Saturday, April 30, 2011

A Death from Pancreatic Cancer

April 30, 2010 -
My niece, Laura Turner, 53, died this morning in Huntsville, Alabama, from a rapidly progressive pancreatic cancer. Laura is one of 40,000 Americans who will die this year from this devastating malignancy. Its cause is unknown. Less than 5% of its victims survive 5 years. And surgery and chemotherapy are ineffective in treating it.

I know of no other disease in which patients and physicians feel so helpless in stemming its relentless tide. Pancreatic cancer personifies our ignorance of the forces of biology and the limitations of medical science. For now, we shall simply have to consider pancreatic cancer an Act of God, like the tornado that stuck Huntsville two days before she died.

Laura was a plain-spoken and clear-eyed person. She was full of earthy humor. In her way, she was spiritual. She was baptized a few weeks before her death. She was loved and loving, and I shall miss her. Her death brings to mind John Donne’s famous sonnet.

“Death , be not proud, though some have called thee.

Mighty and dreadful, for thou are not so.

For those whom thou think’st thou dost overthrow.

Die not, poor Death, nor yet canst thou kill me.

From rest and sleepe, which but thy pictures bee.

Much pleasure, then from thee much more must flow.”

Tweet: Pancreatic cancer and hurricanes may be Acts of God, but that doesn’t make them any easier to take as acts of a merciful deity.

Friday, April 29, 2011

Medicaid and Medicare at the Crossroads

From the beginning, the health reform law has been about extending Medicaid and saving Medicare. In 2014, it will extend care to 32 million more Americans, 16 million of whom will be on Medicaid rolls.

In 2010, Medicaid covered 68 million Americans and cost $406 billion. Under the health care law, 85 million Americans will on Medicare in 2014, growing to 100 million by 2021, according to the CBO. (Medicaid and CHIP Payment and Access Commission. Report to the Congress, http://www.macpac.gove/reports).

In 2010, the total spent on social welfare programs, including Medicaid, Medicaid, Social Security and federal welfare programs was $1.879 trillion, 50.5% of the total federal budget of $3.520 trillion. ( Ferrara, P, America’s Every Expanding Welfare Empire, Forbes Magazine, April 22, 2011).

This is not exactly stingy, despite liberal protests of federal spending as being “shamefully small” and “contemptibly austere.” Many Americans think differently. With a federal budget deficit of $14.3 trillion, American voters are asking for cuts in spending and smaller government.

Over the next 10 years, the Obama administrations proposes to cut Medicare by over $500 billion thorough “savings,” by ending Medicare Advantage plans and through Accountable Care Organizations and reducing physician and hospital payments.

This year 78 million baby boomers started entering Medicare, at the rate of about 1200 each day. By 2014, Americans on Medicare will approach 50 million.

The numbers entering Medicaid and Medicare, which may eventually amount to nearly 50% of all Americans, pose two massive problems.

• How to finance Medicaid and Medicare, given the current $14.3 trillion federal debt, which will continue to grow.

• How to care for Medicaid and Medicare beneficiaries, given the current primary care shortfall of 50,000, which promises to mount as less than 10% of medical student enter primary care.

The first problem, national debt, is obvious to the public and to both political parties. It is the main point of contention in the current debate about reducing federal spending and raising the debt ceiling.

The second problem, the doctor shortage, is not as obvious to the public. Physicians are aware of it because they often have trouble handing the current patient load, because of the failure to fix the SGR (Sustainable Growth Rate) formula which calls for over 20% cuts in Medicare reimbursement in future years; and because the ACA proposes to reduce doctor reimbursements to rates less than those of Medicaid by 2019.

By 2014, when ACA kicks in full force, 16 million Medicaid beneficiaries will become eligible. Then the problem of who to care for them will hit.

Here is how John Iglehart, national correspondent for the New England Journal of Medicine, describes the scope of doctor shortages (Iglehart, J, Medicaid at a Crossroads, New England Journal of Medicine, April 28, 2011).

“According to the National Center for Health Statistics, only 65% of office-based doctors were accepting new Medicaid patients in 2009, as compared 74% and 88% for patients covered by Medicare and private insurance, respectively. A study concluded that the growth in Medicaid enrollment under the ACA will greatly outpace the growth in the number of primary care physicians who are willing to accept new Medicaid payments. On the basis of survey responses from 4700 physicians, the study also concluded that temporary increased in Medicaid reimbursements meant to lure more primary care doctors into the program won’t make much indifference in the states facing largest enrollment jumps.”

By 2014, and probably by the November, 2012, presidential elections American voters will have to decide how much they are willing to support Medicaid, Medicare, and social welfare programs for its citizens, and how much they are willing to pay doctors to care for them. Somehow these programs must be cut or restructured as block grants or voucher programs, and somehow the supply of primary care physicians must increase. Unless something is done, access to physicians will become a political crisis of unprecedented magnitude.

Tweet: Because of the primary care doctor shortage, Medicaid and Medicare are at a crossroads and at the edge of a massive political crisis.

Thursday, April 28, 2011

A Proust Questionnaire on Health Reform

My son, Spencer, who is on the verge of becoming an Episcopal Priest, gave me a book Vanity Fair’s Proust Questionnaire: 101 Luminaries Ponder Love, Death, Happiness, and the Meaning of Life (Rodale, 2009).

Marcel Proust (1871-1922) popularized the questionnaire among Parisians in 1892 by asking everyone within his social circle to take the questionnaire . The idea spread to America. Vanity Fair picked it up in 1993 to probe the inner-thinking of American cultural elite.

I am not among the elite, but I decide to apply it to myself to see what I really think about health reform and its meaning for America.

What is your idea of perfect happiness in health reform?

A health system in which everybody lives in perfect health until they die in bed at 110 with someone else in bed with them and without financial worries and without cost to government.

What is your greatest fear?

That too many well-meaning people will believe this fantasy.

Which historical figure do you most identify with?

Winston Churchill, who said, “The inherent vice of capitalism is the unequal sharing of blessings; the inherent virtue of socialism is the equal sharing of miseries.”

What living health reform figure do you most admire?

Regina Herzlinger, a Harvard Business School professor, who believes health consumers are smart people, and with their doctors, consumers will make rational decisions about their health, and John Iglehart, national correspondent for the New England Journal of Medicine, for his even minded treatment of health reform issues.

What is the trait you most deplore in yourself?

That I know more than others.

What is the trait you most deplore in others?

That they know more than I do.

What is your greatest extravagance?

Time spent reading about health reform and writing blogs and books on health reform.

What is your favorite journey?

Going to Madrid, Spain, to see my son ordained as an Episcopal priest.

What do you consider the most overrated virtue?

Elitism, the belief of those at the top that they have more wisdom than ordinary people.

On what occasion do you lie?

When I seek to please, avoid a straight answer that would make me cover up a personal ignorance or look immoderate.

What do you dislike most about your appearance?

My age.

What living person do you most despise?

No one. I am not a hater. But I detest intellectual bullies no matter what their political persuasion.

What words or phrases do you most overuse?

Clearly…but…the argument is… on the other hand…Nevertheless.

What is your greatest regret?

That I acted impulsively, did not listen closely, or behaved badly at wrong time and while under the influence.

What is the greatest love of your life?

My wife.

When and where were you happiest?

When I was in Minneapolis, being a successful health care entrepreneur and a medical editor saying what I believed to be the future of health care.

What talent would you most like to have?

Integrity and humility – with a dash of self-promotion. I believe in a sense of dirt, a sense of humor, and a sense of proportion - not necessarily in that order.

What is your current state of mind?

Befuddlement on why the importance of doctors in health reform is so underrated – and ignored.

If you could change one thing about yourself, what would it be?

To make myself more believable widely read by the public.

What do you consider your greatest achievement?

Sticking to my guns on health reform.

If you were to die and come back as a person or thing, what do you think it would be?

A bull in Montana, or a robin in Spring.

What is your most treasured possession?

My mind, may it stay with me until the end.

What do you regard as the lowest depth of misery?


Where would you like to live?

Someplace surrounded by friends.

What is your favorite occupation?


What is your most marked characteristic?

Expression as the need of my soul.

What is the quality you most like in a man?


What is the quality you most like in a woman?


Who are your favorite writers?

E.B. White, Peter Drucker, Lewis Thomas. George Orwell, Ernest Hemingway, Don Marquis, all of whom were full of pith.

Who is your favorite hero of fiction?

Don Quixote. He and I share a lot in common.

Who are your heroes in real life?

Everett Koop, M.D.

What are you favorite names?

Spencer and Carter, the names of my sons, and Paris, my late French Bulldog

What is it you most dislike?

Closed minds and those who run their mouths before they put their minds in gear.

How would you like to die?


What is your motto?

Patients and physicians do what they feel they have to do and what the system allows them to do. Don’t judge them too harshly. They are simply being human.

Tweet: A book of Marcel Proust questionnai answered by 101 celebrities and one doctor reveals the meaning of Love, Death, Happiness, and Life.

Wednesday, April 27, 2011

Four Health Reform Worry Stories

What Me Worry?

Alfred P. Newman, Mad Magazine Motto, 1955

I worry about health reform.

Worry Story #1 - Hospital health care costs about to go sky high. Health reform uncertainties are driving doctors into the arms of hospitals. Hospital outpatient activities are growing at a furious pace. Data from 2008 indicates the average doctor-based visit is $199, the average ER visit $922, and the average hospital outpatient visit $1275 (“Outpatient Care in Hospitals Is No Bargain,”Medpage, April 26, 2011). Ergo, hospital outpatient costs will cause reform-induced costs to explode. Not so fast, say the Feds. That smacks of anti-trust. Besides, we will control those costs with ACOs, which will reduce hospitalizations. Not so fast, say I, ACOs may never get off the ground.

