Sunday, July 31, 2011

Health Costs: Nothing Exceeds Like Success

July 31, 2011 - Everybody knows health costs exceed our ability, individually or as a nation, to pay for them. But nobody admits this inability stems from the overwhelming success of medicine to provide what people want.

As comedian Milton Berle cracked, “When it comes to my health, money is no object."

This morning , I was thinking of how well medicine has succeeded. As our Sunday morning coffee gathering, a bunch of old guys were whooping it up at the old salon when the subject of an 88 year friend came up. He was suffering from shortness of breath and periodic blackouts.

One said,”He needs an nuclear heart scan to see what’s wrong.” A second remarked,” He needs a pacemaker, like Cheney.” A third chimed in, “ Maybe he needs a new heart.”

I brought up the subject of cost and pointed out one of us had a pacemaker costing $150,000 – but, even though I was the only doctor in group, I was dismissed.

Thanks to people’s trust in modern technologies, costs have exceeded everybody’s expectations. Consequently, health costs are 17% of GDP, and with costs expected to grow 5.8% a year over the next ten years or so, health costs should reach 20% of GDP by 2020.

Economists agree that medical technologies account for 70% of health inflation, and that these technologies rarely save money, despite all the rhetoric about "disruptive technologies."

Why is this? A number of reasons. Since World War II, Americans have invested heavily in research. We are aging and require more life-saving and function-saving technologies. And the media is quick to seize upon new "breakthroughs" and to broadcast this news to world. There's a shortage of good news these days, and health advances fill the bill - and increase the bill.

Technologies work. Ask your friends, family, and neighbors, and everybody will have a story of how hip and knee replacements has stopped pain and restored function; cataract surgery has averted blindness; stents, pacemakers, and ventricular assist devices have forestalled death; and CT scans and MRIs have provided invaluable diagnostic information.

There is also the “self-interest”factor.

• Every patient wants to live another day, with the hope that the next day will be better than the last.

• Most doctors know that specialists deploying the latest technologies are the important key provider of longevity and improved function.

• Specialists know that patients, health plans, and government itself pay more for specialists performing procedures.

• Hospitals know that their largest profits reside in high tech fields – cancer, orthopedics, heart, and the new kid on the block, robotic surgeries in multiple fields.

Small wonder, then, that the health care system is often the biggest economic game in any community, region, or State, that hospitals, doctors, and various health care facilities are the biggest employers during this recession (Health care has added near one million jobs since the recession began), and that Medicare and organizations like AARP with 50 million members (and its partner UnitedHealth,which boasts its 70,000 employees cover 78 million Americans and supplies all of AARP’s Medicare supplemental policies, are among the most powerful economic and political players in America).

Nothing exceeds like success, which, unfortunately, breeds beneficial excess to those who depend on health care success.

Saturday, July 30, 2011

Obamacare: How Many More Things Can Go Wrong?

Never very popular to begin with, Obamacare continues to face strong opposition from millions of Americans who are indignant that Congress passed it over strong and vocal opposition. They know it is wrong for America. Obamacare is wrong for families, wrong for patients, wrong for business, and wrong for our children’s futures.

Grace-Marie Turner, James C. Capretta, Thomas P. Miller, Robert Moffit, Why Obamacare Is Wrong for America(Broadside, An Imprint for HarperCollinsPublishers), 2011

Anything that can go wrong will go wrong.

Murphy’s Law, saying, 1950s

July 30, 2011
- The past week was a bad week for Obamacare because of two major negative developments.

ONE, Thomas P. Weil, PhD, has written a paper, bearing the title “ACOs Doomed for Failure.”

ACOs, the organizational foundation of the Obama plan to reduce costs and improve outcomes, are slated to begin operation on January 1, 2012.

Weil says ACOs will fail for five reasons: 1) they over-estimate physicians‘ capacities to motivate patients with chronic disease to change their behavior, which has been established over a lifetime and which is unlikely to be altered enough to change the course of their diseases; 2) ACOs require a nearby well functioning multispecialty group; 3) a fully-functioning EHR system linking all parties is necessary; 4) resolving nitty-gritty operational issues – calibrating quality goals, adhering to burdensome rules, being proactive and competitive, implementing a physician reporting system, and resolving anti-trust issues – have a long way to go; and 5) ACOs may anger the public because their major priority is to limit utilization of services desired by the public and physician alike.

TWO, The National Federation of Independent Businesses (NFIB) have just released an extensive survey indicating 57% of small businesses are either likely or somewhat likely to drop coverage for employees when the law takes effect in 2014. Since the health law passed, 12% of small businesses have already terminated coverage. A year from now, 55% says they are “not too likely” (18%) or “not at all likely” (37%) to offer coverage. Finally, 57% say they would likely continue coverage if they had the option of giving employees a “tax-excluded contribution,” an HSA or its equivalent, which would give employees more control over choice of coverage, ownership of a portable policy not dependent on jobs, and incentives to shop for better value.

Two Questions

These two developments raise two questions: How many things have to go wrong before we consider scrapping or severely modifying Obamacare? How long must we wait before Obamacare cuts costs and expands access?

So far what’s gone wrong includes: sharply rising costs and declining access since passage, threats of multinational corporations to drop drug coverage for retirees, issuance of over 1500 waivers to unions and small businesses and some States bypassing Obamacare to avoid its regulatory burdens and expenses; dropping of the audit of business expenses over $600, continuing disapproval of the health law by 55% to 60% of Americans; rejection of the idea of ACOs by most major physician organizations; a survey by McKinsey and associates of American businesses indicating 30% plan to drop coverage in 2014 when Obamacare kicks in in earnest.

Everybody , including critics of the new law, agrees reform is necessary to reduce costs and expand coverage, the twin goals of Obamacare. Of good intentions toward achieving these goals, Obama and the Democrats are right; on opposing the results, higher costs and lowered access for the insured and previously insured with unforeseen consequences. Republicans are right.

I’m reminded of the story of the Blind Men and the Elephant , which might now be modified to read.

And so these men of health reform
Disputed loud and long.

Each in his own opinion
Exceedingly stiff and stern.

And each was partly in the right,
And all in part were wrong.

Friday, July 29, 2011

After the Debt Crisis Resolution, The Deluge

After us, the deluge.

Attributed variously to Madame Pompadour and to Louis XV, after the crushing defeat of the French at Rossbach, 1757

July 29, 2011 - What comes after the debt crisis, the resolution of which all the politicians and the President tell us today is inevitable?

I am not so sure about the resolution, but I am sure of this.

After the debt crisis ends, the deluge will be a deadlocked heated debate over what to do about how, how much, and when to cut from Medicare and Medicaid.

The first salvo came this week in the form of ubiquitous TV ads featuring three people – an older white man, an older white woman, and an older black lady. The three are saying, ”What were you thinking when you decided to cut $100 million out of hospital care for Medicare and Medicaid? What were you thinking?”

What they, the politicians, were thinking, of course, is that hospital costs for Medicare and Medicaid patients are the biggest single force driving government health care costs and the national debt.

Unfortunately, what government giveth is very hard to taketh away.

The demographics of aging, the influx of baby boomers into Medicare in 2011, the coming of a guaranteed 32 million and probably millions more into Medicaid in 2014, the continuing demand for access to medical technologies the increasing desire for more physician services, the shrinking physician supply, the accelerating physician shortage, and the Great Divide between Democrats and Republicans on how to avoid certain Medicare and Medicaid bankruptcy and default will dominate Presidential debates leading up to November 2012.

The debate will be all about supply and demand - with demands – of money, programs, physicians, political will, and truth – exceeding the supply .

The three D's - Demagoguery, Demonization,and Demographics - will dominate the deluge debate.

Thursday, July 28, 2011

Treatment for Low Testosterone Symptoms

Where id was, ego shall be.

Sigmund Freud (1856-1939)

July 28, 2011 - Lately ads for testosterone therapy have begin to rival ads for Viagra and Cialis. I refer to and Ageless Male,T.M. ads on television and talk radio.

Testosterone pitches for youthful rejuvenation are based on this premise. As you age, your testosterone levels drop, your strength ebbs, your energy levels decline, your concentration suffers, and your sexual potency goes away.

