the IRS, the FBI, and the air traffic control system. And these are all relatively simple enterprises involving single federal agencies. Health it’s vastly more complex and must include hundreds of thousands of private organizations that have invested in legacy systems that work reasonably well and are as varied as there are providers.”

“This also has been the experience of the United Kingdom, which has been trying to adopt a similar information technology upgrade for its National Health Service (NHS) since 2002. This plan was far less ambitious than the U.S. version, involving merely 30,000 physicians and 300 hospitals, all of whom are already employed by the NHS. Originally estimated to cost 2.3 billion pounds, it’s already at 12.7 billion pounds--$18.4 billion, or about as much as provided in the stimulus package for the entire United States. A recent report to Parliament admitted the program is four to five years late and may never be implemented as envisioned. The project has lost two of the four vendors who were working on it, and some of the elements that have been installed aren’t meeting expectations.”

“This is not to say health IT’s a bad idea or that hopes for it are unwarranted. Quite the opposite. The health care system sorely needs better management tools and better application of technology. There’s currently a vast amount of entrepreneurial energy, innovation, and money being invested in developing, refining, and marketing the tools the system needs to come into the twenty-first century.”

“The danger is that massive federal intrusion will bring all that innovation to a screeching halt. Systems work best when they’re developed from the ground up, not imposed from on high. In ground-up development, flaws can be detected and eliminated without much system wide damage. Poor vendors can be removed without disruption to the whole system.”

“We don’t yet know what the optimal system will be. Imposing federal standards on health IT in 2009 means the entire system will be locked in to those standards for very long time to come and innovation will not be rewarded.”

“The RAND study said "market forces" are an obstacle to health IT. Just the opposite is true. The market is the best way to test and refine new ideas. The process of repeated testing and refinement may seem slow to people who want instant solutions and shortcuts, but the failure to engage in that process often results in massive mistakes and wasted billions.”

Maybe, just maybe, nationalized electronic medical records are too good to be true.

Thursday, April 16, 2009

blogging doggerel, data, use and misuse - Quants

Once in a great while, I run across of piece of writing I can’t resist. What follows are my poetic summary and the piece itself, which appeared in and was written by Michael Barone, an inside-the-Beltway political reporter.

Beware of geeks, wonks, and nerds,

They’re apart from common herds.

Now we have to worry about “quants,”

Who think formulas satisfy all wants.

For realists, “quants” are for the birds.

April 16, 2009

On Climate & Health, Beware of Easy Formulas

Michael Barone

Beware of geeks bearing formulas. That's the lesson most of us have learned from the financial crisis. The "quants" who devised the risk models that induced so many financial institutions to buy mortgage-backed securities thought they had reduced risk down to zero.

Turns out they got a few things wrong. Their formulas were based on only a few years of actual data. Or they failed to take into account the possibility that housing prices would fall. Or that the market for mortgage-backed securities might suddenly stop functioning.

The lesson seems clear. Don't allow a whole system to become hostage to the workings of some geek's formula. Keep in mind the possibility that the real world might not behave as the formula indicates.

But, astonishingly, our society seems about to forget that lesson, just as it should have been learned. Congress is poised, at least if the Obama administration gets its way, to pass major new laws on carbon emissions and on health care whose success depends on geeks bearing formulas.

Consider carbon emissions. Carbon dioxide is a harmless gas, not a pollutant. But geeks bearing formulas tell us that increasing amounts of it will heat up the world's climate and cause catastrophic damage some decades hence. Al Gore is so certain of this that he tells us all debate must end -- disagreeing is like denying the Holocaust.

But the Holocaust happened, while the disasters that Gore predicts have not. When you try to predict climate, you are dealing with even more factors and more unknowns than when you try to predict financial risk. Prudent people will want to hedge against some risks that seem possible. But imposing huge costs on the private sector economy -- raising the price of electricity for everybody -- solely on the basis of some geeks' formulas seems, well, not prudent. But that's what Barack Obama tells us we must do.

Or consider health care. One element of proposed health care reforms is restricting care to procedures that are indicated as optimal by "quality metrics." The Obama campaign called for comparative effective research to produce such metrics. The problem, as Dr. Jerome Groopman of Harvard Medical School points out, though not in these words, is that the geeks keep producing different formulas. Or as Dr. Scott Gottlieb of the American Enterprise Institute writes of the comparative effectiveness research mandated in the House-passed stimulus package, "The results of studies are always being made obsolete by new science."

There is a more general problem here. The risk models of the financial geeks, the climate models of the environmental geeks and the medical models of the health care geeks are all ultimately forms of social science. But social science ultimately is not science but art. (italics mine).

The geeks use numbers to try to understand the world. And their work is helpful, up to a point. We can measure the damage to our economy better today than during the 1930s because people then didn't know what the gross national product was. The geeks had not yet invented the formula.

As an avid consumer of political and demographic data since childhood, I am not inclined to say that statistics and formulas are worthless. Rather to the contrary. I grew up knowing that I was one of 1,849,568 people living in Detroit in 1950, and the Census Bureau's estimate that there are only 916,952 people living there today tells you something worth knowing.

But numbers are not reality -- they are just clues (italics mine) In 1965, Daniel Patrick Moynihan, perhaps the most perceptive social scientist of recent times, looked at the numbers of black babies born out of wedlock and predicted a grim future that came to pass. It was not just the numbers, however, but his own experience as a fatherless child that produced this insight.

The financial "quants" failed to realize what a trip to subprime mortgage territory in California's Inland Empire might have told them.

The climate modelers work with historical data that do not necessarily predict future weather patterns. The medical statisticians cannot know the human factors that prompt a sensitive clinician to make lifesaving decisions. Geeks with formulas can help us understand the world better and make informed decisions. But the collapse of our financial institutions tells us that we would be fools to rely on them completely in ordering our great institutions.

innovation,organizational, medical megatrends - Bottoms-up!

This is a toast to business owners, nonprofit groups, local hospital, health care entrepreneurs, health agents and others who are finding innovative ways to make health care affordable.

