Friday, February 29, 2008

Pay for Performance - Short Take on Pay-for-Performance, Protocols, Evidence-Based Medicine

I keep six honest serving men
(They taught me all I knew)
Their names are What and Why and When
And How and Where and Who.

Rudyard Kipling, 1875-1936

What – Use of pay for performance, clinical protocols, evidence-based data, and value-based purchasing to meet management and outcome targets as means of judging and paying doctors for quality and minimizing practice variation.

Why - To establish criteria for clinical quality, standardize care, reduce practice variations, increase clinical outcomes, and decrease costs by using data to rationalize, manage, improve care, and cut costs by applying quality indicators to achieve managed care objectives – better care with lower costs.

When - These methods have been applied off and on over last ten years, with P4P being pushed with great vigor in last five years, particularly in hospital settings.

How - Both federal health agencies and health plans are advocating these various programs, ostensibly to increase quality, safety and transparency, reduce costs, and to better manage care.

Where – In most sections of country and especially wherever health plans are powerful, in states such as Minnesota, Wisconsin, California, and Massachusetts, but basically in all sections of the U.S.

Who - Health plan managers, Medicare and Medicaid officials, and executives in many health systems. Physicians resist because results and cost savings have been negative, modest, or not worth the expense. Complying represents a new practice burden, and clinicians fear data will be used against them. They are reluctant to accept the premise that third parties can judge clinical performance. Doctors assert personal and individual relationships between doctors and patients cannot be rated by retrospective data alone, and clinical decisions are difficult to judge without being present at the point of care. There are basically two schools of thought: P4P and related methods: 1) provide data to allow doctors to do well by doing good; 2) represent the practice of medicine bynother names.

Thursday, February 28, 2008

Medicare - A Short Take on Medicare Cutbacks

I keep six honest serving men
(They taught me all I knew)
Their names are What and Why and When
And How and Where and Who.

Rudyard Kipling, 1865-1936

What - Medicare cutbacks

Why - Medicare now accounts for ¼ of all federal spending. Health care spending is projected to double to $4.3 trillion by 2017, led by babyboomers, who will start turning 65 in 2011, and by Medicare, expected to increase to $844 billion, by 2017, and Medicaid estimated to increase to $717 billion by 2017. Health care will make up 20% of GNP by 2017. If unchecked, Medicare could devour most of the federal budget by2030. Something, say federal officials, will have to be done to ward off rates of Medicare cost increases.

- Medicare cuts are now underway, with physician payments set to be slashed 10.6% by June, another 15% in 2009, by refusing to pay for specialty hospital care, by declining to reimburse hospitals for “never, never” complications, by cuts in oncology and anti-anemia drugs, and by reductions in common ticket high tech surgical and imaging procedures, brand name drugs, and systematic across the boards decreases in rate of increases for hospital inpatient, skilled nursing facilities, hospital outpatient, teaching hospitals, inpatient rehab facilities, home health care, hospices, and long-term care hospitals, Medicaid and uninsured cuts with cuts and freezes in many states.

How – This is largely a work in progress – a complex political, legislative, lobbying, and budgetary battle with uncertain outcomes.

- In states where re-elections hinge during 2008 and in Washington, D.C, depending on outcome of presidential and Congressional elections.

Who – Depends on success of Mike Leavitt, Secretary of Health and Human Services, other Medicare and budget officials in cutback initiatives and in programs promoting EMRs, other IT programs, price and quality (P4P), and transparency and on who gets elected. Democrats are more likely to resist Medicare cuts.

Wednesday, February 27, 2008

Eletronic Medical Records - Short Take on Electronic Medical Records and Patient Health Records

I keep six honest serving men
(They taught me all I knew)
Their names are What and Why and When
And How and Where and Who

Rudyard Kipling, 1865-1936

What - A nationwide system of interactive and interoperative Electronic Medical (Health) Records in Physician Offices and Personal Health Records owned by Patients.

Why – To promote practice business efficiencies, to avoid duplications, to promote safety, e.g., inadvertent drug interactions, and to track quality improvement...

When – Unknown, work in progress. Uptake by physicians in 10-20 percent range and among patients in 5 to 10 range despite five years or so of active promotion and electronic records development.

How - .Obstacles have been cost, practice disruption, loss of revenues for first six months, no tangible return on investment, suspicions EMRs are for health plans benefits rather than for benefit of physicians, time and expense of entering data, lack of infrastructure in small or solo practices, little evidence of improved quality, privacy concerns, and fears that payers will use data for surveillance, punishment, and exclusion purposes (e-Big Brother Syndrome). Implementation will probably require positive financial incentives through low cost loans, payments for signing up patients, carrot and stick approaches with P-4-P rewards and punishments, or payer mandates.

Where - Mostly in larger practices and in integrated health organizations with resources and infrastructure. Also being promoted in states like California, Minnesota, Massachusetts, and others with number of large practice or academic groups. American Academy of Family Practice also is EMR advocate.

Who - Physician leaders, young physicians, Michael Leavitt, had of CMS, who advocates mandated EMRs, leaders and members of organizations like HIMSS (Health Information and Systems Society).

Tuesday, February 26, 2008

A Why Health Reform is So Hard - Short Take on Health Reform – Thought for the Day

I keep six honest serving men
(They taught me all I knew)
Their names are What and Why and When,
And How and Where and Who.

Rudyard Kipling, 1865-1936

What – Health Reform.

Why - Because it’s the number #2 political issue, after the economy.

When – Not this year or next, not even soon, since we’re been debating this since 1912.

How – Most likely it will take a world depression, a world war, or an unprecedented natural disaster, e.g, coastal flooding due to global warming.

Where - Most likely in D.C. since state experiences have failed or are being overrun by unexpected costs.

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

Monday, February 25, 2008

Innovation, Wal-mart - Lessons in Retailing from WalMart

Lessons in Retailing from WalMart

WalMart has just announced it will expand its in-store clinics. It will open 400 new clinics by 2010, and it will partner with trusted hospitals in 13 of its new regions. Hospitals will own and operate these 13 new clinics. The clinics will be branded “Clinic at Walmart” and will sport the name of the partnering hospital. The hospitals will provide the nurse practitioners and physician assistants dispensing care, as well as the doctors overseeing them. Walmart will standardize the clinics to achieve a similar look and feel. The clinics will keep similar hours and will post price lists.

Physicians no doubt will respond to this news with ambivalence. Some in physician-short regions may welcome it. Others will see it as unwelcome competition. Others will complain it upsets the continuity of care and threatens the very existence of many primary care physicians who are already in short supply.

I look upon the opening of the new clinics as lessons to be learned from a savvy retailer, already the biggest in the world. In-store clinics are arguably the most significant innovation in health care of the last five years. The move is part of Walmart’s corporate strategy to improve its image of being bad for communities, slackers in providing insurance for its employees, and an unfair competitor to Main Street merchants. Its health care campaign include expansion of health benefits to 70 employees of employees of its $4 prescription drug program, and another step forward in opening access to care and enhancing profitability.