Worry Story #2 - Doctors and hospitals will reject electronic medical records, on which the Obama administration bet $27 billion in its last stimulus plan. Don’t worry. The American free enterprise system may save the day. Cloud computing, wherein doctors and hospitals transfer software and hardware, onto the Web may save the day. Furthermore, EHR companies like Practice Fusion, Inc, in San Francisco are offering EHRs for “free” because advertising on the Fusion site pays the freight. Don’t laugh. Practice Fusion already has 10 million users, more than Kaiser at 8.7 million, the VA hospital system at 7.9 million, and the whole country of Denmark at 5.5 million.

Worry Story #3 - People will start taking the pronouncements of the Dartmouth Health Atlas seriously. For the last 30 years the Dartmouth people has come out with national breakdowns of Medicare claims, which invariably show wide variations between U.S. regions. The current report focuses on end-of-life care for people with chronic illnesses. This time around they found the percentage of deaths in hospital varied by a factor of almost four across hospital referral regions, and the average number of hospice days per patient in the last six months of life varied by a factor of more than six. They attribute these variations of hospital and specialist to ignorance or greed. No matter that socioeconomic conditions vary tremendously, that people in New York City have different expectations than in Minot, N.D. or elsewhere, and that poor people are sicker than affluent citizens.

Worry Story #4 - Health reform pressures will cause kindly solo practitioners to become obsolete. According to Greg Scandlen, a staunch opponent of Obamacare, and I quote:

“The New York Times has published a sobering article by Gardiner Harris which describes how quickly we have allowed the best health care system in the world to slip through our fingers.”

“The story keys off Dr. Ronald Sroka, a family practice physician in Crofton, MD. It says, Handsome, silver-haired and likable, Dr. Sroka is indeed a modern-day Marcus Welby, his idol. He holds ailing patients’ hands, pats their thickening bellies, and has a talent for diagnosing and explaining complex health problems. Many of his patients adore him.”

“But he is being pushed into extinction by academics like David J. Rothman, president of the Institute on Medicine as a Profession at Columbia University who is quoted:

‘Those of us who think about medical errors and cost have no nostalgia — in fact, we have outright disdain — for the single practitioner like Marcus Welby.’

“Mr. Rothman’s disdain and his allies in the insurance industry and government bureaucracies are winning the war. The article explains:

The share of solo practices among members of the American Academy of Family Physicians fell to 18 percent by 2008 from 44 percent in 1986. And census figures show that in 2007, just 28 percent of doctors described themselves as self-employed, compared with 58 percent in 1970.”


Maybe I shouldn't worry. It will all work out in the end. Besides, as the late Walter C. Hagen (1892-1969), the famous golfer, observed,"You're only here for a short visit. Don't hurry. Don't worry. And be sure to smell the flowers along the way." It is April 27, the flowers are blooming, and I am smelling them.

Tweet: Doctor Reece worries about hospital costs, EHR rejections, variations of end of life care, and the obsolescence of primary care.

Tuesday, April 26, 2011

Primary Care Doctors, Education Debts, and Other Burdens

The negative impact of high tuition on physicians has not influenced medical school administration. In the last decade, the costs of a medical education increased at twice the rate of inflation without justified cause. This leaves graduates anxious to increase their salary and feeling justified to enforce co-pays in their practice, overbill and avoid low-paying insurances, including Medicaid patients. Moreover, they often are paying off this debt well into their 50’s at variable interest rates well above those paid by home owners

Andrew Ibraham and John Brockman, “A Moral Imperative to Address the Cost of Training Our Doctors,", April 26, 2011

Medical students are smart.

They know:

.Many of their classmates are over $200,000 in debt upon graduation, and the average debt is $130,000.

.Entering into a primary care career may commit them to paying off debts into their 50’s.

• specialists bring home roughly twice the income of primary care doctors and make $3.5 million more over the course of a lifetime.

• the cost of setting up a solo practice is prohibitive, and they may not be able to even give the practice away should they leave the practice;

. primary care physicians are much in demand by hospitals, who badly need referrals from these physicians to fill their beds;

• specialty-dominated medical school faculties disparage community primary care practitioners as LMDs, local medical doctors;

• current reform measures – federal grants, tuition-free rides to aspiring future primary care doctors, forgiveness to students choosing to practice in doctor-short areas - will take time to filter down to them;

• token increases in codes for primary care candidates – are unlikely to significantly close salary gaps with specialists.

• federally- promoted and incentivized medical homes and accountable care organizations are predicated on the premises of a broader primary care base.

• most medical school administrations are so far insensitive to the debt-inflicted plight of primary care doctors, because medical school tuitions are still climbing at twice the rate of inflation.

• the percentage of their classmates going into internal medicine remains about 25% but only 2% are choosing primary care as a subspecialty of internal medicine.

• the American public is specialist-oriented and is willing to pay more for specialist procedures than generalists opinions and prescriptions;

• where the rubber-hits-the-road, the specialty-dominated RUC (Relative Value Update Committee), which sets the fees for doctors, the committee generally rules in favor of higher specialty fees.

• creditors charge higher rates and remain unforgiving, charging higher rates than homeowners.

• Somehow the primary care slots will be filled by foreign medical graduates, who already provide more than 25% of all primary care positions in American health care.

• The public perceives that American doctors, all of them are doing well, thank you, and indeed, are paid much more than their foreign counterparts.

A note on the latter point. American doctors make more on paper on average than comparable foreign physicians ($230,000 vs. $113,000 for specialists and $161,000 vs. $83,000 for generalists) but these comparisons often ignore factors such as educational debt, which is much less abroad and is often paid by government; malpractice premiums, which are often inconsequential in other nations; costs of meeting third party expenses, which may comprise 50% of overhead; and cost-of-living expenses, which on average are 37% higher in the U.S. than abroad.

Tweet: The United States is singularly unique in the educational debts it imposes of on its physicians, who reap the consequences.

Monday, April 25, 2011

California Dreamin’: We’ve Got No Primary Care Doctors But We’ll Implement Obamacare Anyway

All the leaves are brown
All the leaves are brown
And the sky is grey
And the sky is grey
Ive been for a walk
Ive been for a walk
On a winters day
On a winters day
Id be safe and warm
Id be safe and warm
If I was in l.a.
If I was in l.a.
California dreamin
California dreamin
On such a winters day

Lyrics to California Dreamin’

Californians are warm weather schemers and health reform dreamers, even as California suffers through its budgetary winter, with a deficit of $22 billion. Governor Jerry Brown has proposed $1.7 billion cuts in Medi-Cal and 10% decreases in payments to physicians and clinics.

California ranks 47th among states in Medicaid physician payment rates, and has only one primary care doctor for every 2000 Medicaid beneficiaries, The Golden State would need to recruit 350 new primary care physicians to add to existing 3379 primary practitioners to provide care under the Obama plan, which will increase demand for their services by 70% by 2014.

Here are the words of two policy types from the University of California and George Washington School of Public Health (Bindman, A. and Schnieder, A, “Catching a Wave – Implementing Health Care Reform in California, “ New England Journal of Medicine, April 21, 2010),

“Addressing this shortfall will be very difficult. There's not enough time between now and 2014 to train and deploy sufficient new primary care physicians. In addition, Medi-Cal patients are now highly concentrated among a relatively small percentage of providers: approximately 25% of primary care physicians provide more than 80% of the visits for Medi-Cal beneficiaries . Thus, much of this needed capacity will have to be developed from among physicians who now have little or no involvement with Medi-Cal patients.”

No matter. Dream on. California will provide coverage even if there are no doctors to provide care.

How will California execute this magic trick – coverage without access to doctors?

Well, first, the state plans to expand converge to the uninsured before 2014 on a county-by-county basis.

Two, California will use federal resources available under a waiver to invest in its public safety-net hospitals.

Third, California will expand its use of Medicaid managed care by mandating the enrollment of 320,000 elderly and disabled people.

Then, comes the authors’ caveat: “Meanwhile, other early signs in California are worrisome.”

Translated, this caveat means “No one has the faintest idea who will take care of 1.7 million new Medicaid beneficiaries coming on board in 2104?” No answers here, except somehow physicians will form partnerships with the state to “determine whether coverage expansion translate into access to care and improved population health.”

If this does not happen, add the authors, ”Missing this opportunity to collaborate on improving the population’s health could result in a wipeout of epic proportions.”

Indeed, a wipeout could occur. California is broke. The U.S. is broke. Primary doctors fear of going broke because California underpays them and now promises to overwork them.

For primary practitioners, this situation is, as Californian John Steinbeck, said, "The Winter of Our Discontent.” Californians can always dream. The weather is warm, and fantasies live on. As comedian Fred Allen, observed, “California is a wonderful place to live – if you happen to be an orange.”

Tweet: California is dreamin’ if it thinks he can implement Obamacare while providing care to millions of its new Medicaid beneficiaries.

Sunday, April 24, 2011

Of Zebras, Rare Diseases, and Google

When you hear hoof beats behind you, don’t expect to see a zebra.

Medical aphorism on the rarity of rare diseases

A rare or "orphan" disease affects fewer than 200,000 people in the United States. There are more than 6,000 rare disorders that, taken together, affect approximately 25 million Americans.

National Organization for Rare Disorders (NORD)

I have been asked to speak before a group of seniors about rare diseases. The thought fills me with trepidation. I am not an expert on rare diseases. There are so many of them. I fear being misquoted or misunderstood. I worry about malpractice implications, even though I am no longer in practice.

Nevertheless I am going to give the seniors my two cents worth, which is about what my opinion is worth. The temptation is irresistible. “To talk of diseases,” as Sir William Osler said, “is a sort of Arabian Nights entertainment.”

This sort of entertainment appeals to doctors. Just ask me. For me, the popular feature of the New England Journal of Medicine is its section “Case Records of the Massachusetts General Hospital,” which weekly discusses rare and mysterious diseases. I turn to it first when I read the Journal.