• The AAG (Anti Aging Group) out of Miami, who run the ads, describes your aging problem this way.

“You’re lethargic and your energy level is not what it was….Your body is becoming soft and flabby….You’re having problems with focus and concentration….Your sex drive is down and you may be having difficulties achieving an erection.”

AAG offers these treatment solutions:


• Ageless Male, TM, out of Arlington, Texas, offers an alternative – “an all natural dietary supplement clinically proven to increase testosterone levels by 61%, but still with a normal health range.” It says this supplement “helps Support Normal Testosterone Levels, Which in Turn, Helps support:

• Healthy Sex Drive

• Energy Production

• Positive Mood

• Lean Muscle

• Strong Bones

• Concentration

• More Zest for Life!"

In other words,if you want to become a lean, mean, energetic, sexual machine, take testosterone nutritional supplements and return your testosterone levels to "normal."

Much of this advertising may succeed because of the psychological placebo effect. The placebo effect is defined, as “a sense of benefit felt by a patients that arise solely from the knowledge that that treatment has been given.” If you believe something works, it may indeed work. The male ego may think testosterone treatments will restore his id.

Judging from the volume of ads promising youthful testosterone rejuvenation, the message is powerful, profitable, but it may also be potentially dangerous.

Perhaps no danger exists from dietary testosterone supplements. I do not know, because the ingredients of these “natural dietary supplements” are unknown and unregulated. The caveat or hedge phrase with testosterone supplements is that they help support “normal testosterone levels” as opposed to elevated levels, which can be harmful.

As it turns out, elevated testosterone levels induced by human growth hormone and testosterone injections or gels can be downright dangerous by raising the risk of heart attacks and stroke in vulnerable males.

A July 28 2010 New England Journal of Medicine article, “Adverse Events Associated with Testosterone Administration,” by 28 academics, found in a study of 209 men (mean age 74), with a high prevalence of hypertension, diabetes, hyperlipemia, and obesity, that 23 of the 209 testosterone treated group had “cardiovascular events” compared to 5 in the placebo group. The testosterone group, however, had significant improvements in leg-press, chest press, and climbing stairs while carrying a load.

Taking testosterone to build your muscles, increase your stamina, increase your feeling of youthfulness, and restoring your id may damage your blood vessels. Your choice of whether to take testosterone depends on your present health, how strong you want to become, and how long you want to live.

If I were a poet and a testosterone ad man, my ad copy might read,

Hey, you guys with an ego,
Don’t your youth forego.

Restore your id.
Stop the age skid.

Let those juices flow.
With youth again glow,

But be aware,
Be fair.

High testosterone levels,
Can be blood vessel devils.

Wednesday, July 27, 2011

Health Reform: You Can Please Some of The People Some of The Time, And All of the People Some of The Time, But You Cannot Please All of The People All of the Time

You can fool some of the people all of the time, and all of the people some of the time, but you can not fool all of the people all of the time.

Abraham Lincoln (1809-1965), To a caller at the White House, Lincoln Yarns and Stories(1904)

Americans take pride in the fact that their society – including the health care system – is characterized by a pervasive pluralism. Government – federal, state, and local- does not dominate the economy, the educational system, or the health care delivery system. Most Americans oppose “big brother”; government should be guarded from dominating any critical aspect of their lives. There are advantages to pluralism – form stimulating innovation to avoid the intrinsic rigidities of bureaucracy.

Eli Ginzberg (1911-2002), The Road to Reform: The Future of Health Care in America (The Free Press, 1994)

July 27, 2011- A piece in the July 28 NEJM prompts this blog. Three PhD academic reformers and observers, from NYU, Yale, and the University of North Carolina, argue in “Managed Competition for Medicare? Sobering Lessons from the Netherlands,” that the Dutch experiment with regulated competition among private insurance companies offering universal coverage, launched in 2006, isn’t working out well.

Dutch Problems with Managed Competition

The Dutch problems are: 1)overall costs are still going up at a 5% rate, with costs to Dutch families escalating by 41%; 2) some Dutch people are still uninsured, and many of the insured are failing to pay their premiums; 3) expansion of consumer choice has faltered, and employers rather than individuals are choosing physicians; 4) despite the rhetoric about competition, the Netherlands still depends heavily on regulation.

The Lesson

The lesson I draw from the Dutch experience is this: No perfect system exists, even in a small country like the Netherlands, that can serve as a model for the U.S. Keep in mind that Health Exchanges, a pillar of the new health reform law, are essentially a form of "managed competition."

Kaiser may work in California and selected markets like Denver; Geisinger may work in rural Pennsylvania; Mayo and Marshfield Clinics may work in the upper Midwest; Group Health Cooperative may work in the Pacific Northwest; Community Health Clinics may work in under-served regions; integrated hospital and academic systems may work in certain regions; and Managed Competition models with capitation , the dream-child of Alain Enthoven, and the forerunner for Accountable Care Organizations, may work on the West Coast.

But there is no comprehensive model that will satisfy all of the people all of the time.

Unitary Government System Not in Cards for U.S.

Proponents of unitary government health system covering everybody and pleasing everybody are fooling themselves, but not the people.

As Abe Lincoln so aptly observed, with health system reform,

• You can fool some of the people all of the time - compassionate liberals who believe in using other people’s money to finance universal coverage and universal equity for all and laissez-faire isn't fair.

• And all of the people some of the time – fair-minded liberals, conservatives, and independents who will periodically believe somewhere out there is a system - that will be fair to all.

• But you cannot fool all of the people all of the time - people who want to avail themselves of the best medicine has to offer – access to the latest technologies and breakthroughs and the best specialists – when it comes to their own health, youthful well-being, and serious illness.

To be more specific, you cannot at the same time, fool or even please:

• The elderly, who know $575 billion in Medicare cuts under the new health reform law, will deprive them of benefits.

• The young invincibles, who know that the individual mandate will force them to pay for health premiums, depriving them of money they have previously chosen to spend elsewhere.

• Millions of new Medicaid recipients, who know the Medicaid system provides a substandard level of care because many as half of doctors, who are already in short supply, refuse to see Medicaid patients.

• Millions of baby boomers, 78 million in all, now turning 65 at the rate of 12000 a day over the next 18 years, will have a hard time finding doctors to treat them.

• Millions of businesses, small and large, perhaps 30% according to recent McKinsey survey, say they would rather drop coverage than incur the expense of providing expensive coverage for employees that meets expensive federal standards.

.Hundreds of thousands of physicians, who are aware the health law lowers their Medicare reimbursements to less than Medicaid rates by 2019 and sets up an Independent Payment Advisory Board with the power to lower their payments even further starting in 2015.

• The rest of us, who will quickly became aware that the new health care law, will impose $500 billion of new taxes over the next 10 years, which will be passed on to consumers, and perhaps $2.5 trillion of new expenses for government from 2014-2024.

In a pluralistic society in a culturally diverse, continental nation like the U.S., there is no perfect unitary system that will please some of the people all of the time, and all of the people some of the time, and all of the people all of the time.

Tuesday, July 26, 2011

Health Reform: I Don’t Belong To An Organized Political Party, I’m A Realist

I don’t belong to an organized political party, I’m a Democrat.

Will Rodgers (1879-1935)

July 26, 2011 -
Will, don't turn over in your grave.

I hate to tell you this. But Democrats no longer have a monopoly on disorganization.

The Republicans are just as bad. The GOP has three parts – the establishment, the RHINOs, and the Tea Party, and never the twains shall meet.

When They Say It’s the Principles And Not the Money, It’s the Money

With health reform, neither side is willing to abandon their “principles,” for fear of losing their campaign contributors. With Democrats, this fear translates into not cutting a dime out of Medicare and raising taxes on the rich. With Republicans, the message is to cut government programs without raising taxes so as not to offend the “job creators,” i.e., those with the money to hire and invest. As an aside, the health care sector has created a million jobs since the recession began, and is the most vibrant part of the U.S. economy.

Lack of Realism

Neither side seems to take a realistic position, namely, that we’re going to have to reform Medicare to save it, and we could begin to do it be raising the age of entry to 68 over the next ten years and means test more affluent older Americans.