Here are a few lessons physicians might learn from Wal-Mart.

• Price matters. Wal-Mart’s slogan of “We sell for less” has been a smashing success. Some physician groups have taken the clue by opening and owning their own clinics and by lowering overhead in “cash-only” practices.

• Access matters. Longer hours, no waiting and quick patient processing appeals to health consumers. Some physicians have responded with open-scheduling, see patients on the day they call.

• Transparency matters. Patients like to know in advance or at the site of care what things will cost. Some physicians, particularly in cash-only practices, are posting prices in their offices.

• Predictability matters. Consumers like to know what they are in for. Predictability is what successful corporate franchises, and other in-store clinics, like CVS and Minute Clinics, strive for.

• Location and convenience matters. Walmart got its start by placing its stores in rural and suburbs where competitors had not gone and where parking was ample and free.

• Partnering and brand name recognition matter. In any given community, both WalMart and the local hospital are well-known names. Physicians could take a cue here by engaging in joint-ventures with community hospitals.

• Computer systems matter. Wal-Mart has a significant advantage over competitors because of its on-line, real time, all the time computer inventory system. Likewise, most in-store clinics, at Wal-Mart and elsewhere, feature standardized clinical protocol and electronic health records.

Hospitals say doctors have nothing to fear from these clinics. Hospitals claim in-store clinics are simply a way to expand access to care and to their primary care networks. Primary care physicians sometimes respond they fear patients will go to hospitals for follow-up care rather than to their offices. Hospitals say in-store clinics are an opportunity to enter into joint-ventures with hospitals. The AMA and the AAFP say in-store clinics must be investigated and regulated to assure safety and continuity of care. The American Academy of Pediatrics opposes in-store clinics.

One final cautionary lesson: in-store clinics take two to three years to show a profit, and at least seven clinic operators – short on capital – have closed up shop. Success in the retail world, and increasingly in the primary care

Sunday, February 24, 2008

Medicare - Medicare Advantage Plans - Whose "Advantage"?

Would someone out there please help me? Politicians are saying words matter. I am trying to understand to whose “advantage” Medicare Advantage Plans incur – Medicare recipients, politicians, health plans, doctors, or Medicare itself?

As things now stand, only one of five Medicare seniors has signed on to Medicare Advantage Plans, and many find the new plans, introduced on January 1, 2006, as confusing, limiting, and underpaying.

From the national marketing HMO marketing push and the furor in Congress, it would appear politicians and HMOs embrace Advantage Plans. For politicians there’s lots of lobbying money to be had, and for HMOs there’s $54 billion more than with traditional fee-for-service Medicare. What’s not to like? Furthermore, sales agents receive $200 to $500 for each Medicare Advantage patient they sign up, and private plans receive 11 percent more than with FFS Medicare.

Doctors view Medicare Advantage Plans differently. They see them as a Medicare zero sum game. The $54 billion that goes to the Advantage Plans comes up of their pockets in the form of 10% Medicare fee cuts this year and 15% next year. If these cuts go through, AMA online surveys indicate 60% of doctors will limit the number of Medicare patients they see. Finally, in another AMA survey of 2022 doctors, 50% of doctors said Advantage plans denied services typically covered by Medicare, and 50% also their payments were less than traditional Medicare.

To whose “advantage” are Medicare Advantage Plans,? Regardless if you define advantage as superior position, factors favoring some, and as being taken advantage of, the health plans seem to be in the advantageous driver’s seat.

Saturday, February 23, 2008

Medical tourism, global medicine - Medical Tourism - For Real?

Is medical tourism – sparked by globalization, the Internet, and consumerism – for real? The jury is still out, but it is a trend worth watching.

I was speaking to a medical school classmate. He has been serving as an inspector for the Joint Commission. He tells me Joint Commission International is busy inspecting and accrediting hospitals abroad. These inspections are sparked by active promotion of medical tourism by travel agencies, “medical journey” companies, the mass media, and even by some U.S. employers, health plans, and consumer groups.

What are generally being promoted are package travel deals for elective procedures, joint replacement (hip/knee), cardiac surgery, dental surgery, and cosmetic surgeries. Favorite destinations include Hongkong, India, Malaysia, New Zealand, the Philippines, Singapore, and Thailand.

Among most employers, medical tourism is a relatively new benefit, covered by only 11% of organizations. The differences in lowest U.S. prices and off-shore prices in high quality accredited foreign hospitals are more than 50%, but may be as much as 90%.

The uptake of medical tourism is slower than its promoters initially envisioned. It has a long way to go because of cultural differences, “fear of the unknown,” medical legal concerns, and employer PR fears. These hurdles will have to be overcome before medical tourism goes mainstream.

Friday, February 22, 2008

Patient Views - A Patient's Personal Medical Staff

On Wednesday, February 20, I ran across a poignant piece in USA Today, “Health Care Disconnect,” by Robert Lipsyte, who said , in part.

“I’ve decided to call a meeting of my personal medical staff, which includes a primary care doctor, an ophthalmologist, urologist, oncologist, gastroenterologist, neurosurgeon, dentist, dermatologist, audiologist, osteopath, and podiatrist, all of whom I have seen recently, but never in a group.”

“When I get them together, I will ask three key questions of this nation’s – as well as my own – health crisis. Will you get past your partisanship to talk to one another, will you feel my pain, and are your hands clean?”

“The health crisis we all share –getting good, timely medical service and being able to afford it – is too big for me and my staff to solve. But the overall national plans that the presidential plans propose will be useless unless they also help me get answers to my questions.”

“For all the policy wonk discussions about mandated care for all vs. affordable care, single-payer government systems such as Medicare and private policies, the heart of health care reform is about the doctor and the patient finding their way together towards compassionate care.”

“Even thinking about all this gives me stress. I might just have to add a psychiatrist to my personal medical staff.”

Mr Lipsyte, doctors are listening to what you and each other have to say.

Doctors are talking to one another, some through EMRs, some through FAXes, some through referral letters, some through phone lines, xome face-to-face, some through social networking websites.

Some are even asking patients what to do, what pleases them, what pains them. Milton Seifert, MD, a family physician from Excelsior, Minnesota, has formed a 60-member patient advisory council and meets with them regularly for guidance on everything from billing to what courtesies and services they desire and how he can prevent them from falling through the cracks.

Also in Minnesota, the state legislature will require all physicians to have interoperable electronic records in place by 2015 so all doctors will know what other doctors are doing. Minnesota, with financing from the state’s largest health systems and health insurers, has formed a non-profit organization, the Minnesota Health Information Exchange committed to building a network that will connect all electronic health records across the state.

Even in a state like Minnesota, where large medical groups and large health system dominate and where consensus is the societal modus operandi, whether such a system is doable and can be paid for while protecting patient privacy and without disrupting and bankrupting or disrupting small practices remains to be seen. Medicine, as Robert Lipsyte points out, is a very personal business, even though, unlike Lipsyte, most patients have not had the foresight to form their own personal medical staffs.