Diagnosing rare diseases is a combination of experience, intuition, triangulation, thought association, exclusion, knowledge, serendipity, and listening to the patient. A store of obscure and arcane information on rare or exotic syndromes helps a bit too. Making diagnoses is especially tough in multisystem diseases with vague symptoms that come and go, or in diseases for which there is no definitive diagnostic test or biopsy.

To complicate matters, the Internet has produced a generation of "cyberchondriacs,” who imagine they have every disease imaginable. Managed care and economic pressure compelling doctors to see a new patient every 10 minutes to so to make ends meet compounds diagnostic dilemmas.

Many Internet geeks believe new-fangled algorithms and diagnostic support systems at the point of care will resolve most diagnostic mysteries or at least point the right direction.

Jerome Groopman, MD, a distinguished diagnostician at Harvard Medical School, is not so sure. In his book How Doctors Think (Hougton Mifflin, 2007), he says,

Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment – distinguishing strep throat from viral pharyngitis, for example. But they quickly fall apart when a doctors needs to think outside their boxes, when symptoms are vague, or multiple and confusing or when test results are inexact. In such cases – the kinds of cases where we most need a discerning doctor – algorithms discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they constrain it.”

“Similarly, a movement is afoot to base all treatment decisions strictly on statistically proven data. This so-called evidence-based medicine is rapidly becoming the cannon… But today’s rigid reliance on evidence-based medicine risks having the doctor chooses care passively, solely on the numbers. Statistics can’t substitute for the human being before you; statistics embody averages, not individuals.”

In the main, Groopman is right. But computer diagnosis, particularly on Google, has a place. Articles in the British Medical Journal (Tang.H, and Nu, J, “Googling for a Diagnosis- Use of Google as a Diagnostic Aid- An Internet-Based Study, November 10, 2006) and the New England Journal of Medicine (Greenwald, R, “…And a Diagnostic Test Was Performed, ”November 10, 2005) indicate a Google search may quickly reveal the diagnosis of a rare disease. Google does this through its Page Rank algorithm. A correct hit on Google is called a “Ghit."

The zebras are out there, but don’t look for them first.

Richard L. Reece, MD, has posted 1750 blogs at medinnovation blog over the past 4 1/2 years. His main themes concern health reform and innovation and how they impact physicians and American culture as a whole. He works closely with the Physicians Foundation, but his opinions are his alone. He has written eleven books. His latest book, The Health Reform Maze, is now at Greenbranch Publishing and will be released in June. Doctor Reece’s website,, is now up and running He invites comments and questions on his blog and will respond to each comment or question on his blog or to him directly at 860-395-1501 or

Saturday, April 23, 2011

A Stream-of-Consciousness Health Reform Blog

April 23, 2010 – Stream-of-consciousness writing (SOCW) is spontaneous , emotional, and unstructured. You see stream-of-consciousness writing everywhere today – on Facebook, Twitter, and on blogs. Blogs are essentially SOCW on-line daily logs. They are about connecting with your interior universe.

Here’s my SOCW for today on health reform.

I spent the morning on the final editing of Health Reform Maze, my book out in June. It’s essentially about the ups and downs, ins and outs, complications and consequences of health reform.

I don’t think reform as presented in the law will work very well.

Its ultimate inner workings are up for grabs and will depend on the outcome of current budget debate and on the 2012 Presidential election. The big issues will be soaring cost, State’s rights, the law’s constitutionality, taxing the haves versus providing for the have-nots, and how to cut Medicare and Medicaid costs and benefits without outright rationing or human creulties.

I have no idea about reform outcomes, but I know some sort of reform is necessary. I lean towards incremental market reforms. I like the idea of a double mandate with a lid - a national privately-run system with universal coverage, health plans being forced to accept all comers, and a catastrophic ceiling after which government subsidies kick in. Health savings accounts and vouchers and block grants may hasten the process. Some sort of government oversight, a health SEC, will probably be necessary, but government ought to oversee with a light hand, and let markets do their wonders.

My 53 year niece is dying of rapidly progressive pancreatic cancer. It is terribly sad situation. There is no hope for her, and I’m not at all confident we have a solution to pancreatic cancer in the near future. The solution may be genomic.

It is the day before Easter, and all I can do is to pray for her and pray that research will pay off soon. In the end, spiritual solace, pain relief, and comfort are the best we can offer her and others with terminal pain,

There is not much physicians can do about health reform. We can object to the cost of the present law. We can complain about its onerous regulations and its proposed “innovations,” which are mostly about models restricting the economic behavior of doctors by herding them into new business models with restricted budgets.

Doctors will react in two ways – one, by becoming employees of hospitals and two, by bailing out into concierge practices and other innovative models free of third party payment schemes.

For existing models in which doctors stay in practice, surviving will be all about productivity, efficiency, and practice management dominated by IT applications. I do not believe we will soon have a national inter-operative electronic system connecting everybody with everybody else real-time unless so-called Cloud Computing, off-loading software and hardware onto off-site Internet systems catches on big time at a price hospitals and doctors can afford. It might.

The search for productivity takes strange twists and turns. Doctors, slowed by as much as 30% by the time it takes to enter data into electronic medical records, are turning to humans to speed things up. Doctors are hiring “medical scribes” to transcribe for them. One California-based scribe company, ScribeAmerica, has 800 employees in 21 states. Another, PhysAssist in Fort Worth, has 600 employees. Mostly ER doctors are hiring scribes, but other specialists, like ophthalmologists, are hiring scriveners too, usually young people interested in a medical career.

If you the doctor are slowed by an e-medical record.
And you seek to have your former productivity restored.
Consider hiring a medical scribe.
The scribe will promptly transcribe.
And you will no longer be slowed by the keyboard.
In other words, humanly restructure,
with less electronic infrastructure.

Thus ends my spontaneous outburst.

Friday, April 22, 2011

The Medical Innovation Weathervane

I like the weathervane as a metaphor for medical innovation. Innovation comes from everywhere – the North, the South, the East, the West – and everywhere in between.As a medical meteorologist, I see innovation coming from all directions.

I also like the idea of cows as accurate weather forecasters. If cows cluster together, you know something is up. The closer the cows together, the worse the weather is going to to be. Not that I believe in cows as great innovators. As one sage observed, ”Sacred cows make great steaks.”

Innovation Models

The federal government - The health reform law sets up the Medicare and Medicaid Innovation Center. It has noble goals – better care, better health, and lower costs. It has models for getting there - Accountable Care Organizations, Medical Homes, Community Health Centers, Population Health Centers, scores of regulations and agencies to improve “quality,” models to judge and pay for ” performance,” reward prevention and safety – and do it all from the top . For government and policy aficionados , these models are the “True North” for bringing order out of chaos and costs down to earth. To me, however, government through its regulations and control-freak mentalities impedes innovation. The nature of the beast limits its potential.

Innovation Grade: C- for present, C+ for future. Physicians and ordinary citizens are likely to resist its bureaucratic mindsets, and consumers may resent its limitations of choice.

Integrated Managed competition organizations from the West – Kaiser, Virginia Mason, Intermountain Healthcare, Group Health of Seattle, Midwest – Mayo, Marshfield, Cleveland Clinic, Health Partners, from pockets in the East – the Boston Academic complex, Geisinger, Dartmouth, large academic institions with tentacles out in the community. These integrated organizations have successful track records, capital and market skills, and dominant market share in their regions. They represent a tested and proven business models. They have sterling reputations in their own minds. But they may not have a broad primary care base. They may not lower costs, and they deliver less than 10% of U.S. health care. But all are innovation-minded, are high a new business and technological innovations, and have salaried physicians responsive to central management and business-minded physician leaders.

Innovation Grade: B for the present, B+ for the future. Its physician leadership and the public's continued trust in physicians gives it potential for growth.

The corporate world - The recent formation of Innovation Care, Inc, by Intel and GE is a sign of renewed interest in health care innovation by corporate giants. Other major players are Google and Microsoft, and a host of other large and medium sized players who see gold in the IT sector. All see Gold and sense opportunity in the health sector, which will soon represent 20% of U.S. economy. These various enterprises are focusing on “connectivity,” on connecting patients, consumers, and health care organizations by wirelessly empowering health-conscious consumers. These companies are focusing on more decentralized vision of the health care world - on home care, telemedicine, patient monitoring with mobile devices, and making patients more independent and self-reliant, on providing out-of-hospital, less invasive care, and stressing patient choice.

Innovation Grade: B- present, B future. It has know-how and capital, but operates at the fringes of medicine.

The independent practicing physician and hospital world- This is the most ill-defined and most promising. Truly big innovations require a business plan, venture capital, infrastructure, and entrepreneurial talent and experience. These are things most physicians and hospitals do not possess. Yet there are hundreds of thousands of physicians out there seeking an escape from coercive, regulatory, judgmental forces imposing outside regulations and demands on traditional physician business practices and threatening physician autonomy. Medicare and Medicaid underfund and over regulate hospital. Hospitals and doctors are reluctant business partners. Yet John Goodman, the conservative economist, says these desire to escape from outside pressures, coupled with desire of consumers for more choices and President Obama’s health care law “ will bring a major transformation of the nation’s health care over the next decade in the form of a large migration of patients, doctors, facilities, and services out of the third-party payer system.”

“It will cause a major increase in concierge doctors, concierge facilities, and concierge-type services. It will lead to the creation of new markets where providers are free to repackage and reprice their services without third-party payer approval; where transparency of price and quality becomes the norm for patients.and where suppliers of services compete for patients on price, quality and amenities.”

Innovation Grade: C- for the present, B+ for the future. Hanging together or hanging separately will be the problem. If hospitals and physicians mobilize in significant numbers, they could make all the difference.