Impasse, Chicken, Bluffs, and Political Poker

Meanwhile we have an impasse. Each party is playing games of chicken, and issuing public bluffs without showing their hands, while negotiating behind the scenes. The President has withdrawn from the game. And we have name-calling with the favorite words being “irresponsible,” “intransigence,” and “extremist.” The favorite talking-points are “fair and balanced,” a “balanced approach,” “shared sacrifice,” “adult in the room,” “compromise,” “the problem is spending,” and either “crisis, “ or “Armageddon,” or some other apocalyptic warning.

The Realities

The realities are:

• In a divided government in which the executive and legislative branches are “co-equal,” no party has a whip hand, or bragging, gagging, or fragging rights.

• We had an election last November. Republicans, led by the Tea Party, won in the biggest rout since the Depression. Consequently, calling the Tea Party “extremists” and a “minority” may be a mistake, for the Tea Party represents an enraged Middle America, rising up against Big Government and Big Deficits and motivated by fears for the fate of its children and future generations.

• The American people, in poll and after poll since the March 23, 2010 passage of the Accountable Care Act, disapproves of the new law by overwhelming, consistent margins of 12% to 13%.

• In the face of a mounting deficit and continued unemployment since Obama took office, the old order of things - expansion of the welfare state to achieve equity, perpetual economic growth to maintain employment, and belief in American exceptionalism has been shaken.

• What needs to happen in health care – expansion of the physician supply, greater access to care in rural and inner-city America, prevention and coordination of chronic diseases, curtailment of sedentary and excessive life-styles, a decrease in the proportion of specialists to generalists, hospitals working in harmony with physicians, disruptive innovations to enhance quality and reduce costs – isn’t happening yet, at least fast enough to make a difference.

Expectations have not yet met reality for either party or for most Americans.

Monday, July 25, 2011

Electronic Medical Records Shortfall

July 25, 2011- For five years, in countless blogs, and in two books – Obama, Doctors, and Health Reform (2009) and Health Reform Maze (2011, now at printers), I’ve been saying digital medical records are a dud.

This does not mean I’m a technology Luddite, or a conservative who resists Obamacare in all of its manifestations. It means I’m a realist. For multiple reasons, EHRs simply don’t work for hospitals or doctors. For most physicians, in their present form, EHRs are impractical, unworkable, disruptive, and overly expensive without any tangible return on investment.

EHRs might work if government totally subsidized them without unrealistic “meaningful,” i.e., bureaucratic, conditions, or if EHR vendors offered them for “free” with advertisers footing the bill. But only then would they work if EHRs were useful and user-friendly.

One problem, as I see it, is theological. EHR enthusiasts see digital data in quasi-religious terms, as some sort of government electronic magic wand or Holy Grail that will transform health care into a more perfect, more tractable, more traceable system.

It ain’t going to happen. I’m reminded of a country song I used to hear as a youth in Tennessee, “Mother’s not dead. She’s only sleeping, patiently waiting for Jesus to come.” It’s going to be a long wait, as Sally Pipes explains below.

Government Mandates Make Health Savings More Elusive

By Sally C. Pipes,, July 18, 2011

The Centers for Medicare and Medicaid Services recently released some data that show that the digital revolution continues to evade health care.

Through mid-May, just 1,026 registered hospitals and physicians out of a possible 56,599 have demonstrated that they are using electronic medical records and other health information technology in accordance with federal standards. That’s a scant 2%.

The federal government has tried to promote the switch from paper medical records to electronic ones in hopes of improving efficiency and bringing down health costs.

It’s even putting money behind the push — some $27 billion over 10 years, or from $44,000 to $63,750 per physician and up to $2 million per hospital.

But even that vast sum of taxpayer lucre cannot will the necessary innovations into being.

Worse, like so many roads paved with good intentions, this one may yield some unfortunate consequences — paramount among them a decline in the number of doctors who will take Medicare patients.

A Rand Corporation study in 2005 concluded that health IT could save our health care system about $77 billion a year. Other studies have put annual savings in the $80 billion to $100 billion range.

The Rand study is popular with cost-cutters, but read the fine print: “much of the gains can only be achieved if all, or nearly all, of the healthcare organizations participate.”

At this stage, the cost of implementing health IT is a high threshold for many providers to cross. The average initial cost of an electronic health records (EHR) system is $44,000 per physician, with ongoing maintenance estimated at $8,500 a year.

Most physician office visits still occur in practices with 10 or fewer doctors. These aren’t just medicine men; they’re also small businesses, with the same concerns about remaining profitable as others. These health IT mandates only add a new level of complexity.

According to the head of the Business Management Department at North Carolina State University’s College of Management, “the main barriers to the adoption of EHR by small healthcare firms are due to legal and economic uncertainty.”

For years, politicians in Washington have been seeking a way to harness the savings from health IT. Each time they have tried, they ended up putting success further off.

In 1996, Congress passed the Health Insurance Portability and Accountability Act (HIPAA), predicting that portable health records would usher in a new golden age. Fifteen years later, we’re still waiting.

In 2004, President Bush signed Executive Order 13335 setting the goal of a nationwide health information network within ten years. Time is almost up, and government data show that only 1,026 registered hospitals and physicians — out of 56,599 — use technology that meets federal standards.

Washington politicians have spent years fiddling with carrots and sticks and regulations and mandates. In the process, they have gummed up the work that could have been done by the free market and private innovators.

If we want results, Washington needs to stop trying to legislate Star Trek-style medical tricorders into being. We’re better off leaving technology to the real-world innovators who have put communicators (er, rather, cell phones) into the hands of just about everyone.

Sally C. Pipes is President, CEO and Taube Fellow in Health Care Studies at the Pacific Research Institute. Her latest book is The Truth About Obamacare (Regnery).

Sunday, July 24, 2011

Health Reform: If It’s Fattening, Tax It! A SAD (Standard American Diet)Tale

What will it take to get Americans to change our eating habits? The need is indisputable, since heart disease, diabetes, and cancer are all in large part caused by the Standard American Diet. (Yes, it’s SAD).

Mark Bittman, Food Columnist, “Bad Food? Tax It!” Sunday Review, New York Times, July 24, 2011

If it moves, tax it. If it keeps moving, regulate it. And if it stops moving, subsidize it.

Ronald Reagan (1911-2004)

July 24, 2011 - According to Americans for Tax Reform, the new health care law will raise taxes for working Americans by over $500 billion. This is over and above proposed increased marginal tax rates on the “rich,” sometimes called the “fat cats,” or higher taxes when Bush tax cuts expire.

It also does not include raising taxes on “bad food” – sugar-laden soft drinks, junk foods, potato chips, French fries, animal products, processed foods rich in carbohydrates or fats, and restaurant meals.

Increase Taxes, Decrease Consumption

In his New York Times piece, Mark Bittman argues a 20% increase in taxes on sugary drinks could result in a 20% decrease in consumption, which in the next decade would prevent 1.5 million Americans from becoming obese and decrease the number of cases of diabetes by 400,000, saving the U.S. Government $30 billion.

Look at cigarettes for a parallel, says Bittman. Taxes on cigarettes , which have raised costs per pack to over $4.20, have decreased cigarette smoking from 130 packs per person per year in 1970 to 60 packs per person today. Smoking, in short, is a mirror for eating. Tax either, and bad habits will decline.

With a mere $13.2 billion in federal tax revenues for bad food, we could cover 8% of the expected 2012 $166.2 billion bill for obesity in the U.S. Then we could turn around and subsidize vegetables and grains, say at 50 cents a pound, and cause the consumption of healthy foods to go up.

A Little Tax Increase Is a Difficult Thing

What has prevented taxes on bad food from taking place ?

• Americans’ aversion to higher taxes, the crux of the current debate on raising the debt limit.

• The American fast food industry, which spent more than $4 billion on marketing in 2009.

• The American public, who resist further intrusion into their personal habits by Big Government.

People become rebellious, cranky, and downright death-and-health-denying-and- defying when they learn that almost everything that tastes good or gives pleasure is fattening, addictive, immoral, illegal, oncogenic, diabetes-inducing, or verboten.