Getting people and physicians together in a country like America, where individual reigns and government intervention into private matters is resisted, to reveal all about their health condition poses daunting perhaps insurmountable problems. Frankly, I am not optimistic, nor do I regard it as desirable, or even possible to have mandated physician and patient health records. Some things are personal and will forever, and should, remain private.

Thursday, February 21, 2008

Future - 2020: Cost-Effective Medicine

It’s 2020. Cost-effective medicine has arrived full-bolt, or perhaps I should say full-byte. It’s health 6.0 - the era of universal e-visits, e-connections, and e-interoperability. Cyberspace intimately interconnects payers, vendors, patients, and physicians. Everything is intertwined, transparent, and standardized.

All doctors are salaried, thus eliminating perverse incentives of fee-for-service medicine. Medical records and personal health records are universal. Most medical practice is conducted off-site, online, realtime. Patients submit complaints and medical histories from home. Software guiding history-taking has embedded scales for judging depression, alcoholism, or psychological conditions. Blood pressure, heart and breath sounds, even blood chemistries can be measured remotely, using space-medicine techniques. Remote internet medicine has arrived. Nothing is left to chance.

In ordering procedures or tests, doctors practice flat-of-the curve medicine. Variation in use of health care used to be ubiquitous in the United States. Variation was attributed to differences in supply of medical resources; to identify and unidentified economic, social, and cultural factors; and to idiosyncratic beliefs of physicians. It was perpetuated by the parochial character of clinical practice. No more. All doctors now practice in one standardized common boat, rowing together towards Nirvana.

It was long ago established that most high-cost, high-ticket medicine didn’t produce cost-effective, quality results. Now a more robust scientific foundation for clinical decisions has dramatically cut variations.

Consequently cost of medical care has dropped from 20% of GNP in 2010 to 10% today, thanks to command and control health 5.0, governed from on high. And thanks too to ,

• Predictive modeling and artificial intelligence algorithms

• Electronic access to all previous records and a national interoperative health information system.

• Robust diagnostic support systems with access to the latest medical information system from around the globe.

• Universal cost-effective clinical protocols consisting created by pooled input from thousands of clinicians

• Strict adherence to “scientific-evidence based “medicine” whereby every clinical condition, even if wildly subjective, has a scientific basis.

• Never-never payment by government or health plans for events or complications, inadvertent or advertent that should never have developed in the course of the disease or its treatment.

• Minimization of costs from high-ticket items such as invasive surgical or vascular catheterization with device placement or imaging procedures.

• Omnipresent social technologies, enlightened consumers, and globalization of most cost effective health care approaches from around the globe.

• A public that is aware, sensitive, and responsive and that is rewarded for prescription compliance, and such good health behaviors as not smoking, staying thin, and constantly exercising.

• Cost-sharing savings among doctors and their employers because of the new efficiencies, standardizations, and paperless practices.

• Elimination of most doctor visits and hospitalizations except for the truly ill.

There is one final benefit of health 5.0. Little clinical judgment is required. Clinical judgment is now statistically based. As a direct result, U.S. health outcome statistics – on infant mortality, longevity, access to care, and, above all, cost of care – have soared. To great heights, surpassing those of any other nation.

Little human interaction is needed to achieve these results. Don’t worry. Your patients are only a data-click away, and together, with your feet planted firmly in statistical concrete, you can decide what needs to be done.

I have to stop now. My tongue is lodged in my check, and it’s painful.

Wednesday, February 20, 2008

Alternative therapy, blogging, doggerel - - Doubts about Immune System Supplements*

Marketers say most disease,
Can be brought to its knees.

Just prop up overall immunity,
For citizens in the community.

Sales people say to be a health genius,
Just take your immune system serious.

Recognize healthy foods are not enough,
To prevent disease and to make you tough.

To stay well, take a daily immune dose supplement,
And your health will become an ageless monument.

Everybody knows deficient immunoglobulins,
Are lurking, stalking, hidden disease goblins.

That is what advertisers often claim and so often say,
Ignore your immunity, and your health will go astray.

So daily goose, goad, and garnish your immune system with antioxidants,
Be sure and take those essential vitamins, minerals and otheringredients,

Never mind inadequate scientific proof,
Or the possibility of a marketing spoof.

You must strive to do everything you can possibly do,
Even if the evidence for protection doesn't ring true.

It is ridiculous, say marketeering gurus, to ask.
Questioning their basic premises leaves them aghast.

Yes, immune system boosters may be a pseudoscience.
But on these boosters you can place strong reliance.

They’re a feel-good way to protect your health,
To ward off immune demons that kill by stealth.

Anyway, according to the impresario P.T. Barnum,
Each day someone is born seeking a better nostrum.

Among true believers immune supplements have this charm.
They may just do some good, but they do not do any harm.

That’s their belief,
In brief.

*My doubts stem from JAMA article, G. Bjelakovic, et al, “”Mortality and Randomized Trials of Antioxidant Supplements for Primary and Secondary Prevention, volume 297, pages 842-857, February 28, 2007.

After studying 68 randomized trials, researchers concluded,

“Our findings contradict the findings of observational studies, claiming that antioxidants improve health. Considering that 10 per cent to 20 per cent of the adult population (80-160 million people) in North America and Europe may consume the assessed supplements, the public health consequences may be substantial

“Antioxidant supplements are synthetic and not subjected to the same rigorous toxicity studies as other pharmaceutical agents. Better understanding of mechanisms and actions of antioxidants in relation to a potential disease is needed.”

Antioxidant supplement revenues are now in the $10 billion range and comprise roughly 20% of the $50 billion dietary supplement industry.

Health plans and doctors - Closing Hospital-Physician Relationship Gaps

Two years ago, James Hawkins, a former hospital CEO, and I wrote Sailing the Seven “Cs” of Hospital Physician Relationships (PSR Publications, 2007). The idea was that hospital CEOs had best patch up physician relationships by acknowledging the importance of CEO competence, convenience for doctors, clarity of communication with doctors, continuity of hospital policies, fair competition between hospitals and doctors, resolution of control issues, and fair distribution of cash.

Hospitals and doctors are at odds on such issues as who controls specialty hospitals and surgical outpatient facilities, patient safety and quality issues, and competition between hospital-owned physicians and independent practices.

The AMA has recognized the need for better relations by saying the organized medical staff should abide by these principles.

• Work with hospital governing bodies to improve patient safety and health care quality.

• Be responsible for credentialing and overseeing clinical quality and patient safety.

• Be involved in hospital strategic planning.

• Communicate with hospital governing body in a timely and effective manner.

• Establish binding bylaws that hospital bylaws or policies don’t undermine.

• Have inherent self-governance rights.

• Create bylaws that are binding and mutually enforceable between the hospital and medical staff.

• Determine how much money it needs to carry out the duties of the hospital governing board and to develop a budget the hospital will fund.

• Elect member representation to attend, speak, and vote at board meetings.

• Have individual members be eligible to be full members of board.

• Develop disclosure and conflict of interest policies for physicians in leadership.

• Address disputes with the hospital board through a well-defined process.

These principles are all fine and good, but a few flies are stuck in the ointment.