True innovation to improve care, lower costs, widen access, and afford choice will require everyone to participate. In a capitalistic, center-right, diverse nation like the United States, no single innovation model will dominate. Innovation must come from all directions and all sectors. I agree with Henry Clay (1777-1852), the great Southern Senator, who proclaimed, “I know no South, no North, no East, no West, to which I owe an allegiance..The Union, Sir, is my country.”

Wednesday, April 20, 2011

When You’re Sixty Four

Apologies to the Beatles

When you get older losing your hair,
Ten years from now.
Will Medicare still have a bottomline
Will it send Birthday greetings or feed you a line

If you’ve still out there ten years from now
Will Medicare lock the door
When you need new knees, and you have no fees
When you’re sixty-four

You'll be older too,
If you vote and say the word
Will Medicare stay with you

You can vote for Ryan
Or vote for Obama
Or the Dalai Lama
Anything goes when you're fifty four

Will you pay a Medicare voucher
Will Medicare go bankrupt
Will it still be corrupt
When you’re sixty four

You may still be randy, lighting a fuse
When Medicare lights have gone out
Medicare will no longer burn by the fireside
Politicians may have taken it for a ride

Doing the garden, digging the weeds
Who could ask for more
You will need Medicare, it will still bleed you
When you’re sixty-four

You can go to the doctor, but I fear
But he/she just might be too dear
You can scrimp and save
Grandchildren on your knee
But they may be in a financial cave

Send me a postcard, drop me a line,
Stating Medicare’s point of view
Indicate precisely what you mean to say
Medicare sincerely, wasting away

Give me your answer, fill in a form
Mine for nevermore
Medicare, will you still be there, can I still believe in you
When you’re sixty-four

So sis Boomer Boomer
Bye Bye Medicare
Sorry to see you go
When you're sixty-four

Tweet: When you’re 64, will Medicare still be there, will doctors still be there, will you pay by voucher, will it be the same, when you’re 64.

Book Review: Health Care Will Not Reform Itself

April 20, 2011 - Today I received a copy of George Halvorson’s book Health Care Will Not Reform Itself (CRC Press, 2009). Halvorson is CEO of Kaiser Permanente, the largest not-for-profit health plan and system in America – with eight and a half million members, 160,000 employees , 14,600 physicians, 35 medical centers, 431 medical offices, and $42 billion in annual revenues with $1.3 billion in net income.

Kaiser has pioneered use of electronic medical records and computer connectivity between patients and caregivers. Kaiser has invested $4 billion to computerize medical information for members and patients.

Halvorson’s major thesis in his book is that we have the largest and most costly medical non-system in the world. And for the wrong reasons. Our non-system is piece-meal, functions largely on a fee-for-service basis, costs $2.5 trillion a year to maintain, has 18,000 individual codes, and regrettably no billing codes for better outcomes, cures, data collection, measuring improvement, or for connecting its members.

The consequence of this chaotic system, says Halvorson, is an unlinked, inconsistent, often crazily incented, volume-based array of profit-making business entities. This situation suits most health care businesses, hospitals, and doctors just fine, for individual participants enjoy continual growth and wide profit margins, who do as they please and usually profit from their mistakes.

Everything, it seems, is changing, but the status quo, and present health reform efforts are likely to be futile. To use Halvorson’s words, the system will not reform itself.

What we need, claims Halvorson, is the double mandate, a system operative in European countries like Austria, the Netherlands, and Switzerland, which have systems in which private companies, not government, provide all coverage. Those countries use a double mandate – Mandate One; Everybody MUST buy coverage; Mandate Two: Every private plan MUST sell coverage to anyone who applies.

In other words, the ideal system has universal coverage with everyone in the risk pool.

Halvorsan’s 157 page book is more complicated than just implementing a double mandate. To make such a system work, we need other things as well:

• a culture of health to minimize obesity and diabetes,

• an agenda of continual health improvement ,

.a national forum for cost reduction,

• complete data on care cost drivers,

.a national commission on health care costs,

• a national interoperative electronic system connecting everybody,all the time, real time,

• packages of care rather than pieces of care,

• teams of caregivers rather than individual caregivers,

• virtual care even in remote locations, and continuity and accountability.

Thi is easier said than done, of course, given our fragmented system with incentives to keep things the same and to make more money while doing it.

Halvorson has an obsession with computerization. On last page of his book, he asserts, ”If we computerize care record keeping appropriately, we could have a database that turns 250 million Americans into a huge, ongoing, data-rich clinical trial. We could and should become a nationwide culture of medical excellence, medical efficiency, and continuous medical improvement.”

“Could, should.” These two words pretty much summarize Halvorson’s belief about the need for a systematic approach to care. We could do it, and we should do it. He has put these beliefs into action at Kaiser.

He says one huge obstacle to health reform is loss of revenue for providing better, more efficient care.

For me, a key sentence in his book is:

“That potential loss of revenue from improving care is a harsh reality that American economists and policy gurus need to understand if we really want to reform health care delivery in this country. A few large systems in America – like the Geisinger System, the Mayo Clinics, Virginia Mason, Intermountain Healthcare, Health Partners, Group Health Cooperative of Seattle, and Kaiser Permanente caregivers – are doing important work how health care can be improved with systematic re-engineering. “

“Those efforts are works of ethical commitment, not economic self-interest, and the caregivers involved typically end up with fewer billable events, less revenues, and no economic reward for their efforts. In fact, economic penalties are the usual outcome for most health systems.”

That is why getting from here to there, to systematic health reform, from profitable individual practice to collective non-profit practice , in Halvorson’s view, will be so difficult.

To me, this is an idealistic but unrealistic vision of what health reform will require in America, given that care is delivered in 5000 hospitals and by 500,000 physicians in independent practices, but it is a vision worth pondering. Halvorson’s arguments for reform are logical, but self-interests tend to be pathological and politics psychological.

Finally a word about Halvorson’s writing style. Before becoming a health care executive, Halvorson was a journalist. It shows.

• He writes in short paragraphs with short sentences with short words in short chapters,

• inserts frequent subheadings, bar graphs, and charts.

• Repeatedly stresses his main points – provide the right care at the right time at the right place, have goals, back your care with data, address the big problems, i.e, chronic disease.

• Provide care more cheaply, consistently, safely.

• Strives to be analytical rather than political or partisan.

He fails on the last point. This is a devastating critique of our present system – its incentives, its methods, and its results – compared to other nations.

Tweet: In Health Care Will Not Reform Itself book, Kaiser CEO says -universal coverage and universal acceptance by health plans –lowers cost.

Tuesday, April 19, 2011

For Physicians the Future Is Not What It Used To Be

April 19, 2011 - Before you delve too deeply into this entry, a word of warning. My wife warns me I am being a little too serious and repetitive fin this blog for her blood. She is undoubtedly correct, but here goes anyway.

My favorite book is The Age of Discontinuity: Guidelines to Our Changing Society (Harper & Row, 1968). I keep it at my bedside for late night intellectual nourishment In the book, the late Peter F. Drucker (1909-2005), a social critic and philosopher, describes four discontinuities in modern society.

1. Genuinely new technologies are upon us. Today these new technologies include the Internet, its various search engines, and the social media, which almost overnight, have transformed how we do business and relate, rate, and berate one another.

2. We face major changes in the world economy – Today these would include the same economic appetites, aspirations, and demands – across national borders, languages, and political ideologies.

3. The political matrix of social and economic life is changing fast.
Today’s society is pluralistic, and every major social task is entrusted to large institutions run organized for perpetuity and run by managers. The future does not belong to rugged individualists, but to plugged-in collectivists.

4. Knowledge has become the central capital, the cost center, and the crucial resources of the economy. This changes everything – how we teach and learn, how we react politically and to each other.

Physician Impact

These discontinuities profoundly impact physicians, who are themselves a pluralistic society – aspiring pre-meds and retiring doctors, newly minted, the middle-aged, the old codgers; the entrepreneurs and the arbitrageurs; consolidators, coordinators, integrators, and decentralizers; leaders and followers; women and men; generalists and specialists.

It isn’t easy keeping all of this – and the profession – together. The pressures are immense.

• IPad, IPod, android, Twitter, Facebook, apps, EHRs, EMRs, and PHRs promise instant gratification and monitorization.

• Government overpromises, generates unrealistic demands, and then underdelivers.

• Hospitals beckon. Only they have the capital and infrastructure and marketing skills to make feasible the application of medical technologies.

• Third parties say only they have the IT skills and data to measure and judge outcomes and performance of physicians even when physicians know outcomes often rest more on behaviorally responsible patients and the stage and progression of their disease. Nature generally takes its course, no matter what the physician does.

• Young physicians, leery of the troubles and harassments inherent in running a practice, swirling political controversies surrounding physician motivations and fees, seek refuge in hospital employment. Middle-aged physicians, feeling overworked and underappreciated, either hang in there, switch careers, become employees, or join larger groups. Older physicians , if they can, retire or escape into concierge havens.

My wife is usually right. I tend to be too serious about the deleterious conditions facing doctors. I ought to lighten up. I ought to mix humor and humanity. I ought to br more optimistic. Everything will turn out all right in the end. There is always gloom for improvement.

Tweet: In future, doctors must deal with wireless technologies, government overpromises, becoming hospital employees, and installing expensive EMRs

How an EMR Emotionally Disengages Physicians from Their Patients

Preface: The following blog appeared in I reprint it because it reflects my sentiments. I wish I had written it myself.

by Richard Barager, MD

“See me, feel me.”

Yes, that’s right, the title of a song played at Woodstock by The Who—at sunrise of the third day, no less—is the title of my post. The song begins with those very words sung in dramatic refrain, followed by four more: Touch Me/Heal Me.

The same four imperatives succinctly describe the essence of what patients want from their doctors. But in the age of the EHR (electronic health record), they may have to stand on top the exam table and ululate these lyrics at the top of their lungs just to get their doctors to look up from their laptops. And smash a guitar, too.