• To a janitors’ union in Houstonj who pays for care for its members by having them set aside a dollar a day for care.

• To the University of Texas medical branch hospital, in Galveston, Texas, who covers 430 employees of small businesses at $60 a month + co-pays.

• To non-profit groups in Duluth, Minnesota, Pueblo, Colorado, Muskegan, Michigan, who cover thousands of small business owners at reduced rates.

• To entrepreneurs who are creating worksite clinics for workers so they have convenient access to good care at a fraction of previous costs.

• To health agents across the land who are actively selling high deductible plans with HSAs at greatly reduced premiums and overall costs.

• To doctors across America who volunteer at “free clinics” to provide much needed care to those without resources.

• To cities like San Francisco who are making possible affordable universal care through subsidies from city and county government and a series of city and county wide clinies.

• To Wal-mart, Target, and other discount chains who are offering $4 generic prescriptions.

• To the companies and nurse practitioners who run more than a thousand clinics with predictable affordable prices and convenient hours for those with minor illnesses.

• To small businesses, who conduct 90% of America’s business, and to their employees, who make up 30% of the nation’s uninsured.

To all of them, and to all kindred souls, Bottoms-Up!

Wednesday, April 15, 2009

Government reform - Hey, Big Spender

Hey, Big Spender,

The minute you walked in the joint,

I could see you were a man of distinction,

A real big spender,

Good looking, so refined.

Say wouldn't you like to know

What's going on in my mind?

So, let me get right to the point.

Lyrics, Hey, Big Spender

April 15, 2009 - I know not if President Barack Obama’s big spending proposals to save the economy, invest heavily in green energy, reform health care, and make the U.S. globally competitive are the right thing to do.

Neither, I am persuaded, does anybody else. Nevertheless, the popular sentiment is: we’ve got to do something.

Finally,I know this. This is tax day, and tea parties are being held around the country by hundreds of thousands of Americans in 300 cities, at 750 events, in all 50 states, to protest high taxes and big government spending.

This is apparently a spontaneous uprising. No political parties are involved, and there is no grand GOP conspiracy to discredit the Obama’s spending proposals.

I know this. Tea party backers are taking a page out of the social networking successes if and playbooks to organize “smart mobs” and “flash crowds” at a moment’s notice to send a message, In the tea party case, – that message is: big government spending has a downside – federal deficits as far the eye can see and the mind can stretch. There’s a tangible fear out there that the U.S. is spending our way into national bankruptcy.

And I know this. Doctors fear big spending will make them prisoners of the federal government, unable to offer choices outside of government programs. For years, the Association of American Physicians and Surgeons (AAPS), a small conservative group in Tucson, has been backing the idea of private contracting between doctors and patients outside of Medicare. Ihis concept may resurface soon in other quarters of organized medicine.

And I know this. Obama’s proposals have aroused fears among the medical establishment that a government take-over is at hand. This is more than fear-mongering about “socialized medicine.” It is fear doctors will not be able to treat patients as they see fit outside the constraints of government and patients will be limited in choices of care.

And I know this. An Internet conservative counterrevolution is afoot.
President Obama owes his election partly to a magnificently organized and beautifully orchestrated election campaign rooted in the Internet. He is now using the e-mail collected in his campaign and Obama websites to inform his e-constituency of what he is doing to mobilize support in his perpetual campaign.

The Internet is a nonpartisan two-edged electronic sword. The tea-parties are one manifestation, and efforts of Conservatives for Patients Rights, aptly abbreviated as CPR, are another. Backed by $15 million for Rick Scott, former CEO of HCA, inc, the big Nashville-based hospital company, CPR has launched a series of Internet and television commercials to bebut President Obama's health care proposals.

And I know this.,, and Obama websites will preach the gospel of moral obligation ( see “Health Care for All: A Moral Obligation,” Letters to the Editor, New York Times, April 15, 2009, with tag lines blasting the villainy of private profiteering, such as “Let’s put insurance companies out of business as soon as we possibly can.”

Meanwhile on the other side of the aisle, we shall hear the messages of individual enterprise vis-à-vis collectivism, “The Fewer the Choices, the Longer the Lines, Choice, Competition, Accountability, Personal Responsibility.”

Finally, I know this. The answers lie somewhere in-between, and the Internet Health Care Tug of War is underway to define just where the bipartisan line resides.

For the conservatives it will be an uphill battle. The big spender, whose budget for 2009 multiplies the budget deficit 2 1/2 times to 28.5% of GDP, is good-looking with a radiant charm, is a speaker of distinction, and has a 60% presidential approval rating.

Tuesday, April 14, 2009

Effect of culture - A Nation's Culture, Not Its Health System Shapes Its Health Statistics

Medical care accounts for about 15% of the health status of any given population, life style for 20% to 30%, and other factors – poverty, education, income, and lack of social cohesion, for the other 55%.

D. Satcher and R. Pamies, Multicultural Medicine and Health Differences, McGraw-Hill, 2006

In these days of high blown health rhetoric about the virtues of single payer and superior health statistics of other developed nations compared to the U.S., it’s useful to keep in mind that two salient U.S. cultural factors – one, our high death rates on our highways from accidents and violence in our mean streets, and two, our explosively high rate of immigration, with one of five Americans being a recent immigrant or close relative of one – are decisive in shaping our statistics.


• Col. John Holcomb, the army’s top trauma surgeon, is fond of quoting the statistic, that, among U.S. civilians, trauma leads all diseases in terms of life-years lost, more than heart disease or cancer. That’s useful statistic to keep in mind when comparing national health systems, for if one takes trauma and violence into consideration, U.S. longevity statistics are comparable to any other country. There is little the medical care establishment can do about reducing the number of these deaths, other than heroic actions in emergency rooms and hospitals, often after it too late.

• The number of U.S. citizens born to illegal immigrants , mostly from Mexico, has exploded from 2.7 million to 4.0 million over the last 5 years. One of four illegal Mexicans, or 25%, went without health insurance, and experienced much higher rates of infant mortality among illegal Mexican mothers than infants of U.S. born mothers. Many of these deaths occurred in infants of Mexican mothers who were beyond the reach of our health system. Take into account also that Hispanics, which now comprise about 15% of our population, have an average life expectancy of 74.0 years compared to 81.0 years for American whites.