• The term “organized medical staff “is an oxymoron. The physician culture treasures independence and often acts independently of hospitals. The medical staff is not basically a coherent entity, since most doctors practice separately from one another.

• The “organized medical staff” is ineffective in overseeing business functions of hospitals. Hospitals know certain specialties – cardiovascular, orthopedic, other surgical and procedure-based groups, and oncology – account for 80% to 90% of revenues. Hospitals therefore tend to do “business” with these specialties, and where possible hire other specialties as employees.

• As Jeff Goldsmith, PhD, president of Health Futures has often observed, the chasm between hospitals and doctors is growing not shrinking. Goldsmith has written,

"As health systems integrated structurally, they disintegrated culturally. The gap between professional and managerial cultures that existed during most of the 1980s and early 1990s widened into a chasm by the late 1990s. Professionals of all stripes – not merely physicians, but nurses, technicians, social workers and others – saw their practices increasingly commoditized and marginalized by the growing corporate ethos in their systems; professionals lost contact, physically and spiritually, with the 'adminisphere' – the tiny handful of people running their systems."

Or as a management hospital operating consultant wrote in an email to me,

Most physicians distrust hospital senior management. A war is going on out there. Physicians feel hospital executives have no experience with the 24/7 responsibility of someone's life and the deep accountability necessary with care. My husband, an internal med doc in a large hospital has said the executive team has consistently failed in just about every endeavor to help. The failure gap widens.

Hospital senior management opposes changing organizational structure and processes to benefit doctors. Operational and financial deficiencies are widespread, and senior teams are engrained in a culture that ignores it and hopes it will go away. None have been willing to build real accountability among them. They are insular, protected, and ineffective in leading operational change.

The culture gap between hospitals and physicians will not be easy to close.

Tuesday, February 19, 2008

Health plans - Health Plan Rip-off?

I don’t always appreciate the New York Times reporting on doctors. Too often, it seems to me, the Times portrays us as opportunistic entrepreneurs, using innovative new technologists to pad our bottom lines, even when these innovations improve care and save lives.

Lately, however, the Times has switched from writing about health plan rip-offs rather than doctor rip-offs.

The Times is focusing on UnitedHealth Group’s ownership of Ingenix, Inc. Ingenix processes data from over one billion health plan transactions from over 100 health plans across the U.S. and translates the data into “usual and customary” fees for individual regions. The problem is that doctor and hospital fees in these regions are well above Ingenix calculations, and patients must pick up the difference. The differences are often considerable, as much as 50% to 70% of the total bill, and may create financial havoc among unsuspecting health consumers who fail to read or don’t understand the fine print in their health plan contracts concerning out-of-network care.

If you would like to read what the Times has to say, here are three recent articles you might want to read.

• Reed Abelson, “Health Plans Place Onus on Insured,” February 19, 2008

• Editorial, “A Rip-Off by Health Insurers,” February 18, 2008

• Reed Abelson, Inquiry Set on Health Billing, Feburary 14, 2008

This is an important story to follow. UnitedHeatlh Group, Inc, founded in Minnesota in 1977, serves 65 million Americans, including many AARP members, and involves 500.000 physicians. I compliment the Times on bringing this story to our attention

Sermo - The Power of Physician Information is a physician-only conversational website. Sermo rests on the premise that doctors, as part of the sisterhood and brotherhood,

• will freely exchange views on a secure website

• their views will possess the power to predict trends

• their views will provide relevant and early information to improve the system

Sermo has another power – the power to assemble survey information quickly, sometimes overnight, to fathom how doctors are thinking.

I was thinking of this the other day as I read an excellent article in the New York Times Magazine. “Miracle Workers? Why We Expect Doctors to do the Impossible.” The article contains this paragraph, which is right on.

“Ultimately, it is no doubt simply irrational to expect physicians to simultaneously be great clinicians, great scientists and great psychologists and humanists (as well as great accountants. Some are; but a medical system built on the assumption that such mastery can be normative would be an exercise in folly. Perhaps this is why in recent years, the doctrine of ‘evidence-based medicine” has become so influential in American medicine. By pushing medical providers to makes their decisions almost exclusively on the basis of statistics, this doctrine implies that what is good for a group can be assumed to be good for every individual despite the fact that this is often not the case (italics mine).

The piece cited a 2006 Consumer Report Survey where patients get their medical information. This information influences their decision-making, and in some cases, empowers them

• 59% Read books and articles about the condition

• 39% Read about the condition on the Internet

• 44% Asked the doctor about treatments they had heard about

• 47% Brought a list of questions and concerns

• 28% brought a friend to an office visit.

Given its power to gather information almost instantly, Sermo might consider a survey about how doctors gather their information and make their decisions. Do physicians
rely upon,

• Common sense, clinical experience and patient history

• Patient wishes and expectations.

• Information from journals and books

• Internet sites with diagnostic-support information

• “Evidence-based” information, clinical protocols, and pay-for-performance criteria

• Gathering information for “defensive medicine purposes”

• Gathering information that health plans are likely to pay for

• A combination of the above

Quick access to physician information has power. Physician trends and opinions are a moving targe. The target can be traced through frequent surveys showing what's likely to work or be accepted on the clinical frontlines.

Monday, February 18, 2008

Prevention - As Good as it Sounds?

Prevention sounds good. An ounce of prevention is, after all, worth a pound of cure. All one needs to do is stop smoking , exercise, eat fruits and vegetables, lose weight, and get periodic preventive screening tests. But does it save money?

But prevention sometimes may be the reverse of what Mark Twain said of Richard Wagner’s music, “It’s not as bad as it sounds.” Prevention may not be as good as it sounds when it come to saving money.

It depends on what type of prevention you are talking about. Keep this in mind when current presidential candidates talk of prevention as the best, least costly way to save money.

Here is what the candidates are saying.

• Hillary Clinton. “Focus on prevention: wellness not sickness.”

• Barack Obama, “Too little is spent on prevention and public health.”

• Mike Huckabee, who lost 100 pounds on his own, “Prevention would save countless lives, pain and suffering by the victims of chronic conditions, and billions of dollars.”

These sound bites sound good and are hard to disagree with. . But a few snags loom. Most doctors are not paid for preventive counseling. And even when doctors devote a few precious moments to preventive talk, patients may forget and lapse into their former life styles. Lastly, depending on program, some intensive preventive programs may cost money and worsen health.

Three Boston academics have analyzed the cost of prevention. In “Does Preventive Care Save Money? Health Economics and the Presidential Candidate,” the authors studied 599 articles and 1500 cost-effective ratios in terms of QALYs (Quality Adjusted Life-Years). Low ratios are “favorable,” indicating QALYs can be accrued inexpensively, i.e. costs are saved while improving health.

Here are a few of their findings.