We resist being told to eat our broccoli, or shun our carbs, fats, sweets, and meats, even when we know, chronic or lifestyle diseases now kill more people than communicable diseases.

Needed: A Fat Chat

It’s going to take a few decades and a national educational chat to reverse the trend towards obesity.

As Lewis Carroll said in Alice in Wonderland,

“Wait a bit,” the Oyster said,
“Before we have our chat,
For all of us are out of breath,
And all of us are fat.”

Saturday, July 23, 2011

Ten Medical Megatrends: Then (2000) and Now (2011)

July 23, 2011 – Eleven years ago, as editor-in-chief of Physician Practice Options, I wrote a piece “Predicting Millennial Megatrends Using a Trend Triangle.”

The trend triangle consisted of news gathered from the popular media and the Internet, opinions of practicing physicians and others on the front lines of care, and survey feedback from health care experts based on my resulting megatrend predictions.

In doing this, I was following the lead of John Naisbitt, who in 1982 imbedded the term “megatrend” in America’s minds, through his book Megatrends: Ten New Directions for America.

Naisbitt maintained most trends emanated from the “bottom-up,” from the ground levels of society, not from the “top-down,” from government and think tanks in the Washington, New York, Boston axis.

I thought it might be interesting to see how my 2000 megatrends have worked out in light of what has happened since 2000 – 9/11, wars in Iraq and Afghanistan, the 2007 economic meltdown, doubling of health costs, the 2010 health law, the Tea Party revolt, persistent 9.2% joblessness, and the 2011 debt crisis.

In presenting these 2000 megatrends, I shall share the average agreement of 25 health authorities I consulted. I asked them to rate the megatrends as follows; 5 Strongly agree, 4 Agree, 3 Neutral, 2 Disagree, and 1 Strongly disagree. I then added up their individual responses and divided by 25 to get a feel for their collective predictive judgments.

Ten 2000 Megatrends and 2011 Comments

One - physician websites will become as common as the yellow pages. 4.44

Comment: Market-driven. Physicians, like small businesspersons , have moved to the Net by the hundreds of thousands. Websites are a form of marketing and a place to dispense information and arrangements for refills and scheduling. Websites have little impact or relationship to reform, and are simply a needed expense for practicing and doing business.

Two – E-healthcare, the transition of health care from business and patient-related processes and transaction to the Internet will become a $300 billion industry. 4.40

Comment: $300 billion is an underestimate. Healthcare, like everything else, now moves on Internet time. This transition, however, has not extended to electronic records, which most doctors consider a government demand, not a market need.

Three, handheld computers linked to the Internet will make patient encounter data more accurate, outcome studies more feasible and relevant, and will render obsolete many expensive computer systems. 4.36

Comment: Mostly a pipe-dream promoted by wonks. Although handheld devices are the rage, they have not proven only marginally effective, except perhaps for e-prescribing, in improving care.

Four, the number of procedures done in the office – outside of hospitals and outside outpatient surgical centers – will continue to increase as fees from managed care and Medicare continue to drop. 4.28

Comment: True to some extent, but doctors banding together to buy imagining equipment and physician-owned diagnostic and procedural centers more popular. A peripheral reform issue.

Five, the greatest promise for prevention and cure of disease lies in present genetic research, gene therapy development, and human genome mapping. These advances are likely identifying potential diseases, to prevent them, and to make them remedial.4.24

Comment: This was, and is, ahead of the curve. Not much impact yet at practice level.

Six, E-mail communications with patients – for scheduling, prescription refills, transmitting test results, health information – will become common and will minimize “telephone tag.” 4.16

Comment: Happening but most doctors still resist active e-mail communication with patients because of lack of reimbursement, time constraints, and medical legal exposure.

Seven. The mad scramble of drug companies for new and more profitable drugs will require outsourcing of clinical trials to practicing clinicians and will become an important sure of revenue for more practices. 4.12

Comment: This simply has not happened on any grand scale because of bureaucratic and operational requirements.

Eight, because of the general predilection of Americans for specialists in all walks of life, and for specialists performing high tech procedures, specialists will continue to do well. 4.08

Comment: This still holds true even the face of countervailing movements – Medicare lowering specialty fees, restructuring of Medicare RUC (Reimbursement Update Committee) coding to narrow gap between specialists and primary care physicians, the drive to replace FFS with capitation, and the migration of specialists into salaried positions in integrated organizations.

Nine – For independent physicians in solo or small groups, the Internet will be a blessing because it will allow them to outsource most practice management and business functions through Internet, enabled personal computers.

Comment: Mixed blessing. “Free EHRs” supported by ads through companies like Practice Fusion, Inc., and “cloud computing “ at out-of-office Internet sites are a boon for small practices, but IT infrastructure and hassle costs remain too high for most small practices.

Ten – (Tie for Tenth), American physicians will become increasingly mobile in seeking practice opportunities in other parts of the country and in different careers inside and outside the profession. 4.00

Comment: This “mobility” is mostly to hospital employment and to the so-called high tech ROAD specialties (Radiology, Ophthalmology/Orthopedic, Anesthesia, and Dermatology) with higher pay and more regular hours to locum tenens work (see Merritt Hawkins book Have Stethoscope, Will Travel, 2009.

Ten (Tie for Tenth). Most of America’s 600 Integrated Delivery Systems are in financial and cultural trouble and will shed most physician practices acquired over the last five years. 4.00

Comment: Not true today. Systems have consolidated and become profitable. Did shed unprofitable practices, but are now acquiring more profitable practices of primary care doctors and specialists seeking economic security and more balanced life styles.

Friday, July 22, 2011

Primary Care Dilemma: It’s Not What Wonks Think : It's How Patients Act

Between the idea
And the reality
Between the motion
And the act
Falls the Shadow

T.S. Eliot (1886-1965), The Wasteland (1922)

July 23, 2011 - I’ve heard critics express the idea a thousand times in a thousand ways.

The Idea

The idea goes like this:

The system is terrible. It is fragmented. It is inefficient. It is too costly. It relies too much on specialists. Patients with chronic disease see too many over-paid specialists who don’t talk to each other. What we need is more well-paid primary care practitioners. They will provide accessible, continuous, comprehensive, coordinated, connected-electronically, and patient-centered rather than specialist-centered, care.

The Shadow

The problem is between the idea and reality falls a shadow.
Patients aren’t listening. They prefer the choice and freedom of picking their own doctor. In many cases, this doctor is a specialist who treats their specific problem.

Patients feel they have enough information to make their own decisions as to what physician to choose. The American public is specialist-oriented. This is why the typical Medicare patient with chronic disease sees 5 or 6 specialists a year, rather than going through a personal primary care doctor who directs their over-all care.

The Problem Comes Home

This problem came home to me yesterday. I accompanied a patient to visit her primary care doctor. When her primary care physician diagnosed late-onset type 2 diabetes, she informed him, “ Please refer me to an endocrinologist who specializes in diabetes.”

He replied, “But I can handle your situation perfectly well. I have all the resources and knowledge needed to manage your illness , including a nutritionist and a team of other providers, to handle your diabetes.”

“No, “ she said, “ I want to see an endocrinologist, inside or outside your system.” She was not concerned about the “fragmentation” of the system.

The Dilemma

Therein lies the dilemma – whether patients chose to be handled by “systems of care,” and funneled through a primary care generalist within the system or to go directly to a specialist of their own choosing.

This is not a trivial matter. It stands in the way of widespread establishment of Primary-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs). And it will be a point of dispute between primary care physicians, specialists, and patients. Many patients feel they are perfectly capable of choosing what doctors to go to.

Patients are often unaware of background arguments about primary care doctors working proactively to keep patients healthy, coordinating patient care, achieving measurable better outcomes, and focusing on “whole patient care,” rather than specialists addressing specific illnesses, offering life-style procedural salvations and one-on-one solutions.

In choosing doctors, patients still prefer to think for themselves, rather than having others think for them. If their decision involves “waste” for the system, so be it. One person's idea of waste may not be reality-based.

Health Reform: Gang-Bang - Senator Tom Coburn, MD, and the Gang of Six Proposal

July 22, 2011 - Tom Coburn (R-Oklahoma) and the Gang of Six proposal is making a Big Bang in the Budget Battle. The media says their proposal will be a Grand Bang because it is “bipartisan” and “balanced. “

This may be wishful thinking. It will probably pass in the Senate but be rejected in the House.