When outraged reformers say its poor health coverage.

That makes U.S. statistics worse, don’t take umbrage.

Show them figures on immigration and domestic trauma,

Tell them to plug that into their dramatic docudrama.

Those numbers may help assuage irrational outrage

Health Plans - The Skunk at the Health Reform Party

What kills a skunk is the publicity it gives itself.

Abraham Lincoln

When it comes to health reform, major players agree health plans are an unwelcome guest at the party.

• The Obama administration plans to save $180 billion by having profiteering Medicare Advantage plans compete with traditional Medicare plans.

• Reformers often talk about having overly profitable health plans accept all comers regardless of pre-existing illness.

• Health plan members complain about having health plans cancel their policies in the name of the bottom-line after an episode of serious illness.

• The AMA and four other medical societies from California, Connecticut, Georgia, and North Carolian are suing WellPoint, the nation’s largest health insurer, to recoup physician pay for reduced out-of-network payments based on an Ingenix database.

• New York Attorney General Andrew Coumo has forced 10 plans to commit $93 million towards a new database to replace Ingenix.

• Senator Jay Rockefeller grills and tries to humiliate UnitedHealthGroup, CEO, Stephen Hemsley, fir shifting millions of dollars to consumers by rigging health data to avoid payment.

• Primary care physicians complain health plans have “disintermediated” them by cutting them out of the supply chain of those delivering health care services.

• Membership in traditional HMOs and PPOs plans is dropping as employers and patients shift to less tradititonal coverage vehicles such as high deductible plans linked to HSAs and innovative “basic “ plans providing bare-bones protection.

No Fun Being a Skunk

If you’re a health plan CEO, I’m sure it’s no fun being a skunk in the health reform fight. But deep down, these CEOs know how only they have the data and savvy to administer health benefits. Reformers and Obama officials may talk a big game, but do they have the game to administer public plans to compete with private plans?

Former Congressman Richard Gephardt, who witnessed close-hand the Clinton reform disaster has cautioned the Obama team to 1) think smaller; 2) seek less; 3) don’t fail.

Health care business lobbyists are still a powerful force and may yet expose fallacies in the Obama approach, as set forth by the Commonwealth Fund and other liberal think tanks.

According to Rodger Collier, former heath of a major health care consulting firm, these fallacies incued

Fallacy Number One: Small businesses will accept a “play-or-pay” proposal that forces them to pay a minimum of seven percent of payroll for health care. In the midst of recession, small business associations will fiercely resist paying more of payroll for health coverage.

Fallacy Number Two: The insurance industry will allow the creation of a “public plan” to compete with their own offering. The assumption that it would be the only FFS plan sold through the proposed insurance exchange is especially likely to leave AHIP leaders foaming at the mouth. Providers are unlikely to be too eager to go along with a proposal that slashes payment rates by thirty percent, either.

Fallacy Number Three: Government spending on IT of $120 billion over ten years will yield savings of almost $200 billion.The forecast savings are likely to be illusory. Integrated health care systems like Kaiser may be able to achieve savings, but most US providers aren’t Kaisers. A more realistic view is found in last year’s Congressional Budget Office report on health care issues, “By itself, the adoption of more health IT offers many benefits, but it is generally not sufficient to produce substantial cost savings because the incentives for many providers to use that technology to control costs is not strong.”

Fallacy Number Four:
Establishment of a “Center for Comparative Effectiveness and Health Care Decision-Making” will cut expenditures by more than $600 billion over the next decade. The savings projection seems wildly optimistic. I t’s hard to believe that those high-cost providers in major cities with high costs of living will go along with slashing their income as the CBO report notes: “it would probably take several years before new research on comparative effectiveness could reduce health spending substantially.”

Fallacy Number Five – Hospitals, physicians, and patients will behave the way reformers want them. This wishful thinking is at odds our current supply-driven health care system’ s incentives. Outside of big multispecialty clinics, improvements in provider efficiency are likely to cut incomes, not increase them. It’s no coincidence that areas with the greatest physician and hospital densities have the highest health care costs. Unless we can change the incentives—or control the introduction or distribution of new resources—we will never solve the health care cost problem.

Idealistic reformers may well consider health plans as skunks,

Smelling up reform plans by eating up money in unneeded chunks,

What reformers often neglect to mention,

Is an important management dimension.

When it comes to administering plans, Medicare flunks.

Monday, April 13, 2009

Bloggind, doggerel - Running Republican Elephants Out of the Room

Six liberal Democrats of Congress,

To health carereform much inclined,

Congregated at the hearing room,

Their Party’s interests intertwined,

To see what they could do combined.

The First approached an Elephant in the Room,

Grabbed the Megaphone, and his voice did boom,

"We must place them in benevolent government hands,

We must somehow seal their collective doom."

The Second approached another Elephant in the Room,

Mounted the rostrum and spouted collective gloom,

"No, no,' said she, "‘tis Big Pharma,

That’s causing all the big Harma,

Sweep them out< I say, with our big new broom."

The Third approached another Elephant in the Room,

Glowered at his colleagues and with rhetoric in full bloom,

Declared stentorially, "The real purpose of this reform caper,

Is to do away with all those medical records on paper,

Make them all transparent, do away with the aberrant."

The Fourth approached a fourth Elephant in the Room,

Rose to his full height and began to foam and fume,

Boomed he, "‘Tis those damn arrogant physicians,

Who picture themselves as independent clinicians,

Rein them in, if we are to offer care womb to tomb."

The Fifth approached a fifth Elephant in the Room,

Elevated on her high heels and condescended with aplomb,

"What we need," purred she,"is more regulation,

To stifle all that expensive private innovation,

Patients need less, not more, choices to consume."

