Wednesday, September 17, 2014

Quote to Note: Who Says America Is Not a Compassionate Nation?

"The non-surprise revealed here is that ObamaCare turns out to be just another subsidy program, throwing money at health care. In economics, you can't subsidize everybody but we're trying: 50 million Americans get help from Medicare, 65 million from Medicaid, nine million from the Department of Veterans Affairs, seven million (and counting) from ObamaCare, and a whopping 149 million from the giant tax handout for employer-provided health insurance."

Holman Jenkins, “ObamaCare and American Resurgence,” Wall Street Journal, September 16, 2014

P.S. This means 280 Americans out of our 315 million population or 88.9% receive health care subsidies in one form or another from the federal government.
Population Health Management Era Arrives

The Affordable Care Act, as well as changes in how employers and insurance companies address health care, will try to change these disincentives (individual fee-for-service overuse) and encourage health-care providers to manage populations. A population may include a company’s employees and their families, a union’s members, a group of individuals who purchase a like product on the insurance exchange, or a group of Medicare or Medicaid beneficiaries.

Kenneth Davis, MD, CEO and president of Mount Sinai Health System in New York City, “Hospital Mergers Can Lower Costs and Improve Medical Care," Wall Street Journal, September 16, 2014

We are now in the Population Health Management Era.

The big data revolution made it inevitable. You can now connect instantly connect everything with everybody. You can calculate outcomes for different conditions for different populations. You can measure the overall health of different populations in different states and regions under different health systems. You can compare results. You can evaluate the impact of health reform. Above all, you can “manage” care for large groups of people rather than deal with individual problems. Managing populations and their health is said to be easier, less costly, and more efficient than directing and controlling health of individuals.

What’s not to like? Population health management is rational. It is objective. It is controllable. It lends itself to large organizations, like hospitals, who can now coordinate care, get hospital departments and specialists to work together with caregivers, measure health care improvements.

Besides, as Doctor Davis says, “Physicians participating in larger networks will be able to learn more about the best treatments because they will have larger populations from which to draw conclusions.. one can apply supercomputer resources to mine the data and create predictive models of disease….help individuals better understand their risk of illness, and customize preventive or treatment strategy.”


It is a very persuasive and seductive argument, but it has downsides – loss of personal privacy, narrowing of personal choices, erosion of physician autonomies, and an over reliance on data and actions of policy makers and health executives rather than clinical judgments of patients and their physicians.

Carrying out population health management programs is expensive. It requires major technology investments, faith that electronic medical record system will bring efficiency rather than impediments, a belief that various computer system will flawlessly communicate with one another, and “an army of care coordinators to serve as a backbone of an integrated care team.”

Patients and physicians are not yet convinced that population health management, as envisioned by the Obama administratio and large health sysems is the way to go. Four and one-half years after ObamaCare’s enactment, the public consistently opposes the health law by 10 % to 15% margins. And a just released survey of 20,000 U.S. physicians indicates only 24% say electronic medical records have improved efficiency while 46% say they distract from patient care, and only 25% give the Affordable Care Act an A or B grade while 46% give it a D or an F.

Tuesday, September 16, 2014

ObamaCare and All That Jazz

All That Jazz

Song, Chicago, a stage play, 1975

Here, “All that jazz”refers to the health law bureaucracy and its intricate rhythms. When asked to explain jazz rhythms, Lois (Satchmo) Armstrong (1900-1971) replied, “Man, it you have to ask you’ll never know.”

What follows is daily commentary of the day so you will know.

The Political Gift That Keeps on Giving

Scott Rasmassen, “Health Law is Obama’s Gift to Republicans for 2013,” Real Clear Politics, September 15. Rasmassen explains people who seek to renew health plans will feel burned by higher rates. And in 2017, government will no longer cover costs of insurers’ losses. Ergo, insurers will automatically raise rates to cover expected losses. The higher rates, then not government guaranteed, will be announced in the summer of 2016, just in time to damage the Democratic presidential candidate. Off-setting this will be the 13 million or so of the uninsured receiving subsidies.

Caveat Emptor

Robert Pear “Health Law Has Caveat in Renewal of Coverage, “ New York Times, September 15, 2014. In 2015, consumers will receive notices their policies have been renewed. The notices will contain facts on their new monthly premiums, but they will not be told about new subsidies, new co-payments, new co-insurances, or new deductibles based income. Why not? Because of technological flaws in the, the government does not know. Consumers, especially those 8 million or so who enrolled in 2013 and 2014, on health exchanges will have to revisit to find out. They will not be happy about higher premiums or revisiting with all its bureaucratic jazz.