• H. influenzae type b vaccinations cost-saving
For toddlers

• One time colonoscopies for men cost-saving
aged 60-64

• Family intervention for Alzhemiers cost–saving

• Cochlear implants for deaf children cost-saving

• High intensity smoking relapse $160/QALY
programs compared to low intensity

• Intensive tobacco-use prevention, $190/QALY
Compared to low-intensity

• Intensive tobacco use prevention $2300/QALY
For 7th and 8th graders

• Left-vent. assistance device, $900,000/QALY
compared to intensive medical Rx

• Amoxicillin for kids with heart increases cost,
disease undergoing urinary caths worsens health

• Surgery in 70 y.o for new diagnosis increases cost
of prostate ca compared to watchful worsens health

An ounce of prevention, in other words, is not always worth a dollar of cure.


J T Cohen, P.J. Neumann, M.C. Weinstein, “Does Preventive Care Save Money? Health Economics and the Presidential Candidates, NEJM, 358:661-663, February 14, 2008

Sunday, February 17, 2008

Caretakers - Caretaker' s World: Humanity at Work

Your world is different. When you work in the home, you may receive no pay for your services. When you are caring for a sick relative or a close friend, your reward is their love, well-being, comfort, and appreciation for being there. You prefer the name caregiver. You give rather than take.

If you work in a place housing the terminally ill or a hospice filled with those with no hope for cure, you receive little money. But there is an off-setting benefit. You are part of a loving community of nurses, aides, patients, and grateful relatives – an extended family engaged in a common venture – to care for the helpless and the sick.

Your patients welcome a smile, a joke, an encouraging word, a spontaneous hug, a gentle tug to straighten the sheets, a quick clean up after an uncontrollable body release, a loving lift onto the bed, a guided push of the wheelchair.

You grow to know relatives and friends. They trudge in to visit daily or weekly, whenever they can. They are, along with other patients, part of your extended family. Your co-workers belong to the same human family. This is humanity at work. Together you smooth and soothe, even caress, the downward passage.

Your world calls for heavy doses of comfort, compassion, companionship, consolations, and condolences. You learn little kindnesses go a long way in this world of strive, struggle, decline, and death.

You don’t ask for much, just a little recognition for what you do so well in your special world.

As physicians, we monitor and treat these patients from afar. But you are there constantly, every day, in every way.

Fellow physicians, please join me in saluting these unsung and unheralded caregivers and caretakers. We could not do without them.

Coordination and fragmentation - Falling Through the Cracks

Relatives, friends, and neighbors sometimes ask me how to navigate the system's thickets. They ask where to go, what to do, who to go to, what it will cost, and how much insurance will cover.

As a pathologist, too often I’m lost for answers. I tell them to ask their doctor. But some can’t find a doctor. Most have no doctor to supervise their overall care.

Here’s a typical story of woe. A fifty year old woman with arthritis and kidney disease develops atrial fibrillation. She now has six doctors –a general cardiologist, an invasive cardiologist, a rheumatologist, a nephrologist, a neurologist, and whatever hospital “clinic” doctor happens to be on duty.

She went to the clinic recently for relief from the flu and a migraine. A workup ensued. A $3400 bill followed. She had to pay more than half the bill. The clinic was out-of-network for her health plan.

“All I really wanted,” she wailed, “was Tylenol with codeine for my headache.” As she bounces back and forth between doctors, she observes many have no record what other doctors had done or advised.

Frustrated, she called me. Did I know a physician who could coordinate her care? I’m relatively new to the area. I didn’t know of anyone. I called around.

• I called a retired internist with whom I interned. He said he didn’t know of any coordinating doctor. He added he and his wife couldn’t even find a primary care physician for themselves.

• I called a young highly placed young health care executive. He said it took him six months to find someone to oversee care for himself and his family.

• I called a surgeon, a former head of surgery at a hospital. He didn’t know of such a personal doctor.

• Finally I called the former director of general medicine program at a teaching center. He knew of a wonderful woman general internist in a town 25 miles from where the patient lived. I used his name to refer the patient to her.

How do we heal and seal these cracks in health care?

All of us know the usual recommended solutions - large multispecialty clinics, electronic health records in doctor offices, portable personal health records, cost transparency by doctors and hospitals and health plans, educating more primary care doctors and paying them more.

These sensible suggestions will take time.

Meanwhile, I’ll have to call around and see how I can help fill the cracks for inquiring friends, relatives, and patients.

Can anyone give me any insights on how to handle this problem?

Friday, February 15, 2008

Data, use and misuse - The Devil is in the Hidden Details of the Database Black Box

New York State attorney general Andrew Coumo says he will sue UnitedHealth Group, Inc, and its subsidiary, Ingenix, Inc, for “gross conflict of interest.” Through its database, Ingenix sets the “usual and customary” rates that most of the health care industry uses.

The suspicion, as yet unproven, is that Ingenix manipulates the data within its blackbox database by knocking out price information from MDs with higher charges. The result is that algorithms within the black box consistently underestimate prevailing market rates, forcing customers to pay a greater part of bills.

An example: in New York the typical office visit rate is $200. If a patient goes out of network, the black box estimates usually and customary at $77, the insurer pays 80% of that or $62, leaving the customer to pay the difference of $138.

Among other things, Coumo is quoted as saying.

• “We believe there was an industrywide scheme perpetrated by some of the nation’s largest health insurers to deceive and defraud consumers.”

• “There is no disclosure; there is no transparency; there is no accountability.”

Whether Coumo is right is not yet known. The UnitedHealth Group denies any wrongdoing and says Ingenix is neutral and bases its calculations on more than one billion claims from more than 100 insurers. The impact of Cuomo’s suit could be huge - 54% of those insured are in PPOs with higher fees for out-of-network care, and UnitedHealth covers 26 million people and had $75.4 billion in revenues in 2007.

The outcome depends on bringing to light those opaque, hidden details -which may be quite legitimate – going on inside that black box


Sermo, Physician Leadership - Physician Empowerment Campaign Underway

As I indicated in my last blog, which highlighted the AMA’s call for an April 2 White Coat Rally on Capitol Hill to protest the impending 10.6 percent cut in physician Medicare payments, a physician empowerment movement is underway.

There are other signs as well. A physician only website, now two years old, has over 50,000 participating physicians talking to each other about, among other things, what do do to reform the health system. Recently two recent posts by Sean Khozin, MD, appearedon Sermo : 1) “Open Letter to the People of the United States; 2) “Open LetteCampaign: Let’s Make It Happen.”

Dr. Khozin had a powerful idea: an open letter to the media signed by thousands of doctors. . The time has come for us to stand up, speak out, and make our voice and presence felt in the national media, especially at the height of health reform interest during this presidential campaign. The media cannot ignore an open letter signed by 30,000 to 50,000 physicians.

The physician empowerment movement is underway and has multiple dimensions - the AMA rally, this open letter campaign, doctors challenging health plans, letters to the editor in national newspapers, and appearances on Public Radio and Public Television.

Here’s what I think doctors want and need.

More than anything else, doctors want and seek a voice, visibility, and reality in domestic and national reform. Pundits, politicians, health plans, hospitals, academics, and the media have dominated the discourse. And, because many regard the AMA as simply a doctors’ union, rather than a moving force for the social good, the AMA has partially lost its voice. It has also steadily lost physicians members. Only 1/4 of doctors belong to the AMA , but the AMA remains our voice in Washington on many issues.