The Sixth Democrat approached the last Elephant in the Room,

Revved up his vocal decibels and declared,"We all, I presume,

have to assume this is our best chance,

For the cause of our savior, Obama, to advance,

And to run Republican Elephants out of this damn room."

government reform vs. market reform - Canoeing Down the Reform River

A Little on the Left, A Little on the Right

Jerry Brown , former governor of California , one-time presidential candidate, once major of Oakland, and now attorney general for California, said it best.
“Politics is like canoeing You row a little on the left, You row a little on the right. And you stay in the middle. You wave to spectators on the left and right banks.”

On the Left Bank , The Media

It goes without saying that those in control of the executive and legislative branches of the federal government have the biggest public megaphone and can dominate the media outlets, particularly the nightly television news. The big media tends to lean left with few notable exceptions – talk radio and Fox News.

Canoeing and Writing about Reform

I try to canoe when writing about health reform. Canoeing-writing about reform delicately balances top-down control and equity versus bottom-up choice and opportunity. It’s a philosophical debate between government guaranteeing coverage and reducing coss , and conservatives lobbying for more market innovation and more consumer responsibility. It’s about government-backed health plans; it’s about private plans. It’s about progressive lobbyists pitted against health care industry lobbyists. It’s about order, tolerance, and respect for it people’s opinions. For government it’s dependency, regulation, mandates, and control. For market-types, its choice competition, accountability, and personal responsibility.

Canoeing Amongst the Media

Canoeing isn’t easy.

But I have my ways. I start by reading the New York Times to see what the left is thinking. Then I go to the Wall Street Journal to get the view from the right. I look at a few left leaning blogs, like The Health Care Blog, and medical journal, the New England Journal of Medicine, which can counted on for left center opinions, always in perspective, of course, but always coming down on the left side of the argument.

Conservative Canoeing

Then I lean to right by visiting the websites of the Galen Institute, the National Center for Policy Analysis, the Center for Health Care Choices, and Conservatives for Patients Rights, aptly abbreviated CPR.. I may go to a couple of health care business canoe sites like and, which profess to be neutral, but are skewed slightly to the right because they report the business news of health care.

Real Clear Political Canoeing

Finally, I generally settle in by looking at, a daily digest of national politics. I like it because each day it contains 20 or so in-depth articles and editorials from left and right publications from left and right individuals.

You get a sense of the political sentiments of Real Clear Politics from a poll it runs among its readers, which today runs as follows

• Approve of Obama, 60%, Disaaprove, 30%
• Approve of Congress, 33%, Disapparove 58%
• Generic Mix of Readers, 43% Democrats, 42% Republics
• Direction of country, Right 32%, Wrong 61%

In Real Clear Politics, you’ll often run across pieces by Paul Krugman, to the left of President Obama, and Rush Limbaugh, to the right of Atilla the Hun. Lefty Robert Reich, former Clinton cabinet member, weighs in, as well as other current Democratic stalwarts, and you will often find articles by the likes of conservatively-oriented Dick Morris, Victor Hansen, and Charles Krauthammer.

Where’s The Reform Canoe Now?

Right now, my sense is the canoe is tilted to the left, but not so far as you might think. What the left secretly hopes for a tightly regulated insurance exchange for those without group coverage, a new public plan to compete with private plans , and mandates that force employers to cover employees and plans to cover all regardless of pre-existing illnesses. But as the reform debate approaches, the left is thinking smaller, seeking less, and fearing failure. Meanwhile the right is engaged in a holding action, waiting and hoping that health savings accounts, which now have 20% of the private plan market, will ignite and dampen hopes for universal coverage.

Sunday, April 12, 2009

Reform delays - Congressional Health Care Reform Timetable 2009

Congress will soon engage in debate over the 2010 budget. A big part of that debate will focus on health care. Democrats are cautiously optimistic about prospects for reform. Republicans will argue the budget is fiscally irresponsible because it will produce staggering federal deficits, offers no real savings, and will lead to an unprecedented “socialistic experiment.” Whether Congress will have the stomach to punish an economic sector like health care with its impressive record in creating jobs and serving in many communities remains unknown.

I’m not a disinterested observer. My book, Obama, Doctors, and Health Reform: The Health System, from Top-Down to Bottom-Up, As Seen Through Lens of Cultural Complexity: A Doctor Accesses Odds for Success of Obama Health Reform, is likely to appear in the midst of the debate.

What follows is the health reform timetable prepared by the Director of Federal Affairs for Affordable Health Insurance, Washington, D.C.


April 20 to May 22:

• Congress will be in session for these five weeks.

• Week of April 20: Each chamber should pass the budget resolution with reconciliation instructions included.

• April 21: Senate Finance holds a public roundtable discussion on “Delivery System Reform.”

• Week of April 27: If reconciliation is a sticking point, then Congress should resolve it and should pass the budget resolution during the week of the 27th.

• April 29: Senate Finance holds closed door meeting where Baucus walks the members and staff through the delivery system reform legislative options he is drafting.

• May 5: Senate Finance holds a public roundtable discussion on “Expanding Coverage.”

• May 12: Senate Finance holds closed door meeting on legislative options for expanding coverage.

• May 14: Senate Finance holds a public roundtable discussion on “Financing.”

• May 21: Senate Finance holds closed door meeting on financing options.

May 25 to 29:

• Congress is not in session.

June 1 to June 29:

• Senate committees should approve (“mark up”) their versions of health care reform. This is the start of the legislative process.

• The House committees should move a product during this calendar block. The House versions will be more aggressive than the Senate version, and, if health care is to pass, the final product will look more like the Senate version.

July 6 to August 3 (House) or August 10 (Senate):

• Full Senate should approve health care reform.

• Full House should approve its bill.

August 3 (House) or August 10 (Senate) to September 4:

• Congress is not in session

September 8 to November 20:

• Federal holidays and religious days of observance provide a few days off during this stretch of time, but the breaks aren’t as long as some of the others.

• Conference Committee should work out the differences in the two bills and then each chamber must approve before the final product before it goes to President Obama to sign.

• Congress would like to adjourn at the end of October, but it rarely hits that target date in an off-election year.