Peggy Noonan, former Reagan speechwriter, sums it up nicely in today’s Wall Street Journal,

The Gang of Six—three Democrats and three Republicans in the Senate—this week put forward a plan aimed at reducing the national debt by almost $4 trillion over the next 10 years. It includes $500 billion in immediate cuts, and repeals a costly provision of ObamaCare. The plan would lower the top individual tax rate to 29%, push corporate tax rates down to 29% from 35%, and abolish the Alternative Minimum tax. On long-term spending the plan includes a legislative supermajority and sequester feature. In the words of a senator involved in the bargaining, "For the first time, we have some real teeth" in spending control.

Health Care Components

For health care reform , the basic elements of the Gang of Six proposal are:

• Ending Obama’s Long-Term Care savings CLASS Act (Community Living Assisted Service and Support Act), designed to relieve pressure on Medicaid by keeping patients out of nursing homes and at home by tending to their eating, bathing, and other needs in the home.

• Imposing further cuts on hospitals on top of the $575 billion cuts already in the health care law.

• Suspending the Sustainable Growth Rate (SGR) formula which calls for $298 billion in physician Medicare cuts.

The Gang of Six proposal, particularly its health reform elements, is widely considered to be the catalytic handiwork of Senator Tom Coburn, MD, a tough-minded conservative purported to be a buddy of President Obama.

Whether the Gang of Six proposal will ever see the light of day is doubtful. The Senate may pass it, but the House will probably not give its OK.

In the latest twist of the Budget argument, Coburn says passage of the Gang of Six proposal may not even be necessary. Coburn now says if the Cut, Cap & Balance legislation, just passed by the House, lands on President Obama's desk he would sign it.

Porterhouse Steak Bet

Coburn adds, "So the point is I'm willing to go out across this country, even if the polls are 70 percent against what we're doing -- the fact is you can't solve our problem unless you do what "Cut, Cap, and Balance" wants to do. So, it doesn't matter what the polls are. We've got to fix our country, and this is the only viable plan right now that will do that, and I will bet you a Porterhouse steak if it lands on his desk, he will sign this puppy," C

How Coburn Thinks

To give you some insight into how Senator Coburn thinks, I reprint here an interview I conducted with the Senator back in 2010, before Obamacare passed and before the Budget Battle reached its current epic heights, said by Obama representatives and the mainstream press as threatening to undermine the financial credibility of the United States.

Interview with Tom Coburn, MD, Republican Senator from Oklahoma

Preface: This interview took place on January 26, 2010 – a critical time when Obamacare’s fate hung in the balance. After the bill passed, Senator Coburn, a conservative Republican and a fierce opponent of the health reform bill, caused a stir and raised a few eyebrows by defending Nancy Pelosi as a “nice person” and by taking a swipe at the objectivity of Fox News.

Q: Do you think the President’s and Democrats’ ideology will permit a market-centered system?

A: I don’t know. We will have to wait and see. I don’t assume anything. I don’t think either the President or the Democratic leadership is stupid.

The question is: Do their constituencies allow them to move to the market? Will those who want a single-payer government-run system and those who are hard out on a more socialistic-bent get the message, the message being what they are doing isn’t working?

Leadership is about doing what is right, not in doing what is right for your constituents.

If Obama moves to the center and really tries to accomplish what the vast majority of people in the country want and what is good policy, he could reverse a lot of the perceived losses.

Q: You’re still a practicing physician?

A: I only practice on Monday mornings. I am a family practice obstetrician. I did a general surgery residency and then did family practice.

Look. What is ultimately good for patients will be good for doctors. If doctors are most concerned about their patients and the care they give, they will do just fine.

The reason doctors are in a pinch right now is that we have government-mandated price controls, which do not pay them to give the best care. We need to get back to where we reward great care and don’t reward poor care.

Q: One of the things that concerns me, and which I wrote a great deal about in my book Obama, Doctors, and Health Reform is the impending and growing doctor shortage. I know this shortage is acute in Oklahoma, where I practiced for five years, because Oklahoma has fewer doctors per capita than almost any other state. The next crisis is going to be access to doctors.

A: You are right. It’s important to keep in mind the federal government has mandated the doctor shortage. When the payment differential between primary care doctors and specialists averages about 300 percent, and that is based on Medicare payment rates, Medicare created the primary care doctor shortage.

Medicare augmented too much of a move to sub-specialization through their payment practices. Again we have not allowed market forces to work.

When only one of 50 doctors who graduated from medical school last year went into primary care, you know we are going to have a shortage. We need to let the market solve the shortage.

But we won’t do that. There are things in this health bill to correct the situation, but the plan we need the most is to pay them what they are worth rather than some fixed price that Medicare sets.

Q: Could you tick off the market forces you think are necessary to rectify this situation?

A: Transparency in the market as to price and outcomes, in other words, quality; and reconnecting the consumer with the purchase and payment of health care, rather than saying someone else is paying my bill. In other words, reconnect that. If you look at the Safeway model, what they’ve done, besides emphasizing prevention and management of chronic disease, is that they’ve made good consumers out of their employees by having a $2000 deductible.

The consumers now make a choice and they also shop for price and quality. If you do just those two things and you allow market forces to reward good care, you will get a whole lot more primary care, and you’ll do it by the very tenets you and I were taught in medical school, i.e. listen to the patient. If something has already been done, then don’t do it. And don’t do any harm.

Q: What about these other factors, like shopping across state lines, facilitating health savings accounts, or heath care tax credits for all, for the self-employed and individuals, rather than just corporate employees?

A: Those factors are good as well. We need a real national market for health insurance. Just look at the market for auto insurance and how those rates has come down with real competition throughout the country.

In health insurance, we have regulated minimal competition. Part of that is because we buy it through our employer. Recently many major employers are beginning to copy what Safeway and Pitney Bowes and several others have done. We are going to see those costs come down as we get more aggressive. But we limit that because we have a HIPPA limitation on how much employers with ERISA can do.

Shopping across state lines brings you real competition and is something we need to do. The other thing is to allow consumers to buy what they need rather than what is mandated by a bunch of state legislators that they have to have.

Consumers aren’t stupid. They will buy what they need. That includes the ability to buy a high deductible plan that is truly competitive. Right now the high deductible plans are too expensive, because there is not really any true competition for them.

Q: In my book Innovation-Driven Care, I have an interview with a health agent who sells HSAs to 120 employers in Minnestoa , and he said high deductible plans have taken off in that liberal state. Why haven’t HSAs taken off elsewhere?

A: They have taken off, but they are still too expensive because there hasn’t been enough competition. We limited the amount they could grow by statute, and we’ve limited the true competition for the pricing of the product. When you’ve limited the pricing and how many people can get them, you can see where that’s a restraint on growth.

Q: So your position is we’ve got to free up market forces so they can do what only they can do – bring down costs and raise quality.

A: Well, markets work. We can interfere with them so they don’t work. You can come back and create a safety net for those who need our help, but market forces will certainly allocate costs down and minimize those who need help.

Q: If we unleash market forces, do you envision that will expand access enough to satisfy those on the left?

A: The only thing that will satisfy those on the left is single-payer universal coverage.

Q: So liberals see health care as their historical legacy, and they have got to pass a comprehensive bill while they can.

A: Massive Health care reform should not be the number one priority for our nation right now. The number one priority is to downsize the cost and increase the efficiencies of the federal government so people can have more of their own money to spend on things that concern them most

Thursday, July 21, 2011

Health Reform Updates - The Views of Donald J. Palmisano, MD, JD, President of AMA, 2003-2004, and President and CEO of Intrepid Resources, Inc, a risk management firm.

July 21, 2011 - I recommend my readers regularly consult DJP Update, a daily blog written by Donald J. Palmisano, MD, JD. He has over 250 physician leaders on his e-mail list. His reports give a crisp, clear, and compelling picture of what’s on the mind of physicians regarding health reform.