An article in a recent issue of The Journal of the American Medical Association reviews the Department of Health and Human Service’s ambitious plan for converting the nation’s paper-based medical record system to an electronic one.

“Meaningful use provisions will help improve legibility of clinical records, reduce prescription errors, improve adherence to guidelines, improve patients’ access to their records, and ensure that clinicians and hospitals are capable of exchanging clinical data.”

Laudable intentions, all. And in an effort to fast track this massive undertaking, a $44,000 bribe—er, incentive—has been allocated for each physician who purchases and implements (for about the same cost as the incentive) an electronic health record in his or her office by 2014. The article goes on to warn, like a surgeon obtaining informed consent, of the risks associated with this nationwide conversion.

“Many of these transitions will be poorly executed, some with serious consequences. Poorly designed or poorly implemented EHR systems can cause as much harm as good. Reports of failed adoption and patient harm are likely to emerge.”

And so on and so on, the author’s disclaimer mainly a congeries of tech snafus likely to plague this feverish, government-mandated rollout. I appreciate the heads-up on potential adverse effects, but he left a biggie off the list of unintended consequences: the decided propensity of digital health care records to emotionally disengage physicians from their patients.

Doctors ask patients to submit to unspeakable things: the carving of viscera, the infusion of poisons, the ghoulish machines we attach them to. Their consent to undergo such unnatural acts depends upon an irrational trust—irrational in that an emotional, rather than logical, connection between doctor and patient gives rise to it. Such trust is the coin of the medical realm, and the first step in gaining it is the authentic recognition of the basic humanity of the patients seated in front of us.

Experienced physicians establish patient-rapport in three main ways: eye contact, empathic listening, and touch. Note that verbal communication is not on the list; it’s not that easy to talk someone into trusting you. But the more we stare at our computer screens, the less eye contact we make. See me. And the more time we spend scrolling for lab results, the less time we spend in empathic listening mode, vicariously experiencing our patients. Feel me. The more our hands are on the keyboard, the less they reach out in a reassuring, comforting way. Touch me. And the less successful we are in establishing these empathic connections, the less likely we are to cure the conditions that caused our patients to come to us, like pilgrims to Epidaurus, in the first place. Heal me.

Don’t get me wrong; I’m not some churlish medical reactionary yearning for the halcyon days of Marcus Welby. We’ve had an EHR in our office for nearly four years, and I like it well enough. It got rid of our transcriptionist, freed up an entire room full of paper charts waiting to be shredded, and improved the flow of information to our referring physicians. I encourage all doctors to go digital.
Just remember to look up from the keyboard once in awhile and smile.

Richard Barager is a nephrologist who blogs at his self-titled site, Richard Barager.

Tweet: Electronic medical records disengage doctors from patients. You cannot look at computer screen and patients at the same time compassionately

Monday, April 18, 2011

Eggsamining the Government Easter Bunny

Easter is near. It is time to ponder the eggspert workings of the Government Easter Bunny.

On the face of it, the whole concept of the Easter Bunny is eggsceptional. Imagine: a bunny laying eggs, carrying eggs, helping children look for eggs.

These images lead to a series of Government Easter Bunny queries.

• What’s so eggsordinary about the Government Easter Bunny?
It lays one big egg after another, each bigger than the other.

• What do you find in the Government Bunny’s Easter basket?
Taxpayer’s eggspenditures.

• Why does the Government Bunny paint its eggs red?
To match its end, from which its eggs it eggstrudes.

• What does the Government Bunny do when it runs out of red paint to color its eggs?
It covers them with red tape.

• What does the Government Bunny do when it runs out of chicken eggs?
It prints goose eggs.

• What do you call the Eggsexecutive branch of government?
The Presieggsedential branch.

• Where does the Government bunny get its eggs?
From whomever it can eggstract them.

• Why does it color its eggs?
To color its eggsternal bias.

• Why do you call an Easter egg hunt?
An eggsploratory search.

• How do bunnies stay healthy?

• What do you call Easter when you are hopping around?
Hoppy Easter!

• Why are people always tired in April?
Because they have just finished a long March

• What do you call a Government bunny with a large brain?
An egghead.

• What do you call a bunny with a dictionary in his pants?
Smarty pants.

• What do you call a mad bunny?
A rabid rabbit.

• What do you call ten bunnies marching backwards?
A receding hareline.

• What is the Government Easter Bunny suffering from after a hard day's work?
Eggstreme fatigue.

• What did the rabbit say to the carrot?
It's been nice gnawing you.

• How should you send a letter to the Easter Bunny?
By hare mail!

• What do you call angry rabbits who have just marched in a sweltering Easter parade?
Hot cross bunnies

• How does a rabbit make gold soup?
It begins with 24 carrots.

• Which side of a rabbit has the most fur?
The outside.

• How do you tell what’s going inside the Eastern Bunny?

• How did the soggy Easter Bunny dry himself?
With a hare dryer!

• What would you get if you crossed the Easter Bunny with Chinese food?
Hop suey!

• How do you catch a unique bunny?
Unique up on it!

• What did the bald Easter Bunny say?
Hare today, gone tomorrow.

• What should the writer of this blog do?
Realize his time has eggspired.

Tweet: When you closely eggsamine the Government Easter Bunny. You will realize it lays one big egg after another and covers it with red tape.

The Composition of The RVS Update Committee

Preface: Lately RUC, short for the Resource-Based Value Update Committee, has come under fire for favoring specialist pay over primary care pay. I have heard the side of the argument saying the AMA is somehow in collusion with CMS favoring specialists. This favoritism, it is said, is directly responsible for runaway health costs.

Here is how the AMA explains and justifies its position on RUC.

Annual updates to the physician work relative values are based on recommendations from a committee involving the AMA and national medical specialty societies. The AMA formed the AMA/Specialty Society Relative Value Scale Update Committee (RUC) to act as an expert panel in developing relative value recommendations to CMS.

The AMA established a process in the course of its activities to develop relative values for new or revised CPT codes. This process was established in the course of the AMA's normal activities and as a basis for exercising its First Amendment right to petition the Federal Government as part of its research and data collection activities, for monitoring economic trends and in connection and related to the CPT development process.

In addition, CMS is mandated to make appropriate adjustments to the new RBRVS in response to the Omnibus Budget Reconciliation Act of 1989 to account for changes in medical practice coding and new data and procedures. The purpose of the RUC process is to provide recommendations to CMS for use in annual updates to the new Medicare RVS.

There have been numerous changes and improvements to the payment system since 1992, many initiated by the RUC, but the principal role and purpose of the RUC remains to provide final RVS update recommendations to CMS. The RUC is a unique committee that involves the AMA and the specialty societies and gives physicians a voice in shaping Medicare relative values. The AMA is responsible for staffing the RUC and providing logistical support for the RUC meetings. Neither the RUC nor any of its subcommittees or workgroups have the authority to direct the AMA to conduct work projects, products or research.

Composition of the RVS Update Committee (RUC)

The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies including those recognized by the American Board of Medical Specialties, those with a large percentage of physicians in patient care, and those that account for high percentages of Medicare expenditures. Three seats rotate on a two-year basis, with two reserved for an internal medicine subspecialty and one for any other specialty. The RUC Chair, the Co-Chair of the RUC Health Care Professionals Advisory Committee Review Board, and representatives of the AMA, American Osteopathic Association, the Chair of the Practice Expense Review Committee and CPT Editorial Panel hold the remaining six seats. The AMA Board of Trustees selects the RUC chair and also the AMA representative to the RUC. The individual RUC members are nominated by the specialty societies and are approved by the AMA.

American Medical Association Representative
CPT Editorial Panel Representative
American Osteopathic Association Representative

Health Care Professionals Advisory Committee Representative
Practice Expense Review Committee Representative

• Anesthesiology
• Cardiology
• Colon and Rectal Surgery*
• Dermatology
• Emergency Medicine
• Family Medicine
• General Surgery
• Internal Medicine
• Nephrology*
• Neurology
• Neurosurgery
• Obstetrics/Gynecology
• Ophthalmology
• Orthopaedic Surgery
• Otolaryngology
• Pathology
• Pediatrics
• Plastic Surgery
• Pulmonary Medicine*
• Psychiatry
• Radiology
• Thoracic Surgery
• Urology
* Indicates rotating seat

Sunday, April 17, 2011

Occasional Verse: Taxing the Rich

The problem the Democrats have is that they can no longer say with a straight face that raising taxes on the wealthy is going to enable them to pay over the next generation for the programs they cherish. So what do you do?

William Galston, a Democrat, “The Budget Debate, Revealed,” New York Times, April 17, 2011

Taxing the rich,
has this hitch.
You can never collect enough.
This is strictly off the cuff,
but you can't cover one year of D.C. spending,
and offset interest on other nations' lending,
by simply taxing the rich,
or chasing down the tax snitch.
That's the lesson of Laffer's famous curve,
The more you tax,the lesser the hor'd'oeurve.
Taxing 100% of incomes of $250,000 or more,
gets you 140 days for running the store.
Taxing all the profits of the Fortune 500,
gains you 40 days to cover IRS plunder.
Confiscating assets of all billionaires,
gives 30 more days to settle D.C. affairs.
That leaves 155 days,
On others’ taxes to raise.
Who are: guess who?

P.S. I have been asked how my son, Spencer, a nationally known poet, would grade this poem. I think he would give it a failing grade, but no matter

Roses are red,
Violets are blue.
Daddio' do,
What they want to do.

Primary Care Revolt: Replace the RUC

April 17, 2011 - An under-the-radar revolution is going on out there. It is a revolt of primary care physicians against the AMA and CMS. It is a request for parity with specialists. It is a movement to replace how primary care practitioners are paid.

Why the revolt against the AMA and CMS? Because primary care doctors yearn to correct myths about primary care vis-à-vis specialists, and because they believe, by altering how the AMA and CMS pay doctors, health costs can be brought down, and primary care can be re-invigorated. Health systems with a broad primary care base have lower costs. In the U.S., two-thirds of doctors are specialists, and one-third are in primary care, the reverse of most nations, which have 50% or lower costs.