• Congress should wrap up its legislation business for the first session of the 111th. Congress. If it doesn’t, it will return after Thanksgiving and finish before Christmas.

Saturday, April 11, 2009

Consumer-driven care - Mind Piece

Give us the tools, and we will finish the job.

Winston Churchill, Radio Broadcast, 1941

A mind is a terrible thing to waste.

Slogan of United Negro College Fund since 1972, now part of American vernacular

If you don’t mind, here’s a piece of my mind.

I believe minds of home-bound, chronically-ill, recently discharged from the hospital, elderly patients may be one of the most underrated and greatest single source of Medicare savings.

The April 2 edition of the New England Journal of Medicine contains a special article, “Rehospitalization among Patients in the Medicare Fee-For-Service Programs.” It says 20% of Medicare beneficiaries discharged from the hospital in 2004 were rehospitalized with 30 days, and 34% within 90 days. For those rehospitalized within 30 days, 50% had no record of a physician visit between discharge and readmission. The authors estimate the cost of unplanned rehospitalizations in 2004 was $17.4 billion.

The good news is you can cut these readmissions to near zero for patients with congestive heart failure, who comprise the bulk of readmitted patients, by using existing technologies and the minds of patients.

The technologies are ordinary phone lines, an audiovisual device smaller than a breadbox through which patients can talk and listen to doctors and nurses , and some space age stuff that allows caregivers to weigh patients, take blood oxygen levels, and listen to hearts and lungs.

But by far the greatest thing is the minds of these ill patients. Their bodies may be compromised but their minds are not. They have proved to be quick spotters and learners of complications of heart failure – fluid retention, malaise, chest pain, shortness of breath, even mental short circuiting.

And, not a small thing, patients can initiate communication with their care overseeing, who are only a phone call and a direct audiovisual observation away. By taking control of their situation, patients can ameliorate or ward off complications, and avoid those dreaded emergency room visits or return hospital visits, and Medicare can save a passel of money.

Most of what I know about this subject stems from chapter I wrote in Innovation-Driven Health Care: 34 Key Concepts for Transformation (Jones and Bartlett, 2007), which in turn, was based on interviews with Randall Moore, MD, CEO of American Telecare, and Erin Denholm, MSN, CEO of Centura Health. In a 6 month study at Centura using the audiovisual device, re-hospitalization costs dropped 73% after paying for the telehealth program, and home care nursing visits dropped from 11 per episode with telehealth to 3.5 visits. This study is just one of many and shows the power of a combined high-tech/high touch approach.

In worshipping power of computer technologies,

for our mind we make unnecessary apologies.

We tend to forget a perfectly sound mind,

accompanies most diseases of mankind,

The mind can overrule and overcome most pathologies.

Friday, April 10, 2009

political language - Meaningful Health Reform: The Meaning of "Meaningful"

”Starting in 2011, physicians can receive extra Medicare payments for the ‘meaningful use’ of a ‘certified’ EHR that can exchange data with other parts of the health care system.”

“Thus, physicians demonstrating meaningful use starting in 2011 could collect $44.000 over 5 years.”

“Meaningful use of EHRs in 2011 will earn hospitals a one-time bonus payment of $2 billion plus an add-one , which phase out over a 4-year period, would apply to every admission up to a (yet-to-be designated) maximum amount.”

“Much will depend on the federal government’s skill in defining two critical terms: ‘certified EHR’ and meaningful use.”

David Blumenthal, MD, M.P.P, Adviser to the Presidental Campaign of Barack Obama, Director of the Institute for Health Policy, Massachusetts General Hospital –Partners Healthcare System and Harvard Medical School, National Coordinator of Health Information Technology, “Stimulating the Adoption of Health Information Technology,” New England Journal of Medicine, April 9, 2009

I shall begin by distinguishing between Health Care and Healthcarereformanship.

Health care concerns serious matters of maintaining health, preventing disease, treating illness, speeding, and coordinating convalescence.

Healthcarereformanship, on the other hand, is a politically-based word game. Reformers use words to press the cause for“meaningful reform.”

Meaning of Meaningful

“Meaningful,” of course, is an adjective meaning “ full of meaning, significance, and purpose, as in a meaningful wink, or a meaningful choice.” Progressive politicians and think-tank wonks, gurus, and analysts favor “meaningful” because it shows their work has overriding social significance.

Indeed, its significance is well above the common fray and mundane, even plebian efforts of caregivers or profiteering health care suppliers on the ground, whose work tends to be “meaningless.” – meaningless because it focuses on self-interest and personal and business survival rather than the interests of the public-at-large.

Meaning of “Meaningful Reform”

On the other nad, all ‘meaningful reform” efforts are directed towards the “common good,” rather than toward selfish individualism, free choice, innovative entrepreneurmanship, or gasp! profit.

What’s Required for “Meaningful Reform”

According to the Robert Wood Johnson Foundation, a meaningful think-tank, “meaningful health reform will require a comprehensive approach to extend coverage, improve quality, and emphasize prevention.” Needless to say, “meaningful reform” is a key phrase for Obama officials.

Before his untimely and forced departure as a candidate as head of HHS, former senator Tom Daschle repeatedly used “meaningful reform” as a political catch phrase. Now, in the recently enacted stimulus bill –the American Recovery and Reinvestment Act of 2009 (ARRA) - “meaningful” has become an official part of the language in the $19 billion all-out-push to promote the adoption and use of health information technology (HIT) and especially of electronic health records (EHRs).

This use of “meaningful” reflects the shared and serious (I have never know “meaningful reform” advocate to show the slightest glimmer of humor) of the Obama administration, Congress and many health experts that information systems are essential for improving the health and health care of Americans.

In pushing for HIT –collectively called HITECH in the stimulus package - meaningful reformers are going full-steam ahead in spite of these obstacles As noted by David Blumenthal, President Obama's Natinal Coordinator of HIT,

“However, proponents of HIT expansion face substantial problems. Few U.S. doctors or hospitals – perhaps 17% and 10% respectively – have even basic EHRs, and there are significant barriers to their adoption and sue; their substantial cost, he perceived lack of financial return from investing in them, the technical and logistic challenges involving in installing, maintaining, and updating them, and consumes’ and physicians’ about the privacy and security of electronic health information. HITECH addresses these obstacles head on, but huge challenges await efforts to implement the law and fulfill Presient BRACK Obama’s promise that every American will have the benefit of an EHR by 2014.”