So what else do doctors want and seek?

They want and seek respect. They are weary of being hectored and lectured by outside experts on how to run a practice and what strategies to use to become more efficient, safer, and more productive. They are tired of being lampooned in the New York Times as greedy entrepreneurs.

They want and seek reality. Nothing brings you closer to reality than treating sick or dying patients. They know what patients need and want, and what it takes to make them better or to accept their fate. They do not need to be told how to be compassionate.

They want and seek an end to the entitlement mindset. Medicine is and never will be “free.” Pretending it is so opens up the floodgates. It shifts responsibility away from patients to doctors. It fosters more doctor visits, often for minor problems. It overburdens already burdened doctors, who only have so much time in the day.

They want and seek realistic expectations. Doctors cannot make patients young, reverse behavior -induced illnesses, control most disease outcomes, of fix all problems with technology. These expectations invite lawsuits, and lawsuits invite distrust and defensive medicine, which cost up to $100 billion a year.

They want and seek direct patient interaction as the basis for decision making, rather than having remote third parties decide what is best. That is why 2/3s of doctor favor a market-driven system over single payer.

They want and seek to be respected for their knowledge, based on experience. They want to be partners of patients, rather than being told by patients armed with half-baked Internet information what to prescribe or what to do. An informed patient is a blessing, a misinformed patient can be a curse.

They want and seek health plans and authorities to know that data alone, no matter how massaged, manipulated, and manufactured, has limits in individual cases. Doctors know patients live, get better, or die as individuals, not as statistics. Using retrospective claims data to judge rank, and exclude doctors and to intervene in clinical decision-making is a perilous, chancy, and delusional game.

They want and seek the public to know that EMRs, PHRs, and electronic records, may be desirable , but impeccable computer-based records are not miracle-makers that assure quality, safety, and better care. They are ancillary tools – not something that will ensure perfect medicine. Medicine has always had a subjective humanistic side, called the Art of Medicine, and objective data, even if one calls it Science-based, does not, in most cases, make it “scientific.” Give me a doctor who listens, rather than one who records.

Doctors want and seek to be appreciated as economic beings , subject the same laws of economics as patients, with demanding creditors, heavy educational debts, rising overheads, limited incomes, and with only so much time to spend with each patient in order to meet their obligations. The myth of all doctors as privileged high earners needs to be debunked.

Medicare - “Something is Rotten in The State of Denmark.” Shakespeare: Hamlet

The other day the mailman brought a giant postcard from the AMA bearing this message on its front side: HAD ENOUGH BROKEN MEDICARE PROMISES? IT’S TIME TO MAKE A HOUSE CALL ON CONGRESS.

And these instructions on its backside:

“On July 1, Medicare physician payments will be cut 10.6 percent unless Congress passes new legislation.

On April 2, join the American Medical Association (AMA) and your physician colleagues from across America to press Congress to provide Medicare payments that reflect increases in medical practice costs. Wear your white coat and join in a rally on Capitol Hill as part of the AMA’s annual National Advocacy Conference.

Your voice, your presence on Capital Hill will send a strong signal this election year that Congress must change its approach to Medicare payments.”

Another Indication

Well said, and another indication there’s something rotten with the state of Medicare in America.

Something is rotten with these 10.6 percent cuts

• When Medicare payments are so low many physicians are forced to turn away new Medicare patients in order to meet payroll and the bottom line.

• When the Medicare budget is the biggest budget within the U.S. government and the fourth biggest budget on the planet, exceeding that of most nations.

• When Congress, Medicare officials and employees, and other government officials refuse to consider 10.6 percent cuts in their own pay, thereby tightening all belts together.

• When the cuts are superimposed upon a widely acknowledged physician shortage of 50.000 doctors exists.

• When the rapidly growing Medicare population, soon to be fueled by aging baby boomers, is already having trouble gaining access to care.

• When the cuts impact directly and negatively on the dwindling numbers of primary care physicians – – usually the first to see and treat Medicare patients.

• When it is widely known and a historical reality that health plans covering non-Medicare patients and Medicare patients with supplemental plans follow Medicare reimbursements patterns in lockstep.

• When Medicare is the Sheriff of the System, and everybody feels obligated to follow the man with the badge.

• When physicians are forced to come year by year, even month by month, with hands held out to beg for sufficient pay to meet relentless increases in the costs of providing care, due in part, to mounting federal regulations.

Physicians are not beggars. We are highly trained professionals trying to make a difference in the lives of our patients while trying to make a living.

Saturday, February 9, 2008

Government vs. Market Reforms - Health System Reform Choices

This high octane presidential campaign season overflows with health reform proposals. I was recently asked what I see as reform options. Here are my choices and realistic likelihoods. The final solution will likely be combinations of these choices with gridlock in the near term.

Choice I – Universal top-down government coverage based on individual mandated coverage. This is Senator Clinton proposal and is basis of California (collapsed) and Massachusetts experiments (big cost overruns anticipated.)

Choice II – Expanded coverage based on cost reductions and universal coverage of children. This is Senator Obama proposal (untested).

Choice III – Expanded coverage based on market reforms, universal tax credits, severing employer-based coverage, bolstering of HSAs, aggressive insurance marketing to the uninsured with low-cost premiums, subsidies to those who can’t pay, portability across state lines with reduction and uniformity of mandates This is basic Republican approach (mostly untested with limited progress).

Choice IV – Universal coverage administered by private plans, not requiring employer participation and modeled after Dutch and Swiss plans (untested and unlikely).

Choice V –
Universal coverage with vertical integration in large health systems (e.g Kaiser) and with virtual integration of independent practices, health plan and Medicare bonuses to hospitals and doctors who comply with performance guidelines, universal online linkages connecting government, health plans, doctors, and patients and focusing on coordinating acute care, chronic care, prevention, compliance, and end-of-life care (this sometimes goes under banner of doctor-patient connectivity or medical homes (in progress but complicated, difficult to explain in simple sound bites and opposed by many doctors because of hassle factors and fear of e-Big Brother monitoring, tiering, and exclusion from networks).

Choice VI
- Innovation with improved access, more choices, and stability and persistence of present system with retention of current practices of most businesses, health plans, pharmaceutical companies, hospitals and physicians with opposition to bigger government and costs of reform falling on them (most likely but messy as are all things in a democracy)

1. J. Oberlander, “Presidential Politics and The Resurgence of Health Care Reform, NEJM, November 22, 2007.

2. P. Kuttner, Market-Based Failure – A Second Opinion, NEJM, February 7, 2008.

3. G.M. Turner, “Moving Forward,” The Galen Institute, February 8, 2007.

4. G. Halvorson, Health Care Reform Now! John Wiley & Sons, 2007.

5. A.C.Enthoven, “Going Dutch – Managed-Competition Health Insurance in the Netherlands, NEJM, December 15, 2008.

6. L.D. Brown, “The Amazing Noncollapsing Health Care System – Is Reform Finally at Hand?” NEJM, January

Friday, February 8, 2008

Longevity, Reece, Personal Musings - Ponce de Leon and The Quest for Normality

We doctors are conquistadors. We seek to conquer disease. We strive to restore our patients as close to youth as possible. We do this by keeping or returning patients to “normal” values of youth, for weight, blood pressure, lipids, and glucose by any means we have at our disposal – drugs, diets, and advice to exercise.