In the early 1990s, the AMA formed the Relative Value Scale Update Committee (RUC), which specialists now dominate. RUC sets payment codes for doctors. Since RUC’s inception, the payment differential has been growing between primary care doctors and specialists, so much so that the typical primary care doctor now makes only 30% of what an orthopedic surgeon makes. On average, primary care incomes are 50% of those of specialists.

To make a long story short, 94% of the time, CMS signs off on what RUC recommends. Primary care societies are threatening to withdraw from RUC. Furthermore, a law suit may be brought against CMS for being a party to this arrangement, which may be illegal.

For more on what is going on, you may want to visit, a website formed by Brian Klepper, PhD, a health care analyst and Paul Fischer, MD, a family physician in Augusta, Georgia.

According to Klepper and Fischer, the RUC ought to be replaced. The first step, they say, to remedy this situation is for primary care medical societies to visibly and loudly withdraw from participating in RUC, thereby de-legitimizing the process.
Towards this end, they recommend:

1. Making the public aware of the RUC’s role and urging the primary care societies to stop “enabling” the RUC through their participation.

2. Recruiting experts who can credibly calculate economic impacts of RUC’s actions, and who can devise alternative payment methodologies.

3. Demonstrating the unlawfulness of CMS’ (and HCFA’s) two-decades long reliance on RUC.

4. Collaborating between primary care and non-health care businesses who pay for employee health benefits.

Klepper and Fischer believe RUC is primarily responsible for unsustainable health costs and performance of unnecessary high-tech specialty-based procedures. You may want to visit their website to understand their reasoning.
Doctor Fischer says four myths have been used to justify pay differentials between primary and specialty care.

1) The first myth is: what primary care doctors do is easy, when, in fact , it requires extensive knowledge to sort through chronic disease complexities and complicating emotional and societal factors.

2) The second myth is that it requires less intensive training than other specialties and mid-level practitioners can replace primary care physicians.

3) The third myth is that all primary care practitioners do is diagnose colds and prescribe antibiotics for upper respiratory infections and drugs for chronic diseases.

4) The fourth myth, perpetrated by managed care organizations, is that the sole role of primary care physicians is to serve as gatekeepers, as a revolving door to specialists and hospitalists.

According to Klepper and Fischer, the public and even primary care physicians know little and appreciate less the role of RUC, a specialist-dominated panel within the AMA. Yet RUC is extremely powerful and opaque. Through its longstanding relationship with CMS, RUC and the AMA have contributed heavily to exploding health costs over the past 20 years. RUC is why primary care physicians are paid so poorly compared to specialist colleagues and why few medical students, 8% at last count, now choose primary care as a career. Correct the RUC, Klepper and Fischer maintain, and you will rid America of much health system waste and expense than all the cost control measures in the health care reform law combined.

I am not quick to dismiss specialist procedures as such a monumental “waste” to the system. After all, these procedures are much in demand and can be life, life-style, sight, and mobility changing. Still, I can see where the revolution and replacement movement may have legs as a potent antidote to high health costs. I can also foresee where hospitals, specialists, the AMA, and CMS will fight tooth and nail to resist changes to the current system. What primary care doctors are asking for is a fair fight, which seems fair to me.

Tweet: Primary care doctors are threatening to withdraw from RUC, an AMA-CMS backed committee that sets doctors' fees and underpays primary care.

Saturday, April 16, 2011

Health Reform: Hospital Safety and Cultural Change

April 16, 2011- This last week I came across two articles that alerted me to the necessity for cultural change on the part of hospital caregivers and visiting physicians.

One was by Maureen Dowd, the New York Times columnist blaming doctors for the death of her brother from infection, because they were distracted and wore ties in the ICU; the other was by Richard Platt, MD, from the Department of Population Health at Harvard Medical School.

Both were asking for culture change and increased awareness of the dangers of hospital infections.

Their message did not fall on deaf ears. I have been saying for years that resistance to cultural change and ingrained behaviors are what make health reform so difficult. This is true for the nation as whole, which is conservative and reluctant to change, as well as for doctors, who prefer the status quo, the devil they know, to the unknown demons of reform, which often descend down from Washington.

This resistance came into focus this week with the news that the government has launched a hospital safety campaign to protect patients in hospitals from hospital-acquired infections. The goal is to save $10 billion by avoiding 60,000 hospital deaths from medical errors and hospital infections, particularly from Methicillin Resistance Staph Aureus (MRSA) infections.

In the NEJM editorial, Platt notes that hand hygiene, spotting MRSA carriers, avoiding ventilator-associated pneumonias and central-line infections, warning signs on infected patients’ doors, and rapt attention to “prevention bundles of care” dramatically reduce deaths, particularly in ICU settings.

To achieve these results across the nation, Platt concludes, “it will be necessary to change the culture of clinical care.” By this he means systematic , organized, and purposeful changes by teams of caregivers collecting data and implementing changes over time across the hospital environment.

This will not be easy in a culture that cherishes autonomous behavior by individual caregivers. The government has said it will address the problem by withholding payment for certain hospital-acquired infections.

Whatever happens, it is apparent that a cultural change stressing an increase in vigilant precautionary measures over time will be necessary, both by caregivers within hospitals and visiting by physicians. Hospitals are dangerous places. Perhaps this danger will serve as a spur for systematic cultural changes.


1. Maureen Dowd, “Giving Doctors Orders,” New York Times, April 12, 2011

2. R. Platt, “Time for Culture Change,” New England Journal of Medicine, “ April 14, 2011.

Tweet: Protecting hospital patients against infection requires a systematic cultural change and team effort among caregivers and physicians

Friday, April 15, 2011

Health Reform and the Friday after Obama’s Speech

April 15, 2011 – It’s Friday – the Friday after President Obama’s speech questioning Republicans’ budget deficit plan , asking for more taxes on “the rich, ” rallying the forces of the left, and laying out his plan to reduce the federal deficit.

I spent this Friday morning reviewing the health care community’s reaction to the speech, which promised to cut $480 billion from the deficit, mostly by reducing “fraud and abuse.” and putting a ceiling on health care spending.

How will President Obama impose this ceiling? By creating a top-down non-partisan government agency , called the Independent Payment Advisory Board (IPAB), starting in 2018, which will set a ceiling of 0.5% plus GDP, then arbitrarily deciding whose payments shall be cut.

For those of you not in the know, The Independent Payment Advisory Board, or IPAB, is a United States Government agency created in 2010 by sections 3403 and 10320 of the Patient Protection and Affordable Care Act. The Board has the explicit task of reducing the rate of growth in Medicare and Medicaid without affecting coverage or quality.

Reaction came swiftly. The AMA, the AHA, and the American College of Cardiology, among others, announced opposition to the IPAB. The AHA asked for IPAB repeal, saying its actions would be “arbitrary.” The IPAB would be out of touch with reality with forces driving health costs – chronic disease, aging, new technologies, and increased prescription drug use.

The IPAB will be a board composed of 15 doctors, nurses, health care experts, and economists – all appointed by the President and acting “independently” of the Congress and the President.

Critics asserted if you believe in the IPA’s “independence,” I have a bridge to sell you. In the real world, “IPAB,” they say, is short for “ Intellectual Pabulum, “ meaning the new agency is long on politics and short of substance.

Perhaps most telling was this passage from an article by Jason Fodeman, of the Galen Institute, commenting on the health reform law which contains a provision establishing the IPAB.

“PPACA will strip away physician autonomy, drown doctors in bureaucracy, and drain job satisfaction. As the profession deteriorates, older doctors will retire while younger doctors will look to switch careers. Many students considering a careering in medicine will pursue other opportunities. The supply of providers will dwindle as demand for services reaches an all-time high. Ultimately, the consequences of health overhaul law will be passed along to patients through restricted access, long wait for appointments, and rationed care.”

This passage may be overstated, hyperbolic, and apocalyptic. Still, it harbors truths. The health reform law and its IPAB provision aimed at limiting physician pay may well precipitate an access crisis for patients and a crisis within the profession itself.

Tweet: The AMA, AHA, , and most physicians oppose the Independent Payment Advisory Board proposed by President Obama for not being “independent.”

Thursday, April 14, 2011

“Burned” by EMR: Try Ascending into Cloud

Preface: I have long thought many current EMR systems are so flawed many physicians are either discarding them, going back to paper, or seeking alternative systems. This April 13, 2011 WSJ health blog confirms my suspicion.

Athenahealth’s Bush on the Electronic Medical Record ‘Burn Unit’

By Katherine Hobson

Plenty of medical practices spent a lot of time and money to put in place electronic-medical record systems only to find that physicians find them so cumbersome to use that they, well, don’t.

So many, in fact, that Athenahealth has created a group called a “burn unit” to handle these physician practices that have been “burned” by the old systems and are looking for a new solution, the company’s chairman and CEO, Jonathan Bush, told us on a visit to Health Blog HQ.

About 35% of Athenahealth’s new EMR business comes from medical groups that have already tried one of the traditional software systems and aren’t happy with it. In many cases they’re large, hospital-owned physician groups that have either bought the systems themselves, or are unsuccessfully trying to roll out the system used by the hospital.

Athenahealth’s approach to those practices: come in, shut down the systems, extract the data and put the information on the company’s own cloud-based system.

With its own EMR, physicians have to apply to get in on the functionality fun, Bush says. At first, receptionists use the system to check patients in and out. Nurses, with a physician’s okay, put through orders. Doctors needn’t play — they can continue to use whatever paper charts or diagrams they prefer to document clinical visits, and Athenahealth will then scan those into its own system.

And, if doctors wish to get beyond the velvet rope, they can eventually ask to learn to use the system themselves.