Don't Sweat The Details

Never mind that most EHRs have proven to dysfunctional and counterproductive. Never mind that 30% of those installed to date have been dismantled and discarded. It's still full-steam ahead.

“Meaningful reform” is, after all, meaningful, i.e, noble, cause and requires persistence, bonuses for adopters, financial punishment of non-adopters. What’s good for the government goose is good for Americans, and nothing should stand in the way.

Should physicians and hospitals continue to resist the intrinsic self-evident goodness and ignore finacial rewards of HIT and EHRs, reformers can always resort to the artful use of language, particularly to the use of the word “meaningful “ in concert with other health reform buzz words.

Deploying “Meaningful Reform” through Words

Nearly 40 years ago, a member of the U.S. Department of Agriculture first described “buzz words.” These words can be used to advance bureaucratic or political causes. The words attractive, abstractive, and sometimes meaningful. In the case of health care reform, these words are best used in combination with other reform words. To use these words effectively, arrange them in three columns – two qualifying adjectives and an abstract noun. If anyone should ask a question about the value of reform, drop them into discussion in any combination.
1 2 3
meaningful managed care
universal supportive mandates
total health coordinator
Primary integrated analyses
comprehensive ambulatory centers
national resource services
coordinated pilot priorities
quality involvement projects
interdependent paramedical planning
interdisciplinary extended reform
preventive effectiveness indicators
systematized digital utilization
feasible electronic effectiveness
unmet scientific implementations
community evidence-based objectives
centralized algorithmic systems
longterm comparative parameters

Using these words in any combinations, the noble cause for “meaningful reform” will be advanced and will prevail.


Health care reformers insist they seek to do something “meaningful,”

something noble and socially significant yet with serious political pull.

something that is system-wide, universal, coordinated and comprehensive,

something that puts them on the political offense but is socially inoffensive.

something which they can control and manage and get credit in full

Thursday, April 9, 2009

Safety, nurses-Hairpiece

Last week, while I was in the hospital with a myocardial infarction, my wife, a nurse, came to visit. Her former nursing instructor accompanied her.

While there, a hospital nurse came to change the bandage covering my femoral cut-down site, where the cardiologist had inserted a catheter and snaked it up my aorta to study the anatomy of my coronary arteries.

The nurse wore no cap, and her long hair hung loosely, blowing freely in the air-conditioned breeze and nearly touching the still raw wound. As she treated my wound, her cell phone rang, and she brought it up to her ear in her still-gloved hand to answer the call, then returned to tend my wound. Oh well, in one ear and into another era.

This sequence of events, which I had witnessed before but thought nothing of it, shocked my aseptic visitors, who had been brought up in an era in which nurses wore caps over hair drawn back in a bun to avoid bacterial transmission. Now I have no idea whether my nurse’s unfettered, flowing locks bore bacteria. I do know, of course, that operating room nurses wear caps to contain and cover their hair. The same goes for nurses doing procedures.

In any event, my wife said, “You’ve got to do a blog on this.” Naturally my first move was to google nurses’ hair and infection. Most of the pieces that popped up concerned hair as a potential source of infection, with staph aureus and fungi, and pointed out good nursing technique dictated keeping one’s hair covered. I also read that nurses’ watches may carry bacteria. No mention was made of cell phones. That may because ubiquitous cell phones are a new fangled development, too modern to mention and too wireless to be a possible source of infection.

I’ve read many hospitals know swab patient’s nasal passages to see if they are carriers of methicillin resistant staphylococcus aureus (MRSA.

Why not do a systematic study based on swabs of nurses’ hair? Hair, after all, is just an extension of the skin, and skin in notorious source of bacterial infection, and as we all know, washing one’s hands has become a fetish as a means of preventing hospital acquired infection.

It might even be simpler to require nurses to wear caps, or to wear their hair pulled back in a bun. But that might offend nurses. The Bible says, “If a woman has long hair, it is a glory to her.” Modern nurses’ unions might rare up and use language that would either curl your hair or make it stand on end.

I end with a verse from Hamlet. If you read Shakespeare , you will generally find there’s nothing new in the world, under the sun, or under a nurse’s cap.

I could a tale unfold whose lightest word

Would harrow up thy soul, freeze thy young blood,

Make thy two eyes , like stars, start from their spheres,

Thy knotted and combined locks to part,

And each partial hair to stand on end,

Like quills from the fretful porcupine

There, dear wife, is your blog.

patient views - The Doctor-Patient Has the Floor

As I lay flat on my back on the mobile hospital bed, after the cath and the stent, tethered by intravenous fluid lines, health monitoring leads, and devilish device called Femstop, a pressure–driven plastic globe pressing down on my femoral cut- down site to prevent a hematoma, a quote from a talk by Alistair Cooke, “The Patient Has the Floor,” delivered at the Mayo Clinic in 1965, came to mind.

Cooke said. in part,

“I wish to talk of the fears of some statesman, lawyer, or other grandee who never appears before a doctor except to have his chest tapped, his knees jerked, his tongue depressed, his innards photographed, his rectum protoscoped, and his juices filtered, measured and pronounced upon. It is, though you may not know it a permanently humiliating relationship: I mean the relationship between doctors and the rest of mankind. And it is because most people do not care to bring it up in public that I believe it might be useful for me to do so.”

Hospital Experiences and Impressions

Well, I thought it might be useful for me to talk about my experience and impressions as a doctor of being a doctor-patient in a modern hospital. Certain professional courtesies go with being a doctor, and I appreciate the kindnesses extended to me. I became aware that knowing precisely what was going on facilitates being a patient.

I would not describe the relationship between myself and other doctors and the hospital as “humiliating “ but rather as mix of helplessness, appreciation, and curiosity.