I applaud us for pursuing these noble normality goals for our patients. But is this quest for youthful normality realistic given changes associated with aging? You no doubt have observed that specialty societies have recommended patients should maintain,

• a normal body mass index

• a systolic blood pressure of 110 or less

• a serum cholesterol of 200 or less

• a calculated LDL of 100 or less

• a blood glucose of 110 or less

• a glycosylated hemoglobin of 6.0 or less.

We advise patients to strive for normality. We prescribe drugs if they can’t achieve normal values on their own. I‘ve been part of this quest for normalcy. In the 1980s, I came up with something called the HQ (Health Quotient). The HQ, like the IQ, had a normal range of 80 to 120. Anything below was “subnormal.” Anything above was “remarkable good health.” The HQ was based on a collective deviation from normal for blood pressure, blood lipids, glucose, and body mass index. We tested the HQ
on thousands of patients. In retrospect, it was an idealistic quest for good health based on normal values found in the young. Subjects with HQs of over 150 were invariably young women or young males.

But as I age, my hair grays, my middle thickens, my sight dims, my memory fades, my blood pressure rises ever so slightly, my friends drop off, my movie idols disappear, and as more people take more drugs to achieve normality, the realism of aging has begun to replace the idealism of my younger years.

Let me share with you two reasons why.

• I have a friend, a 105 pound, 5’ 2”, 81 year old widow, with a blood pressure of 120/70, a cholesterol of 205 with a calculated LDL of 104 and a blood glucose of 110. She has no history of chronic disease.

Her doctor has suggested she be treated with blood pressure drugs, statins, and a low sugar, low fat diet lest her weight, blood sugar, blood pressure, and lipids spin out of control. My friend has asked me for advice, and I have recommended she do nothing for now.Despite my reassurances, she remains terrified of exceeding normality and paying the mortal consequences.

• A New York Times article crossed my desk on February 8 bearing this title, ”Diabetes Study Partially Halted After Deaths.”It told this story, “ A major federal study of more than 10,000 middle-aged and older people with Type 2 diabetes has found that lowering blood sugar actually increased their risk of death.”

How could this be?

I called Stanley Feld, MD, a Dallas endocrinologist widely known for commanding and persuading his patients to maintain stringent near-normal blood glucose levels. He went so far as to issue T-shirts to patients bearing the words, “In Control.”

I asked Stanley , “What’s going on?” He gently pointed out the study was done on older diabetics, many with heart disease. They were monitored with glycosylated hemoglobin levels. These levels reflect average blood glucoses over the past three months. This average doesn’t account for day to day variations. When their “average glucose” of these high-risk patients was driven to normal, many patients may have had hypoglycemic episodes, with release of epinephrine, and sudden death.

At about the same time, February 7 to be precise, the NEJM released a study “Effect of a Multifactorial Intervention on Mortality in Type 2 Diabetes. “ The study showed intensive intervention with multiple drug combinations and behavior modification reduced vascular complications and deaths from any cause and from cardiovascular causes. It restored my belief in maintaining normal or near normal glucose levels.

Still, I wonder: is it worthwhile or even desirable to drive blood chemistries and body weights to normal in aging individuals? My elderly friend is terrified lest her daily habits and failure to follow physician advice precipitate some terrible illness.

I fear we’re creating a nation of hypochondriacs. As we age, we’re not going to have the same blood chemistries, blood pressures, or body mass indices we had at 20 to 30 years of age. Furthermore, is it worth the enormous drug costs required to maintain or reach this state of normality?

I told my elderly friend: Relax. You’re OK for your age. Your measurements go with the territory.

Is my advice wrong?

Thursday, February 7, 2008

Access - It's All About Access

Recently I met with a group concerned about innovation themes to help doctors succeed. We discussed medical homes, patient-doctor connectivity, productivity approaches, innovation itself, and other august matters.

In the meeting’s aftermath, the thought came to me: from the patient’s point of view, medical innovation is often all about access. How can I get medical care quickly, conveniently, affordably, reliably, at a predictable price, at any hour of the day or night, without endless waiting? Providing answers to this multipronged question isn’t as saimple as A (All), B (aBout), C (aCcess).

But, if you give the matter any thought at all, there are multiple developments out there that indicate access is much of what the medical markets and opportunities for doctors are all about.

• Foremost among these developments are outlets in retail outlets open for long hours and manned )if you’ll pardon the expression) by nurse practitioners. These are growing like topsy nationwide, especially in states like Massachusetts and Florida. Doctors may think of these outlets are either a threat or an opportunity. The opportunities are to serve as backups to these clinics, to own them yourself, to prolong your hours to counter them, or to set up and organize competing entities.

• Another development, little noticed but growing, are worksite clinics, set up by employers with over 1600 employees, in which primary care physicians are salaried at $200, 000 or so to run practices with embedded EMRs, practice protocols, preventive programs, and prescribed drugs at no or little cost and no co-pays. Again this approach may be regarded as a threat or opportunity, depending on ownership, but physician might think of setting up their own model.

• Yet another sign on the access horizon is the setting-up of specialty clinics for treating minor ailments. A leader in this sphere are the Jewett clinics, run by an orthopedic group in Winter Park and Orlando, Florida. These clinics are staffed by orthopedic surgeons who the skills and diagnostic wherewithal to differentiate strains and pains from fractures, ligament tears, and disc ruptures.

• Then, of course, there is the flowering of urgiclinics nationwide, which may be open 24/7 and offer on-site doctors and the skills and equipment to back them up. These offer an alternative to hospital emergency rooms. ERs tend to be overcrowded, expensive, and rushed. Futhermore, they too often feature long-waiting lines – the bane of the modern, time-strapped, consumer.

• Finally, there’s home access – going to homes to provide care for the chronically ill or overseeing nurses and others to provide care in homes. National chronic are companies have seized the initiative here. But there’s no reason these services could be part of the medical home concept.

For many physicians, these access approaches represent a wrenching departure from the time-honored single office. They entail going to the patient rather than having the patient come to you. But no one ever said innovation was easy.

Tuesday, February 5, 2008

Prevention, Wellness - Cholesterol Conundrum: Call for Comments

The word “cholesterol” gibbered through the land as the word “unclean” used to herald the approach of a leper. There was a tremendous to-do about the lethal snags created in the bloodstream by carbohydrates and animal fats, either separately or in combination. Cholesterol was as fatal as slit along the riverbed and was responsible for most of the heart attacks and strokes of what was called successful men.

Alistair Cooke, The Patient Has The Floor. Alfred A. Knopf, 1986

Cooke’s words came to mind last week on two occasions.