• More Health Plan Cancellations

Investors Business Daily (IBD). IBD, no friend of Obama and his health law, has just run this headline in a September 14 editorial “Another ObamaCare Cancellation Wave Approaches.” IBD notes 250,000 Virginians have learned their health plans have been cancelled if they bought their policies before ObamaCare was enacted on March 23, 2010. According to Kaiser Health News, other consumers in other states received the same notices. These cancellations, opines IBD, will be “fresh reminders of the extraordinarily high costs of the ‘Affordable Care Act,’” which it implies, is not so “affordable” after all.

Notices to Immigrants and Those with Unverified Incomes

• Louise Radnodsky, “Tens of Thousands of Immigrants May Lose Coverage” Wall Street Journal, September 15, 2014. 115,000 immigrants could loss coverage because of missing September 15 deadline to prove legal residence. In addition, federal officials will send notices tp 279,000 whose income cannot be verified but the feds will give until September 39 to submit further verification. Both of these problems are said to be due to technological glitches in website whose backend is still being fixed. It must comfort Americans to know that Big Brother is still watching even though his computer lenses are sometimes flawed and foggy.

Monday, September 15, 2014

Apple Watch and Survival of the Fittest

The expression used by Mr. Herbert Spencer 0f the Survival of the Fittest is more accurate.

Charles Darwin, The Origin of the Species

Apple has done it again.

It has come up with a product that fits the Apple image of innovation to a T.

It has designed something that the public didn’t know it could do without and will not do without in the near future.

It is the Apple Watch, the latest in watch and wear gear.

It is beautifully designed.

It fits the fashion world. It is a fashion plate.

It is highly visible. Wear it on your wrist for all to see, and they will notice.

It fits the fitness mood of the times. if you are young or old, stay fit, you will live longer and feel better if you are fit.

It fits the movement towards wellness.There are already 20 million, soon to be 30 million people out there, running, walking, bending, stretching and moving about in quest of personal health and fitness.

Just look at your watch, and you will know where you fit into the movement.

It fits into the work of other major IT companies and health care companies – among others, Samsung, Google, Microsoft. Mayo, Kaiser.

It is fit to be tied into and can be integrated into other health and fitness apps that measure blood pressure, cholesterol, other lipids, weight , height, response to exercise, and all that other data on electronic health records.

It fits all generations – young and old – who believe they can grow younger with exercise despite age or chronic disease.

It fits all understandings, things anybody can understand. Monitoring the heart makes sense. It makes sense to keep track of your heart rate and rhythm, seeing how many steps you take each day, being reminded to stand and get off your chair, being encouraged to take brisk walks, and above all, to integrating all that information with data currently available on most electronic health records.

The Apple Watch is more than a passing fantasy to me. Thirty years ago, I helped develop the software for the HQ, the Health Quotient, a measure of health and wellness, with a normal range of 80 to 120. If your HQ fell below 80, you could always take steps to improve your HQ. If your HQ was above 120, you were doing something right. In both cases, you knew where you stacked up against your peers.

The Apple Watch is ideally suited to display similar useful information, even if one has to recharge the batteries every night. It's your life you're recharging.

So hats off to the Apple innovators.

Here’s to the crazy ones, the misfits.

The rebels. The trouble makers.

The round pegs in the square holes.

The ones who see things differently.

They’re not fond of rules and

They have no respect for the status quo.

You can quote them, disagree with them, glorify, or vilify them.

But the only thing you can’t do

Is ignore them.

Because they change things.

They push the human race forward.

And while some may see them as

The crazy ones, we see genius

Because the people who are

Crazy enough to think

They can change the world.

Are the ones who do.”

Watch out. The Apple Watch is in.

Sunday, September 14, 2014

Questions to Ask about Health Reform

What can I contribute?

Peter F. Drucker (1909-2005), The Effective Executive

A question not to be asked is a question not to be answered.

Robert Southey (1774-1843), Poet Laureate of England, The Doctor XII

Are you asking the right questions?

The management guru and social historian, Peter F. Drucker, was famous for saying effectiveness is not about doing the right thing but finding the right thing to do by asking the right questions.

Drucker said effectiveness was all about asking: What can I contribute?

• For patients and the public at large, the contribution questions might be.

How can I improve my health? Literally, what steps should I take? 10,000 walking steps a day? What foods should I eat? How much sleep should I get f? What weight should I seek to maintain? How do I lose weight? What bad habits should I avoid? What measures of my health should I seek so I can improve upon them?