I looked upon my hospitalization as an opportunity to study what makes the modern hospital tick, to talk to caregivers about their hopes and anxieties, and to see how my perceptions of the system matched realities. The best way to do this is tell the tale of my heart attack.

The Pain

Eight days ago, substernal pressure discomforted me. I thought I had heartburn, so-called GERD (gastroesopheal reflux disease). That ought to have been a clue to my misdiagnosis. One rarely has GERD for the first time at my age 75. In any event, the discomfort, a dull ache, 3 or 10 on a scale of 10, didn't respond to Prisolec and Maalox – another clue, he who treats himself has a fool for a doctor.

Anyway, I have no personal or family history of health disease. But I had clues of coronary precursors – an untreated blood pressure of 140-150/85-90 and a recent gout attack. but my lipid panel – total cholesterol 141, LDL 69, HDL 47 and triglyerides 120 – was clean as a whistle and gave no indications of an impending occlusion. Though I considered a heart attack, I dismissed and denied the possibility.

The pain came and went, was worse when I lay down, better when I sat up. It didn’t radiate, and wasn’t accompanied by sweating, nausea, dizziness, shortness of breath, or pain on exertion. It persisted for three days, and the third night, it prevented sleep. On the morning of day of day 4, I felt unwell, and my wife drove me five miles to an emergency clinic five miles away, where my general practitioner had directed me to go.

The Bottom-Up Functioning of the System

The ER visit began my bottom-up view of the health system. I sometimes write about the health system being viewed from the top-down, i.e., from Washington, and not from the bottom-up, from the grassroots. To me the most useful solutions to health care usually emanate from the clinical trenches, not from federal bureaucratic back benches.

The ER physician, an athletic-looking, alert forty five male, quizzed me briefly, did an electrocardiogram, and drew blood. Ten minutes later, he informed me I had suffered an myocardial infarction, had classic ECG and enzyme changes, gave me nitroglycerin to relieve pain, and ordered an ambulance to transport me to a academic medical center 45 minutes away for a heart catheterization . Ours was a no-nonsense conversation, and with me being a doctor, no explanation was needed.

The Ambulance Ride

On the way in, I interrogated the emergency medical technician (EMT)... He was 40 years old, father of three, and a full-time firefighter who worked 16 hours a week at an EMR to make ends meet. He told me heart attack riders like me were more frequent in the spring, and he was riding side saddle in case my pain worsened or I arrested.

He gave me my first insight into the new technologies. Technology is said to account for 70% of health care inflation, and it comes in all forms, large and small. He said a new device had come onto the market. The device could be placed under and on top of the patient and delivered chest compression as rates of up to 100 beats a minute. This device, and the more pervasive presence of external defibrillations in public places, in his experience, had increased immediate survival rates after arrest to about 40% compared to 5% in the past – not a bad investment – considering the alternatives.

The Cath Lab

Upon arrival at the hospital, I was whisked directly into the cath lab – large room bristling with overhead imaging equipment, tables strewn with procedural gear, and three or four nurses and technicians bustling about getting ready for the cath.

I was informed I was one of the 12 “caths” for the day (about 4 million cardiac catheterizations, inpatient and outpatient, diagnostic and interventional, are performed each year in the U.S., and roughly 1.5 million of these result in “stents” to bypass blockages. Other developed countries do about one-fourth as many caths as the U.S. Whether we do too many, or the rest too few is upon to debate.

About 30 minutes after I arrived it was done – a right femoral artery cut-down and placement of a drug-coated stent in my circumflex artery. The typical patient, I was told. received 1.7 stents per cath. I was awake during the procedure, heard some chattering between the cardiologist and his crew during the procedure, and experienced little pain other than a lidocaine stick before the femoral artery cut-down. After the procedure, the cardiologist explained precisely what had been done and what to expect.

Off to the Intensive Care Unit and then to the General Cardiac Ward

Then it was off to the ICU where my rhythm and vital signs were constantly monitored. I was told to stay flat, not to raise my head, not to cross my legs, but to wiggle my toes. A parade of cardiologists, cardiology fellows, nurses, residents, nurse assistants, a nurse practitioner, medical technicians, and others followed.

Each was unfailingly courteous and scrupulous about reading my wrist identification band. Each asked I had pain (pain estimates are now regarded as a vital sign), most listened to my chest, and felt my ankle pulses (important when you’ve had a femoral cut down). I had a Phillips heart wireless monitoring device in my gown pocket, which displayed my heart rhythms at the nursing desk.

Who is Interviewing Whom

Many people came to interview me and check me over, but it often ended by me interviewing and checking them over. I made a point of asking each and everyone their name, where they were from, who they came to be health professionals, and how they viewed the system.

When it became evident my vital signs had stabilized, I was sent to the general cardiology ward, where I had the luxury of ordering my own food from a menu. The assortment of choices was impressive, but because I was on a heart diet, no salt or sugar was allowed, and the food tasted flat.

The State of Mind of Health Care Personnel

Most nurses were pleased and preoccupied with their work and didn’t complain about the terms of their employment. A few groused about the ceaseless paperwork and endless requirements to record and duplicate the same data in multiple locations. One nurse unfurled a three foot long spread sheet with multiple columns like a paper accordion. Some of the older nurses expressed skepticism about chances for health reform under the Obama administration and foresaw a flurry of more regulations.
They may have a point. I’ve read that 25% of hospital costs are devoted to meeting federal regulations. The volume of paperwork to meet regulations is certain to increase with programs to meet all quality indictors and to show irrefutable evidence that safety standards have been met.

Among doctors, doubt and apprehension about present and future workings of the system were more prevalent. The younger doctors in training openly worried about paying off $200,000 educational debts, and many candidly said they would not enter private practice as general internists and instead would choose work as hospitalists, proceduralists, emergency room doctors, with regular hours and predictable income. A friend of mine, Dr. Paul Grundy, Director of Health Care Transformation at IBM. divides the doctor world into “comprehensivenists” and “partialists.” It’s my impression in the academic setting, the “partialists” are winning. Specialists, by the way, don't appreciate being dubbed as partialists, which they take to mean they aren't real doctors.