In recent blogs, Dr. Palmisano questions the value of a President Obama appointed Independent Payment Advisory Board (IPAB) working in conjunction with Patient-Centered Outcome Research Institute (PCORI) and dismisses the Obama administration’s “mystery shopping” initiative as another bad idea.

He has long championed health savings accounts, tax credits for all Americans, private contracting with physicians by Medicare patients, and comprehensive tort reform.

I am indebted to Doctor Palmisano for two reasons.

One, he wrote the following words of praise for my new book, The Health Reform Maze; A Blueprint for Physicians (Greenbranch Publishing), which will available for sale in August, 2011.

This is a must read collection of essays that gives the good, the bad, and the ugly of the new healthcare law, PPACA. Dr. Reece shares a balanced approach of proponents and opponents of the law and gives hope for a better way to reform the system.

Two, last year he granted me the following interview , which appeared in Modern Medicine on April 27, 2010, but was conducted before passage of PPACA on March 23, 2010.

Health Care and Medical Liability Reform: Perspectives from a Doctor-Lawyer - Interview with Donald Palmisano, MD, JD, former AMA President and Founder of Intrepid Resource

Donald Palmisano, MD, JD, a physician and attorney, is perhaps organized medicine’s most articulate spokesperson and one of the few who equally grasps medicine and the legal issues that surround it. Recently, he and two other former AMA presidents wrote a widely quoted Wall Street Journal article offering up “…Better Ideas to Increase Coverage for the Uninsured.” He is Founder and President of Intrepid Resources, a medical risk management and patient safety company. Dr Palmisano discusses health care reform in America and how independent physicians in small practices can succeed.

We have reached what has variously been called a tipping point, a sea change, and inflection in the health system. Have we reached a watershed moment in American health care?

• Yes, we have reached a critical moment because government and third-party intervention are disconnecting the patient from the physician and the decision making from the patient’s best interest. The ideal system is one where patients own their health insurance and make decisions with the doctor as trusted advisor.

• What system do we have now?

• Currently we have third parties telling doctors which treatment will be allowed and not allowed. We have government taking away the right of private contracting between patients and physicians. With Medicare, doctors must accept what government pays because if you do a private contract the physician is removed from Medicare for 2 years. Unfortunately, we are moving towards more government control, a system that will not lower costs, and one in which physicians are being paid less than the cost of delivering care.

Consequently, a patient’s Medicare or Medicaid card does not guarantee that the patient will find a physician in his or her hour of need. Fewer and fewer doctors accept Medicare or Medicaid patients because federal and state government pays less than the cost of delivering care. Price fixing has never worked in the history of the world, and it is not going to work in medicine.

•Is it fair to say that you’ve been opposed to the House and Senate bills?

• Let me correct you. The system needs to be fixed. We have the best care in the world, but the financing of the system needs to be fixed immediately. The bills that came out of the House and Senate have disaster in the details. I’ve written about this disaster in the October 5, 2009 Wall Street Journal with two former AMA presidents and in the May 12, 2004 issue of JAMA with two PhDs.

I recommend expanding coverage through tax credits, consumer choice, market enhancement, low cost health savings accounts, individual ownership of insurance, extending subsidies to those who need financial help, the right to privately contract between patients and doctors, and purchasing insurance across state lines.

These are free market principles and would take care of the monopsony power of health insurers and what they allow patients to receive and what they pay the doctor.

• Can independent doctors in small practices do anything to change the dynamics?

• That’s an important group of physicians because they represent 80% of practices. They deliver most medical care, rather than those giant clinics you hear so much about. They should not just sit around the coffee pot and grouse. They have to be engaged in the political process by contacting their representatives in Congress and their two Senators and telling them how adversely this interference is affecting their practice. They should encourage their patients to do the same. Otherwise folks in Washington will remain in their bubble. They don’t hear enough about what’s happening in the actual practice of medicine. They are just listening to talking heads and think tank wonks.

What do you think about the information coming out of Washington?

• The public is being given bad information. When the President of the United States says a physician would amputate a leg to get $50,000 rather than treating the patient medically, he must be getting bad information from his advisors. When he says a doctor will do a tonsillectomy rather than treating a child for tonsillitis, it is not appropriate. Such statements do not resolve anything, and it they don’t lead to positive solutions. They make people angry and uncertain. People are saying, “Can I trust anything that’s being said in Washington?” or “Can I trust my doctor?”

We need to get the real facts. I love Aldous Huxley’s quote, “Facts don’t cease to exist because they are ignored.” Let’s make sure we have the real facts, not opinions or theories. Louis Pasteur, another person I admire, said, “Imaginations should give wings to our thoughts, but we always need decisive experimental proof.”

Doctors in small practices need to say, “We don’t need a big experiment on America.”

What difficulties do you see facing those who are looking for reform?

• What we need to do is identify what the problems are:

First, some health insurers ignore patients and physicians. Their misplaced monopsony power allows them to dictate terms that are not necessarily in the best interest of the patient. We fix that by competition across state lines.

Second, we need to get insurance for people with pre-existing conditions. We can do that with voluntary purchasing cooperatives so people can get together in groups of 10,000 or more. Everybody can be accepted when they have the options of getting bids on large groups, just as in a large company like IBM.

Third, then there’s Medicaid recipients. Why should people on Medicaid have less than ideal access to care? Convert Medicaid into a defined contribution. Give them the same advantages as people in the Federal Employee Health Benefits (FEHB) Program. Give them a voucher, and allow them to choose from an array of choices.

Government should not assume the American public is not smart enough to make their own decisions. We need to give the patients more control, with the same tax advantages for every American.

You use the phrase “disaster in the details.” One of the details ignored in the House and Senate bills is that more doctors are choosing not to accept new Medicare patients, or opting out of Medicare altogether. How does Congress address that issue?

• That’s the natural consequence of price-fixing. When you price-fix, you get decreased availability of a product or service. Price-fixing never works. The main concept in the book, Economics in One Lesson written many years ago by Henry Hazlitt, can be summarized in one sentence: You have to look at the long-term consequences of any action rather than just the immediate consequences.

If you reduce physician Medicare fees by 21%, as now being proposed, you will save money in the short term, but what are the long-term consequences? You will get lack of access to doctors. Doctors will say, “I can’t afford to see these patients. I won’t be able to buy my medical liability insurance. I won’t be able to pay my staff, so I will have to stop seeing Medicare patients.”

This is even more dramatic in Medicaid. With this government plan, we will end up with Medicaid-for-all, long waiting lines, and no doctors to treat them. Physicians will do something else. They will limit their practice, or switch to concierge or cash practices and directly contract with patients.

They will get out of Medicare, Medicaid, and all insurance programs. That’s not good for anybody. Suppose after you finish this interview, you go for a walk, and a car veers off the road and hits you. You will be taken to the ER, and there may be no specialist there to treat your head injury, your broken bones, and your internal injuries.

Do you see any lessons we can learn from other countries?

• The answer is, when the government decides some group needs help, it gives them an indemnity payment or a voucher, and the patient and doctor privately contract. I just returned from Australia, where I lectured on my book On Leadership: Essential Principles for Success.

Here’s how it works there: The Australian government encourages people to get off the government system and onto a private system. They do that by giving a 30% subsidy for the purchase of private insurance. They also allow what they call “negotiating the gap,” where the patient and doctor can negotiate the difference between what the government and private insurer pays.

You’ve been a big advocate of “private contracting” between doctors and patients. What’s the status of that?

• It’s not available in any of the bills. It’s not available in Medicare or Medicaid. I presented this to the AMA out of Louisiana in 1993 as a resolution. It was passed and has been reaffirmed multiple times. It restores the right of liberty—the right of private contracting. This is not a new idea. It’s like when you go to buy a car, you can negotiate the price of the car.

You’ve started a company called Intrepid Resources—a risk management and patient safety enterprise. You often say the current liability system has a “hidden cost.” Is one of those costs limited access to care? How significant is that?

• It’s a real problem, which I’ve mentioned in my AMA inaugural address and in my 2004 Thomas B. Ferguson talk before the Thoracic Surgeons. Unwarranted liability increases cost. When I was AMA president, the costs of medical liability in Dade and Broward Counties in Florida for obstetricians were $249,000 per year.