Tweet: Jonathan Bush, CEO of Athenahealth, says his firm spends 35% of its time replacing EMRs and transferring their functions to the “cloud.”

Wednesday, April 13, 2011

Poll-lution of Health Reform-Repeal

Amid a budget debate that will affect the health care of virtually every family, a new poll finds support for President Barack Obama's overhaul at its lowest level since passage last year. But in a ringing defense of Obama's policies, Medicare chief Donald Berwick pleaded Tuesday for more time on the health care law, and branded a leading Republican plan "unfair and harmful" and "a form of withholding care." The Associated Press-GfK poll showed that support for Obama's expansion of health insurance coverage has slipped to 35 percent, while opposition stands at 45 percent and another 17 percent are neutral.

Kaiser Health News, April 13, 2011

April 13, 2011
- I watch polls as indicators of how the health reform-repeal debate is going. Yesterday’s Associated Press poll is not a happy sign for the Obama Administration, especially when coupled with national poll averages as collected by Real Clear Politics.

RCP Poll Averages.

1) Approval of Democrat – Obama Health Plan (average of 7 national polls)

• For, 39.6
• Against, 52.0

Spread, -12.4

2) President Obama's Job Approval

• Approve, 47.3
• Disapprove, 47.9

Spread,- 0.6

3) Congressional Job Approval

• Approve, 23.6
• Disapprove, 70.4

Spread, -47.2

4) Generic Congressional Poll

• Democrats, 41.3
• Republicans, 50.7

Spread, -9.4

5) Direction of Country

• Right Direction, 27.8
• Wrong Direction, 65.0

Spread, -37.2

Of course, President Obama’s speech today on the budget calling belatedly calling for cuts, for higher taxes on the rich, and bashing Republicans could improve these averages. Until then, there is not a positive poll in the bunch for Democrats or for President Obama, for Congress, the Senate, or the Administration as a whole.

Tweet: If multiple polls are any indication, President Obama’s health plan is in deep trouble and may well be repealed if he is not re-elected.

Bureaucracy as a Barrier to Constructive Physician Health Reform Changes

You will never understand bureaucracy until you understand that for bureaucrats procedure is everything and outcomes are nothing.

Thomas Sowell (1930- ), Hoover Institute, economist, social theorist, political philosopher

Many potentially worthwhile health law provisions - electronic health records, accountable care organizations, medical homes, hospital safety programs – may never come to pass. As I point out in my upcoming book, The Health Reform Maze (Greenbranch Publishers, 2011), for physicians bureaucratic procedural demands may get in the way of outcomes. The means may defeat the ends.

Hard-pressed, sometimes overwhelmed, physicians are busy, harassed professionals. They want to spend more time with patients. Taking care of patients is what they are trained to do. It is what they are good at. Patients are their main sources of satisfaction, of improving health, of restoring life-styles, of achieving cures, and of providing income. How physicians react to bureaucratic procedural requirements is important for the future of health care.

In the minds of many physicians, meeting demands of federal regulations distracts from their work, takes an inordinate amount of time, and generates unnecessary direct and indirect expenses. The unfortunate result is that too many physicians choose to either ignore federal regulations, wait and see what develops, or escape from government and other third party oversight.

Consider a few examples.

• Installing EHR systems to qualify for federal bonuses requires meeting “meaningful use” criteria. Under the government HITECH program, eligible health care professionals and hospitals cannot qualify for Medicare and Medicaid incentive payments until they adopt certified EHR . Establishing and implementing a “certified” and “standardized” EHR system takes time, outside consultants, roughly $50,000 in start-up expenses, and meeting government procedural demands. For many, if not most busy practitioners in small practices, these demands are a “turn-off.”

• Becoming part of an accountable care organization - CMS is in the process of issuing procedural rules before the end of the year for becoming part of ACOs and engaging in joint-ventures with hospitals. To engage in these things requires hiring consultants and lawyers to avoid antitrust issues and being labeled as a hospital-physician monopoly. The run-up to an ACO may entail up to $1 million in expenses and countless meetings and hospital-physician negotiations and trade-offs. These are not things physicians are trained to do or feel comfortable doing and may strangle infant ACOs in the cradle.

Physician time, expense, and income barriers posed by federal bureaucratic procedures may lead to physicians opting out of the system with defeat of desired outcomes.

It could even lead to a market-based outcome envisioned by conservative economist John Goodman, founder and president of the National Center for Policy Analysis,

“President Obama’s health care law will bring a major transformation of the nation’s health care over the next decade in the form of a large migration of patients, doctors, facilities, and services out of the third-party payer system.”

“It will cause a major increase in concierge doctors, concierge facilities, and concierge-type services. It will lead to the creation of new markets where providers are free to repackage and reprice their services without third-party payer approval; where transparency of price and quality becomes the norm for patients; and where suppliers of services compete for patients on price, quality and amenities.”

If this were to happen, it would lead to a major political crisis of unprecedented magnitude – lack of access of Medicare and Medicaid patients to physicians.

Tweet: Government bureaucracy in the form of procedural demands upon physicians may cause thousands of doctors to opt out of Medicare and Medicaid.

Richard L. Reece, MD, has posted 1730 blogs at medinnovation blog over the last four years. His main themes concern health reform and innovation and how they impact physicians and American culture as a whole. He works closely with the Physicians Foundation. His opinions are his alone. He has written eleven books. His latest book, The Health Reform Maze, is now at Greenbranch publishing and will be released in June. Doctor Reece’s website,, is now up and running He invites comments and questions on his blog and will respond to each comment or question on his blog or to him directly at 860-395-1501 or

The Medical Home as a Primary Care Solution to Health Reform

April 13, 2011 - In my book Obama, Doctors, and Health Reform (2009, available on Amazon), I have the following chapter, “IBM Puts in Its $2 billion and 2 Cents Worth,”featuring a speech by Paul Grundy, MD, director of health care transformation at IBM.

Dr. Grundy is a driving force behind the medical home concept, an innovation prominently mentioned in the new health reform law.

According to the Engelberg Center for Health Reform at the Brookings Center, the medical home has general strengths and weaknesses:

It supports new efforts by primary care physicians to coordinate care, but does not provide accountability for total per capita costs. It does not necessarily give incentives to hospitals and specialists to participate, encourage global accountability, decrease volume, or put primary care doctors at risk. On the other hand, it requires patient assignment and a per member, per month payment structure.

Chapter Seven , IBM Puts in Its $2 Billion and 2 Cents Worth

Insurers’ corporate customers have been increasingly critical of the value of their health coverage. I.B.M., for example, says the industry is not helping to provide care that’s more cost-effective in helping their workers live longer and more productive lives. The insurers “don’t have a clue about providing what we really want to buy,” said Dr. Paul Grundy, the executive at I.B.M, who oversees its health care efforts.”

Reed Abelson, “Health Insurers, Poised for Round 2,“New York Times, March 1, 2009

If I’m elected President, I will support patient-centered primary care.

Barack Obama, during his successful Presidential campaign, 2008

What follows is the text of a speech delivered by Dr. Paul Grundy, Director of Healthcare Transformation at I.B.M. He’s giving this speech, or variations of it, as he crusades around the country, speaking to legislators, governors, policy makers, physicians and anyone who will listen about the importance of personal primary care physicians for patients, as embodied in the concept of the medical home.

I.B.M. spends $2 billion a year for health care for its employees, and Grundy feels too much of this money flows to specialists for procedures, rather than to primary care doctors, for prevention.

Grundy envisions “transformation” of American medicine to a patient-centered, primary care-system powered by real-time electronic communications between all major health care parties.

Grundy does not think nurse practitioners or nurse “doctors,” skilled, though they may be, will replace generalist physicians. Nurses are trained to be supportive and nurturing, he notes, but have not yet proved to function well or for long in independent accountable practices.

Furthermore, Grundy insists American already has, in effect, a single-payer system. It’s comprised of Medicare, Medicaid, and a private coding update system that favors specialists over primary care physicians. The reimbursement and support system for primary care physicians has to improve to encourage more medical students to enter primary care.
Last year, Dad died in Houston, Texas, at age 87 of congestive failure with complications. He had multiple specialists but no personal primary care physicians. Dad had no personal doctor to whom I could turn to help me and my family understands the totality of what was going on.

As Director of Health care Transformation at I.B.M., Dad’s death brought home to me why I’m fighting so hard to change the care we buy for our employees and dependents. That change is the patient-centered medical home. The medical home focuses on providing better and more comprehensive primary care. For our employees, this case will serve as a “fence” to reduce the “ambulance fleet” of expensive specialists at the bottom of the expense cliff. Present care costs are unsustainable at I.B.M. and the U.S. as a whole.

In a February 6 New York Times piece “UnitedHealth and I.B.M. Test Health Care Plan “, I called the present care I.B.M, buys as “garbage.” Perhaps “garbage” overstated the case. But the lack of coordination in my father’s case frustrated me.

We have to make health care, institutions, and industries smarter. Not just at moments of crisis like we see today, but integrated into our day-to-day reality. Our current health care processes are simply not smart enough to be sustainable.

Think about how many of the medications we prescribe that go untaken or interact badly with other medications another doctor gives you. We lose tens of thousands of lives every year because we don’t have the data and systems in place to address the simple issue of medication.

Here’s where technology can help. A computer can provide connection and memory for a doctor’s brain. Just as an x-ray allows the doctor’s vision to expand, it’s health IT that allows his mind to expand and be connected in real time to thousands of other minds and to real data that makes a difference.

In truth, the health care system isn’t a “system” at all. It’s antiquated. It doesn’t link diagnosis, drug discovery, health care deliverers, insurers, employers, and employers. Meanwhile, personal expenditures on health now push more than 100 million people worldwide below the poverty line each year.

Smart health care can lower therapy costs as much as 90 percent. That’s what ActiveCare Network, based in Columbia, South Carolina, is doing for more than two million patients in 38 states. ActiveCare monitors delivery of people’s injections and vaccines so they can lead active and independent lives.