EMRs and Data Systems

Two of the younger doctors had received part of their training at the VA. Although they found the VA’s EMR system functional and useful, they doubted if it would work in small practices. But the VA and other big health systems like Kaiser, Mayo, and the Cleveland Clinic have shown EMRs work in big systems. New York-Presbyterian Hospital centers and clinics, which provide about 20% of the health care in New York City, have just announced it will offer consumer-controlled health records for patients.

Specialist Frustrations with Paperwork

One of the cardiologists, a nationally prominent figure, commented to me, “They’re always talking about primary care doctors being unhappy. Hell, I’m unhappy too. Most paperwork in the name of quality wastes my time. The paperwork kills satisfaction and hampers productivity.” He went on, “Documenting isn’t the same as doctoring. We’re sometimes asked to be on standby if a president is in town on a weekend. The next time that happens, I‘ll tell them, ‘No, I’m a government employee, and I don’t work weekends.” He ended by say, “I would never recommend medicine as a career for my kids.”

A Grateful Doctor-Patient

On the whole, I am grateful for the care I received and for the clear explanations of what to expect. From a personal point of view, the money invested in new heart-sparing and life-saving technologies in the cardiac sphere was worth it, at least to me, and quality of care and safety of the hospital were superb.

The dangers of hospitalization in the U.S. may be overstated. The rate of adverse events in U.S. hospitals in only half that of England, Australia, and New England. I received a daily dose of subcutaneous heparin, which I was told, was to prevent pulmonary embolism, the number one cause of sudden death in hospitals. A nurse informed me subcutaneous heparin was part of hospitals efforts to follow The Institute of Healthcare Improvement campaign to save 100,000 lives in hospitals and also to avoid Medicare nonpayment for complications of pulmonary embolism.

Home Again

Six days after my infarct diagnosis, I’m now at home on the five medications routinely given to stent patients (a statin, beta blocker, aspirin, plavix, and blood pressure lowerer and rhythm suppressor) and have been assigned to a cardiac rehab unit. Sometimes in our efforts to identify villains in the health system, we point fingers at the pharmaceutical industry for profiteering and marketing activities, while forgetting the industry brings live-saving technologies to the table, which in the case of heart disease, have tremendous. Preventive as well as therapeutic elements.

At this point, I'm happy with the system, but am fully cognizant that as a physician I enjoy certain courtesies, privileges, and advantages , due in part to my knowledge of disease and the system.

Conclusion – Facing Global and Local Realities – Real-time

Nothing brings you closer to reality than being a physician. As a 75 year old physician who is just recovering from a heart attack, who has just spent five days as a heart patient in an academic heart center, and who is a frequent commentator on health care reform, I’m acutely aware of real-time realities.

When it comes to realities, I believe in thinking globally, acting locally, or, in health care lexicon, I appreciate top-down policies, but relish bottom-up innovations. America is an overwhelmingly bottom-up society, but it must act in concert with top-down federal policies.

Perhaps no one realize this more than President Obama, who has this to say in statement at a White House forum on March 6, 2009,

“This time is different because the call for reform is coming from the bottom up, from all across the spectrum — from doctors, nurses and patients, unions and businesses, hospitals, health care providers and community groups, as well as state and local officials.”

At the same time, it's Obama vision that health reform will help us cover the uninsured while cutting costs to government and corporations, and while ameliorating our long-run fiscal crisis and making businesses more globally competitive.

As much as I applaud his vision, I’m not sure it’s possible to expand coverage while reducing costs for following reasons, which were reinforced by my recent 5-day hospital stay.

• We are a technological nation that looks as the body as a machine – when plumbing clogs up, we unplug it or bypass it; when the joints cease working, we replace them; when the face of the machine sags, we lift it up.

• We are an impatient, even a spoiled nation, brimming with 78 million baby boomers becoming Medicare eligible in 2011, with a population that believes we deserve quick access to modern technology’s wonders.

• We believe in choice, freedom, and pursuit of longevity, and maybe sometimes in eternal youth, or at least the appearance of it.

• We believe in equal opportunity, but not necessarily in equal results, making it difficult to create homogeneous federal health policies that cover everyone equally in our multicultural, heterogeneous vast continental nation in which one of five Americans is a recent immigrant or a close relative of one...

• We believe in experts, in specialists in command of various organ systems and specific disease, even though this belief engenders inefficiencies, high costs, and a fragmented delivery system.

• As much as we nostalgically applaud family physicians, our Medicare, Medicaid, and the Reimbursement Update Committees (RUC) do not reward primary care doctors sufficiently to attract medical students to primary care specialties and to create a comprehensive, coordinated health system.

• The government regulatory and payment pressures on hospitals – meeting each and every quality indicator, avoiding a host of common complications for which Medicare will not pay, meeting system-wide safety standards - are enormous and create an environment in which documenting becomes more important than doctoring.

America still believes in private health care, which pays 68% of the nation’s health bill versus 32% paid by government (Medicare, Medicaid, Veterans Affairs, Department of Defense health services). I thought of this in my hospital bed, when my two successive roommates were a 28 year old and 46 year males being evaluated for heart disease. While Medicare is the biggest single payer and the Sheriff of the System who sets the pace for payment and regulatory policies, Medicare does not yet control what doctors order or what tests they perform.

Federal regulators may yet do what foreign health regulators do now:

• Reduce payments to doctors. other skilled health care providers, and hospitals.As American-trained doctors became scarce, more foreign trained doctors and physician-extenders will be needed.

• Limit medical technology. In Canada, patients have to wait for months for MRIs, so those who can come to America for immediate diagnostic services. With a nearby MRI, the tragedy of Natasha Richardson may not have occurred.

• Ration available treatment to fit the federal budget and comparative effectiveness requirements. The universal digitized health data may well be used to justify non-treatment on a cost-benefit basis.

We are not there yet.

I shall end by simply saying from my vantage point, admittedly a biased one, we have a superb medical system.