Just imagine who suffers from that exorbitant cost. The doctor cannot make enough money delivering babies to pay that cost, so the doctor leaves that community. In Texas, legislators passed a tort reform law in 2003 and changed the state constitution to allow caps on noneconomic damages. Premiums promptly dropped 17%, and the Texas Medical licensing board had to add staff to handle the flood of out-of-state doctors wanting to practice in Texas. \

In Texas, legislators—both Democrat and Republican—passed that law because patients were angry, upset, and at risk because they couldn’t find a doctor for emergencies. People were dying or having to care for themselves. One woman, a nurse, had to deliver her own baby along the side of the road. Medical liability is not only about increased costs. It’s about patient safety.

Then there are defensive medical costs. Someone hits their head, and if there’s a delayed or occult subdural hematoma, and if you haven’t ordered a CAT scan, you’re liable. As a result, everybody who hits their head gets a CAT scan, whether it’s indicated or not, whether or not neurological signs are present.

The Congressional Budget Office says the cost of defensive medicine is $54 billion for 10 years, and it’s probably much more than that. I testified about this before the House Ways and Means Committee in 1975, and I recently spoke about it before the American Enterprise Institute. We passed a reform law in Louisiana in 1975, but not all states gets the message. A good example is Illinois, who’s Supreme Court declared a cap on damages as unconstitutional.

• How important has your legal training been in putting medical issues in context?

• It’s been very helpful. I went to law school when I was a busy surgeon. My five partners were generous in covering for me while I was in law school. I paid them back hour-for-hour on the weekends.

I’ve found my legal training helpful in 3 ways:

One, it helps me understand how the courts analyze the law.

Two, it taught me legal research and how this can help physicians avoid errors and learn more about legal jargon.

Three, it exposes me to a lot of wonderful lawyers all over the country, who I can call upon for resources.

The conventional wisdom is that the trial lawyers of America, who are huge contributors to the Democratic Party, have effectively kept tort reform out the House and Senate bills. Is that true?

• Absolutely; it is true. Howard Dean, the doctor from Vermont and Democratic stalwart, said the people who wrote the bills in Congress “did not want to take on the trial lawyers.”

President Obama says we will study tort reform. That’s like saying we will form a committee and then do nothing.

The big driver for trial attorneys is the contingency fee. Doctors don’t say “I will treat you if you give me 20% of your earnings for life.” If you have a patient in the ER hemorrhaging from a ruptured spleen, you don’t say, “If you die I won’t charge you, but if you live you’re on the hook for part of your lifetime earnings. I only want 20%, not the 33.3% or 50% you take.”

What do you say? I used this example in a debate with a lawyer on TV, and he went ballistic. Why do we differentiate between legal and medical ethics? Lawyers will tell you the contingency fee is the key to the courtroom door. We could say a contingency fee is the key to saving your life, but we don’t.

Let’s end this interview with a conversation about the AMA. Last October in the Wall Street Journal, you and two former AMA presidents took exception to the AMA’s endorsement to the House reform bill. The AMA is in trouble with doctors and only about 15% of practicing physicians now pay membership dues. What can the AMA do to regain the confidence of America’s physicians?

First of all, let me say I believe the AMA is a wonderful organization. It does much good. It has terrific scientific journals. It has a council on ethical and judicial affairs.

But I do criticize AMA’s health system reform decision endorsing the Obama administration’s stance. They wanted to have a seat at the table. They were concerned if they didn’t have that seat, they would be cut out of the negotiation.
What the AMA should have said is, this is our policy: medical liability reform, the right to privately contract, defined contributions. If you put those things in the bill and you don’t insist on more government control, we will support the bill, rather than saying, now that we have a seat at the table, we will work to change it. The AMA made a serious mistake.

• So what can the AMA do?

• I think at the AMA House of Delegates, physicians ought to get somebody other than board members to run for President. Somebody from the floor ought to be elected. That would send a strong message for change, just like the message in Massachusetts.

AMA ought to be open in their board meetings, with the proceedings being on the equivalent of C-Span. AMA members could put in their membership number and watch video clips at any time of the day or night. This would help doctors decide who they want to vote for in the next election to the House of Delegates.

Wednesday, July 20, 2011

Trends To Watch For Curbing Health Costs

Preface: Kaiser Health News invites viewers to reprint their material as long as viewers give them credit and insert a link to KHN. Here are six trends to watch as seen by health leaders interviewed by KHN with accompanying comments by me.
By Marilyn Werber Serafini and Mary Agnes Carey.
KHN Staff Writers, July 20, 2011

As President Barack Obama and Capitol Hill lawmakers scramble for ways to cut federal spending, changes to federal health entitlements have been a key negotiating point. Separately, hospitals, physicians and other health care providers are already moving forward with their own efforts to aggressively test a variety of initiatives to rein in costs.

Emerging models include vigorous consolidation, better coordination of care, new financial arrangements among health care providers, and greater use of medical data to identify practices that lower costs.

In recent interviews with Kaiser Health News, policy experts and industry leaders identify some of the most intriguing trends to watch. The following are edited excerpts of the interviews.

Trend One - The Big will grow bigger.

Robert Blendon, M.D., professor of health policy and political analysis, Harvard School of Public Health.

There is a chance that you could arrive [in Massachusetts] 10 years from now and there are three organizations to negotiate with, and every physician and hospital is affiliated with one of the three. There are mergers, consolidations, groups merging with larger groups, so when negotiations come, there are going to be very large players, even larger than the systems that most people envision.

So at one side, we’re doing experiments with the (accountable care organizations) paying primary care physicians, but at the other there is this very visible sign of concentration among providers, which they argue will lead to less expensive care, but economists argue will lead to monopoly.

Driven by Obamacare and need for expensive infrastructure to meet federal demands, the big are getting bigger. I, for one, do not think this is necessarily good in that it reduces physicians to system serfs.

Trend Two - The Blues, Primary Care and Accountable Care Organizations will be the wave of future.

Alissa Fox, senior vice president, Blue Cross and Blue Shield Association:

Blue Cross Blue Shield plans across the country have a whole series of different types of initiatives under way: patient-centered medical homes, providing primary care physicians with additional tools to coordinate care, and accountable care organizations, where we are partnering with hospitals and doctors to really change the way care is delivered. We’re reimbursing doctors and hospitals to pay outcomes instead of just paying for more care. We would like Medicare to start paying for outcomes because that’s (an approach) we think is most successful.

Comment: I would not be so sure. Given their choice and the wide availability of Internet information, Americans still prefer to go to specialists, and as far as I can see, ACOs are DOA among physicians.

Trend Three - Compliance will force consolidation.

Chip Kahn, president and CEO, Federation of American Hospitals

In the (health law) you have requirements that are coming, including: value-based purchasing, restrictions on (Medicare payments for) readmissions and hospital-acquired conditions. All of these compliance issues are going to lead to more consolidation of hospitals and health care. At the end of the day, though, I think hospitals and doctors and other kinds of providers are going to have to find new ways to work together. In some areas there will be more integration with hospitals (employing) physicians, but in other areas, I think there will be just more lines of communication. In some, the expansion of health information technology will lead to virtual connections between them.

Comment - This is a safe bet, but it does not mean physicians and hospitals will work together seamlessly or without friction. It is a good bet, ACOs, if they ever come to be, will cause relationships between hospitals and doctors to deteriorate.

Trend Four – Organizations that promote shared savings will gather steam.

Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University

The most interesting conversation going on right now is in Rochester, N.Y., where they are indeed focused on reducing [hospital] readmissions and unnecessary admissions for conditions that probably would not have led to an admission if the person had gotten proper primary care. The conversation is among hospitals, health plans and primary care docs, and they are working out new payment models so they can share the savings.

Comment - Of this trend, I am skeptical. Shared savings are based on the premise that hospitals and doctors will both voluntarily lose money with the hope of gaining money through shared savings. All you have to do is trust government to make up the difference.

Trend Five - Outcome measurements in large organization of what doctors accomplish will drive down costs.

Stuart Butler, director of the Center for Policy Innovation, Heritage Foundation.