The single most important part of healing is the patient-personal physician RELATIONSHIP. It’s health care’s backbone. Smart health care supports that relationship by improving communication, allowing expanded communication with a patient, and empowering the doctor.

Personal doctors tend not to forget to ask an important question, be it about the patient’s personal life or a key fact to the healing process. Smart health care can send little reminders of care compassion and express a doctor’s investment in a person who needs a healer and healing.

A smart health care system can help with compassion by reminding the patient of important things that would otherwise be missed in a busy doctor's life like e-reminders of a visit, or that mammogram that was forgotten to be completed.

Smart health care makes sure that the right drug is used on the right patient at the right time, taking into account the person’s genetic makeup other medications they’re taking. It ensures authenticity of pharmaceuticals and security of patient information. It changes everything from how health care organizations do business to how they enable their employees to collaborate and innovate.

In the U.S., we at I.B.M. estimate that smart health care will generate lots of new jobs in companies small and large, but most will be small. In a recent conversation with the Obama administration, I.B.M.’s CEO Sam Palmisano estimated that widespread adoption of personal health records will create 212,000 jobs.

I’m not just referring to large enterprises, but also to smaller and mid-sized companies— engines of economic growth. When we think about systems like health care supply chains, health care delivery, care management, prevention, we’re really talking how hundreds, even thousands of companies, most of them are small, interact.

In the Mid-Hudson valley here in New York, we’re already on the path to deliver integrated health IT to all doctors and hospitals. This has created small companies like Med Allies in Fishkill, whose 40 employees work with doctors’ offices to get them up and running with health IT and keep them connected in a powerful and useful way for the patient. In North Dakota, there’s a small company called MDdatacore that provides the register for all the doctors in North Dakota. It now employs 42 folks.

Smart health care is giving rise to a new model for primary care, the “medical home.” About three years ago, the people at I.B.M. started talking about all the things that large employers in the U.S. have done to reduce costs and improve quality. We realized we were failing to address a fundamental issue: primary care and the doctor patient relationship.

Shortly after that, I helped found the Patient-Centered Primary Care Collaborative (link PCPCC), a coalition of large employers, consumer organizations and medical providers.

We developed a health care model based on the premise that’s more holistic. Primary care saves money by cutting the incidence of major health problems like heart disease or diabetes later in life. It’s a back-to-the-future approach to the family doctor, enabled by IT.

In the medical home model, a primary care physician acts as a health care coach – leading a team that manages a patient’s wellness, preventive and chronic care needs. The doctor spends more time with the patient in person, is available for consultations via email or phone, and has expanded hours and coordinates across an entire care team – nurses, specialists, pharmacists and hospitals.

A diabetic could give daily blood test readings by phone, email or remote monitoring device and get instructions the moment she needs them, rather than wait for an appointment. Her care team would have a holistic health plan that focuses on diet and exercise as well as monitoring glucose levels.

This is already happening outside the U.S. In the U.K., they have adopted a similar “family doctor” model that makes health care more accessible and effective – and makes patients happier.

Electronic health records – central in the U.S. health care stimulus bill – are pivotal to making medical homes work. Electronic health records are the single source of information that can be shared across a network of providers and specialists. There are other IT tools that can help patients and doctors alike – online portals to make appointments or look up lab results, or e-prescribing.

Health analytics can look across a patient’s history and pick up trends that provide insight into the treatment of a disease. The list goes on. But it’s important and can’t be stressed enough. That technology supports the care and compassion in the doctor patient relationship but will not replace that or even get in the way of it.

Over the next couple of years, there will be winners, and there will be losers. And though it may not be easy to see now, I believe we will see new leaders emerge who win not by surviving the storm, but by changing the game.

The importance of this moment, I believe, is that the key precondition for real change now exists: People want it.
Trust your family doctor, and think about the concept of the medical home., especially if you work for a corporation paying your health bills. Employers pay 68% of the nation’s total health care bills, and their ideas are to be heeded. When you’re I.B.M.’s Director of Health Care Transformation, Doctor Paul Grundy, you think of your employees’ health from Monday to Sunday. For them you seek better prevention and higher productivity through primary care doctors with overall patient accountability, So you crusade for Medical homes every moment of every day.

Tuesday, April 12, 2011

The Health Reform Debate: Sad Stories from Both Sides of the Political Aisle

With Republicans determined to disrupt implementation of the new health-care law and promote their own fixes to Medicaid and Medicare, and Democrats hopeful of swaying a stubbornly divided public to embrace the law as it takes effect between now and 2014, no one expects the fight to let up anytime soon. And for Democrats and supporters of the law, the weapon of choice is the compelling individual story, a tool honed by former President Ronald Reagan that has been archived and analyzed, computerized and systematized to new levels for this battle.

N.C.Aizermann, “Individual Stories Weapons of Choice in Fight over Health Care Law, “ Washington Post, April 9, 2011

April 12, 2001 - Expect Democrats and Republicans to feature health care sob stories in the upcoming reform debate.

Democrats are better at this anecdotal game than Republicans. Their base is the “have-nots” and others who depend on Medicare and Medicaid. At Families USA, one of their affiliates, Democrats have collected a vast database of compelling individual stories.

Today, April 12, Democrats will trot out 5 stories from 5 states, to be followed relentlessly by other tales of woe from those who have benefited from the health care law. The personal narrative, as told on video and at Congressional hearings, will be the centerpiece of their political strategy. The White House website contains a clickable map of video testimonials “50 states with 50 stories,” asking viewers to share their experiences on the subject “How is the Affordable Act helping you?”

Meanwhile Republicans are collecting stories on a theme that might be called, “How the Affordable Care Act is hurting you now and in the future.” It will feature stories from people who will say they have had to drop coverage because of soaring premiums, from employers who will say they can no longer afford to cover employers because of increased costs related to Obamacare, and from budget-minded politicians who will say “Your children and your grand-children will left without care” because the nation will be bankrupt.”

Monday, April 11, 2011

ACOs: Another Top-Down Idea, Another Likely Dud

Here’s the problem with ACOs: They are a tool in a big tool box of care and cost management tools but, like all of the other tools over the years like HMOs and IPAs, they won’t be used as they were intended because everybody—providers and insurers—can make more money in the existing so far limitless fee-for-service system.

Robert Lasweski, “Why ACOs Won’t Work,” The Health Care Blog, April 7, 2011. Robert Laszweski currently serves as the president of Health Policy and Strategy Associates of Alexandria, Virginia.

April 11, 2011 - I have spent most of my life as a physician watching Washington-based policy solutions go down in flames and up in costs and bureaucratic smoke, leaving independent physicians in the ashes.

First, it was HMOs,

then, IPAs,

then, physician companies on the stock market,

then, integrated health systems,

then, hospital employment,

now, accountable care organizations.

Each solution requires organizing doctors into business-oriented groups with outside oversight.

Each approach fails because physicians treasure their autonomy and stand more to gain in peace of mind from staying the way they are, as mavericks practicing fee-for-service medicine in order to stay close to and to best serve their patients.

Here, according to the Engelberg Center for Health Reform at the Brookings Institute, a liberal-leaning, influential Washington, D.C. think tank, are the characteristics of accountable care organizations that should be good for the U.S, but are unlikely fail to catch fire.

ACO Characteristics

General strengths and weaknesses – Makes hospitals and physicians accountable for total per capita costs and promotes coordinated lower-cost care, but does not require patients or physicians to “lock-in” into ACO.

My questions: Why should physicians join n ACO if the ACO intent is to lower physician income and force them into partnerships with hospitals with which they now compete? Anyway, what’s in ACOs for patients?

• Strengthens primary care directly or indirectly
- Designed to give physicians incentives to focus on disease management within primary care through medical homes and partial capitation.

My question: Is delayed gratification of sharing savings with hospitals sufficient incentive to overcoming barriers of spending hundreds of thousands of dollars, even a million, for setting up an ACO and installing EHRs to tracking population health?

Fosters coordination among all participating providers - Designed to provide significant incentives to coordinate among participating providers.

My question: What is the incentive for specialists, who constitute 2/3rds of all American physicians, who are doing just fine outside ACOs, and who stand to lose income by playing second fiddle to primary care physicians and hospital administrators?

Removes payment incentives to increase volume of patient visits - Adds incentives based on value , not volume.

My question: Do not patients consider hip and knee replacements, coronary stents, cataracts, pacemakers – to be of “value,” as evidenced by the increased volume of these procedures? Gatekeeping and capitation has already been tried and failed, Why would it work now?

Fosters accountability for total per capita costs – Offers shared savings when total per capita costs are reduced.

My question:
For the typical physician and hospital, don’t you think “total per capita costs” is an abstraction that does not apply to them?

Requires providers to bear risk for excess costs - The present model does not require physician or hospital risk sharing.

My question: Get real. Do you really believe hospital and doctors, who are already paid at 70% to 80% of private plan rates by Medicare, with beds and doctors in short supply, are going to willingly bear risks to join ACOs?

• Requires “lock-in” of patients to specific providers
- Allows patients to be assigned on basis of previous patterns of care but includes incentives to provide services within realm of participating providers.

My questions: Why would patients abandon their present pattern of choice of hospitals and doctors for a theoretical concept to follow government mandates that limit those choices? Why would physicians and hospitals abandon the known for the unknown?

Richard L. Reece, MD, has posted 1725 blogs at medinnovation blog over the last four years. His main themes concern health reform and innovation and how they impact physicians and American culture as a whole. He works closely with the Physicians Foundation but his opinions are his alone. He has written eleven books. His latest book, The Health Reform Maze, is now at Greenbranch Publishers and will be released in June. Doctor Reece’s website,, is now up and running He invites comments and questions on his blog and will respond to each comment or question on his blog or to him directly at 860-395-1501 or