• For physicians, the questions might be.

How can I best improve the health of my patients? By telling them that improving their health is up to them, not to me? How can I communicate with them better? By spending more time with them? By making access to me more convenient and more open? By sharing with them the limitations and risks and options of medical procedures? Is it socially and morally responsible for me to opt out of government and insurance programs in order to provide direct access and more time with me by becoming an independent direct pay physician? Should speak out against counter-productive government reforms?

As the midterms grow near, and as we as a nation ponder whether to keep ObamaCare or to change it, should I encourage patients and colleagues to be more open and vocal about asking these questions.

• After six years, have results of the health reform law meet its rhetorical promises?

• Have your health care premiums gone up or down?

• Is your health care more affordable than it was in 2010?

• Do you feel more protected against health care debt than in 2010?

• Have you been able to keep your doctor or your health plan?

• Are you experiencing difficulties in finding a primary care doctor?

• Do you have more or less confidence in the government’s ability to manage your health or protect you from medical debt?

• Who should be primarily responsible for maintaining your health – the government or yourself?

• Should government protect citizens against catastrophic health care debts?

• Do you think you should be able to choose your own health plan – and willingly pay for what you think you need?

• Do you believe that you ought to be morally obligated for paying for health care subsidies for those who do not have the means to pay for their own health care?

• Do you believe that those who do not take care of their health should pay the same premiums as more responsible citizens?

• Should health insurance be more like auto insurance – competitive shopping across state lines, high deductibles, based one one’s personal driving records?

• Do you believe health insurers should be forced to accept all comers and not ask questions about health status, even though these verboten things will raise health premiums for you and others?

. As a physician, do you feel the health reform law has improved your effectiveness as a doctor or has made your patients healthier?

Saturday, September 13, 2014

Joan Rivers and the Future of Ambulatory Surgical Care Centers

Yesterday is history, tomorrow is a mystery, today is God's gift, that's why we call it the present.

Joan Rivers (1933-2014)

When comedy legend Joan Rivers died suddenly and unexpectedly at age 81 of a cardiac arrest at a New York City ambulatory care center specializing inendoscopy, it may have set in motion a series of events that will threaten free-standing physician-owned ambulatory surgery centers.

There are now 5300 of these centers in the U.S., and their numbers have been growing as much as 20% each year. The centers performed 23 million surgical procedures last year, and deaths were less than one in a million. Usually complications occur in obese patients, patients with prior cardiac surgery. those with history of stroke, or in the frail elderly. None of which existed in Joan Rivers who was active until the very end.

The Yorkville endoscopy center, where Joan suffered her cardiac arrest, has been open since February 2013 and had performed 18,000 procedures. It hasreferred only 4 patients to a nearby hospital.n The center said Ms. Rivers was pre-screened by a gastroenterologist, an anesthesiologist, and a nurse. The center had 4 board-certified anesthesiologist on duty and said it was prepared for just such an emergency.

The reasons these centers' numbers are growing are crystal clear: the centers are much more efficient than hospital surgical units, surgeons can create their own teams, use their own tools, schedule their own cases, deliver care more efficiently for themselves and patients, save as much a 50% for the health system, patients, insurers, and self-funded companies, and make more money and get a return on their investment.

Some surgical care centers, like the Oklahoma Surgery Center, have statistics showing they can perform ambulatory surgeries more safely than hospitals, which are prone to be havens for hospital-acquired infections.

The death of Joan Tivers of 81 of a cardiac arrest at a site removed from a hospital, throws the merits of ambulatory surgery centers into doubt. The doubts center on the myth that the endoscopy center was ill-prepared for the arrest and had no resuscitation plan. n the Rivers case, there are also doubts that the surgeon who was to remove a lesion on Ms. Rivers vocal cord was not certified to do so, that she experienced vocal cord spasm, and that she may have received too much of an anesthesia or drug to prepare her for the excision.

No one knows at this point precisely what occurred, but the suspicion exists that this was an unnecessary death.

Certainly this tragic event will play into hospital strategies to label doctor-owned independent ambulatory centers as unsafe, and it may well lead into more extensive and expensive certifications and regulations to avoid future tragedies. It may slow the relentless tide towards decentralization of the health system. And it may cost the health system money, for costs for procedures done in a hospital are inevitably more than those in free-standing units, whose owners do not have to bear the burden of paying for non-profitable services like emergency rooms, burn units, and mental care and psychiatric units.