One, while sitting around drinking coffee with 12 male friend of a certain age. Ten of the 12 were taking statins to lower their LDL, and all knew their precise cholesterol “number,” which in all hovered below the magic number of 200.

Two, while reading a NYT times Op-Ed Piece “What’s Cholesterol Got to Do With It?” The author, Gary Taubes, author of a book Good Calories, Bad Calories: Challenging the Conventional Wisdom on Diet, Weight Control, and Disease had the audacity to say cholesterol and LDL-cholesterol had little, if anything to do, with heart disease. This assertion opened up a can of worms in the form of a spate of letters to the editor. Here are some typical excerpts.

• From a cardiologist from Tufts, “ Twenty years of research describing hundreds of thousands of patient-years has unequivocally proven that lowering of LDL eventuates in reduced mortality as well as significant reductions in the likelihood of suffering a heart attack, stroke, or the need of surgery.”

• From a “medical doctor” in Brookline, “After reading Gary Taubes’ article I quickly realized that the myth of the relationship between low-density lipoproteins and heart disease was but another example of Sir William Osler’s aphorism, “the greater the ignorance, the greater the dogmatism.”

As a clinical pathologist, I used to write algorithms and give advice on how to interpret the various lipoprotein types. I’m no longer in the advisory game, but when I was, I observed the follow.

• Total serum cholesterol is not a static or stable number. I had my own blood drawn daily over the course of two weeks, and my serum cholesterol varied by +/- 20 points.

• Serum cholesterol and LDL can be misleading predictors of coronary artery disease. I question the wisdom of placing people with type II familial hypercholesterolemia on statins. These patients are not necessarily at risk for heart disease, yet they are routinely placed on statins when cholesterol or LDL exceed 200 or 100.

• Also I wonder how clinicians out there treat the so-called metabolic syndrome, which is characterized by a normal cholesterol, high triglycerides, and low HDL.

I doubt if anything doctors do will alter the public’s belief that elevated cholesterol and LDL have everything to do with it.

Your comments, please, on the LDL, total cholesterol conundrum.

Friday, February 1, 2008

Doctor Patient Relationships - A Practical Reform Solution: Doctor-Patient Connectivity

Today I spoke to Ed Fotsch, MD, CEO of Out of our conversation came one practical solution to many of our health cost and effectiveness problems.

Ed used a hockey metaphor to make his point: skate towards where the puck is going. The puck is clearly headed toward health plan- pharmaceutical company- patient-doctor connectivity focusing on partnerships between the three.

Ed said the managed care wars (pay less to do less) are over, and a new market paradigm (pay doctors more to enlist patients in online programs) to coordinate care, promote wellness and prevention, and educate patients about drug compliance is gaining steam.

Think about it this way. If the typical primary care patient has 2000 patients in his/her network, and with help of health plans and drug firms, educates them online, reminds them online of dangers of drug non-compliance , and failure to take preventive steps or modifying behavior, health of patients will improve and costs will drop.

The key to this scenario is rewarding doctors financially for connecting with patients. This approach makes sense for all parties. Doctors make money for doing the right thing, patients get timely relevant information, health plans and pharma provide online informational tools to improve care, and liability companies can lower premiums with better outcomes.

It makes sense in other ways, too. In the Bridge to Excellence coalition, if doctors can show they have created a “medical home” through patient online connection links,they'e eligible for annual awards of $125 per patient. The medical home concept – backed by The American Academy of Family Physicians. American Academy of Pediatrics, American College of Physicians,l and American Osteopathic Association - engages patients having a personal physician. These doctors receives payments for leading a practice network that coordinate acute, chronic, preventive, and end-of-life care facilitated by online information. In a sense, this is what so-called pay-form-performance progams are about.

There are other possible benefits as well.

• Doctors can connect online with patients at minimal expense: no expensive electronic medical records system is required.

• No extra time is required by doctors, who can simply link to automatic online patient education, prevention, and educational programs.

• An automatic database is generated, allowing doctors to compare their patient outcomes and compliance to other doctors.

• Doctors can save time: company,, permits patients to generate their own medical history based on review of systems, chief complaint, and symptoms, which save 4 minutes per patient encounter.

• Medical liability companies have expressed an interest in lowering premiums proportionate to the number of patients in the doctors online network connections.

• Health plans and pharmaceutical companies become partners in promoting better outcomes and better health, rather than nettlesome micromanagers or aggressive drug vendors.

The age of internet medicine, focusing on positive doctor-patient relationships, aided by health plans and pharmaceutical companies, enhancing rather than disrupting those relationships, facilitated by Internet links, and improving care in the process, is poised for arrival.

Reece, personal musings - Thoughts of a Non-Apocalyptic Thinker

"Amid the myriad social transformations, corporate reorganizations, and policy innovations that have shaken the U.S. health care system, one great puzzling constant endures. For roughly 40 years, health care professionals, policy makers, politicians, and the public have concurred that they system is careening towards collapse because it is indefensible and unsustainable, a study in crisis and chaos.”

Lawrence Brown, PhD, professor in the Department of Health Policy and Management, Mailman School of Public Health, Columbia University, “The Amazing Noncollapsing U.S. Health Care System – Is Reform Finally at Hand?” New England Journal of Medicine, January 24, 2008

The world and the woods are full of apocalyptic thinkers. Their thinking goes,

• The United States is going the way of the Roman Empire.

• Global warming is upon us and will doom us all.

• A deep recession or world-wide depression is drawing neigh.

• Medicare, spurred by greedy babyboomers, will eat the federal budget alive.

• Health care costs will drive millions of more Americans into the uninsured ranks or into bankruptcy courts.

• Health costs will make American business non-competitive.

• Safety net hospitals will disintegrate.

• The hard left will triumph, and we will have a rigid, centralized command and control “socialized medicine” system.

• The hard right will win, and we have a dog-eat-dog competitive system without an ounce of compassion.

I’m not buying any of this. I believe in the American people will come down on the side of a centrist system. I believe in the checks and balances of the Constitution. I believe costs will moderate, as

• the public, health plans, and government shift to generics and other reasonable options;

• innovations such as retail, urinary, and worksite clinics, and flexible open scheduling by doctors give wider, quicker, less costly, and more convenient access to care;

• doctors and hospitals develop new practice models such as Big MACCs (multispecialty ambulatory care centers), surgicenters, and outpatient diagnostic and imaging centers;

• Combined effects kick in of Health Savings Accounts, more transparent information about cost and quality, tax equity for all, portability of health plans across state lines, lower costs premiums for the young and healthy, and realistic subsidies to those who can’t afford care;

• Preventive and wellness movements take hold in the workplace, toxic effects of smoking and obesity become known and countered, and more people realize they are prematurely digging their own graves with their teeth and bad habits.

The U.S. health system will adjust, innovate to make necessary changes, and collaborate to produce a better, more affordable system. The system will remain stable and will not collapse from within. It will surely change, and business, health plans, drug companies, and doctors will have to take some hits, adjust, and innovate. But the health care apocalypse will not come, reasonable reforms will take place, and the frontiers of medicine will remain open.