The most hopeful trend that is occurring is in places like Geisinger (Health System in Pennsylvania) and Kaiser (Permanente), where they are really looking in detail at examining what doctors actually do and what the results are in terms of outcomes and then feeding it back into the system. You begin to see changes that other doctors make according to their colleagues. I think that's going to be key to really getting costs down. That said, I really don't think you're going to get overall spending down until you put some kind of limit on direct spending in the health care system in the public sector because I think that is driving increases in costs.

Comment –
I agree decreasing public sector costs will be key to decreasing all costs. I do not agree outcomes data will be the way to do it.

Trend Six – Everybody – public, private, federal, state – needs to be on board to develop new models of care.

Anne Gauthier, senior program director, National Academy for State Health Policy.

The Center for Medicare and Medicaid Innovation is one of the most exciting things coming online in terms of being able to try new models of payment and new models of care delivery. The most important thing [the innovations center] can do is to recognize there needs to be an investment before we start to receive savings and to focus on multiple payers, not just Medicare or Medicaid models. To impact the whole delivery system, we need to include private, Medicaid, state employees and Medicare in terms of some of the payment innovations that are going on.

Comment- I am not impressed by governmental innovation skills. It may be that government-sponsored organizations such as the Patient-Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs) will revolutionize primary care specifically and overall care in general. But given the projected physician shortage by 2020 of 200,000, mainly in primary care, and the continued preference of medical students for specialties, the long-term prospects of these new “models” are cloudy. And given the fact that these new models will require expanded “teams” of providers (medical assistants, nurse practitioners, nutritionists, care coordinators) and electronic health records, I remain to be convinced the new models will lower costs. Manyt physicians regard these models are organizational “overkill.”.

Tuesday, July 19, 2011

Slowing the Speeding Medicare Cost Train

July 19, 2011- The Medicare train continues to hurdle down the tracks towards its rendezvous with bankruptcy. Forty six million are currently on board, and 12,000 baby boomers will be joining the Medicare passenger list each day, 78 million over the next 18 years.

Obamacare was designed to slow the ride to Medicare insolvency. But that was before the 14% increase in costs since the law was enacted. It was before it was revealed Medicare utilization is 50% higher than private health-insurance utilization, even when one compensates for aging and disease. It was before President Obama, in the heat of the budget debate, said Medicare cuts were “on the table,” without being specific. It was before ARRP and the American Hospital Association weighed in saying Medicare cuts were “unacceptable.” And it was before the current budget debate, in which both sides fear being electrocuted by touching the “third rail” of American politics - seniors who vote and who are likely to swing the 2012 Presidential election.

Somehow this train of events reminds me of the title of a February 21, 2011 Robert J. Samuelson column in the Washington Post, "Who rules America? AARP."

And it was before the question was asked, “Why do Medicare Patients see Doctors so much?” The answers from Merrill Matthews, resident scholar at the Institute for Policy Innovation in Dallas, and Mark Litow, a health –care actuary, in a July 14 Wall Street Journal OP-Ed piece are:

• Lack of cost-sharing between patients and Medicare, thus insulating patients from the true costs of services. High deductibles and health savings accounts, say the authors could remedy this problem.

• The widespread use of Medicare supplemental insurance, which further insulates patients from the true costs.

. Confusion among seniors at what's actually at stake and what costs when paying Medicare bills. Simplify Medicare, assert the authors.

• ObamaCare’s promise of “free preventative care,” which further drives up spending.

• The promotion of Medicare as an “free entitlement,” which obscures the fact that patients contribute only 1/3 of what Medicare actually costs, with taxpayers and private payers taking up 2/3s of the slack. The result has been a spending explosion. Part A (hospital expenses) were projected at $9.1 billion; actual spending was $67 billion and are now nearing $500 billion.

• Fraud and abuse. The GAO, in a report released in March, says “improper payments” Medicare and Medicaid totaled about $70 billion.

Matthews and Litow conclude:

“Medicare needs to be revamped. The benefits package needs to be rationalized so seniors can tell what their financial exposure is and choose from the private sector, high deductible options, including a Health Savings Account plan. Seniors need to benefit financially from good choices. Giving them more options and control is the best way to reduce that 50% additional utilization while preserving the program for the future.”

Matthews and Litow believe “Relying on unelected bureaucrats, such as ObamaCare’s Independent Payment Advisory Board, to ratchet down Medicare price controls won’t control over-utilization.”

In the end, government cost controls will not work. They never have and never will. Only informed Medicare recipients, with a nominal “skin in the game,” and knowledge of costs at stake, can effectively control costs.

Monday, July 18, 2011

The Usefulness and Uselessness of Electronic Medical Records

Nothing is so useless as a general maxim.

Lord MacCaulay (1800-1859), On Machiavelli (1827)

I dare say that I have worked off my fundamental formula on you that the chief end of man is to frame general propositions and that no general proposition is worth a damn.

O.W Holmes, Jr. (1809-1904), as quoted in The Practical Cogitator, 1962

July 18, 2011-
The general maxim and general proposition behind the rationale of a national interoperative electronic medical record system in every physician’s office is that you can never get too much information and that government can use digital data to cut costs and improve care.

The Problem

Sounds good, doesn’t it? The problem is that so far, after nearly a decade of advancing this maxim and proposition, perhaps 80% of physicians in independent practice aren’t buying. And this, in face of the reality, that government has proposing spending $27 billion to get EHRs off the ground. And beginning this year, CMS will start offering as much as $44,000 per physician over a staggered five years if physicians make “meaningful” use of “certified” medical records. Many doctors regard such rhetoric as empty talk that will accompanied by unreasonable bureaucratic requirements, as surely as dawn following night.

Why no “buy-in” among doctors? Why have two national IT coordinators appointed by Obama, David Brailer,ND, in 2005 and David Blumenthal, MD, in 2011, resigned in frustration over the failure to persuade doctors that gathering electronic data and measuring care is a good thing? If universal EHRs are such a good thing, why have physicians and hospitals not raced to embrace EHRs?

As Steve Lohr of the New York Times, a leading thinker in health care innovation, says in yesterday’s Times (“Seeing Promise and Peril in Digital Records,”

“What is beyond doubt is that the promise of digital records will be unfulfilled if doctors refuse to adopt them, because they regard the technology as cumbersome, time consuming, and possibly dangerous.”

To date, most doctors, except for enthusiastic early adopters, IT nerds, and those in large organizations, have found EHRs “useless” in their daily work. EHRs cost excess money, show little return on investment, change the very nature of practice, slow productivity, tell no narrative tales, cause conflicts among staff and colleagues, require extensive record keeping, are subject to hacking, and, more often than not, are useless as a tool for communicating to colleagues, hospitals, and other doctors outside your practice.

When the government establishes “usability standards” that work, maybe doctors will come on board the electronic train. Until then, says Dr. Edward H. Shortliffe , a professor at the University of Texas Health Science Center in Houston, “Usability is going to be the single greatest impediment to physician acceptance. “
If EHRs are not made more useful and soon, universal digital records may turn out to be a giant boondoggle rather than a scientific bonanza.

Health Reform Books: It’s E-lementary, My Dear Watson!

In the past years, e-books have skyrocketed in popularity..For new releases, the first week brought an increase in sales of electronic copies than of print copies.

Julie Bosman, “E-Book Revolution Upends a Course, “ New York Times, July 17, 2011

July 18, 2011- As everybody knows by now, E-books have taken off, Amazon’s Kindle is the hottest retail product on the market, everybody with an E-reader loves their new gadget, the print book industry is threatened by extinction, E-books are regularly listed on the New York Times best seller list, and you can easily convert a print book into an E-book.

No Sentimentality

There is no use getting sentimental about these trends, said Jame Gleik in yesterday’s New York Times, “Stop Being Sentimental about Books.” He should know. He has written a 2011 best-seller The Information : A History , a Theory, a Flood .

Go with the flow of history, Gleick says,”An object like this (A book) – a talisman, is like a coffin at a funeral. It deserves to be honored, but the soul has passed on.”

What To Do?

If you’re like me, a author of print books, what do you do?

You act.

• You begin to publish E-books (The Pros and Cons of ACOs(PSR Publishers, www.

• You spread the word that your publisher is producing your new book The Health Reform Maze, (Greenbranch Publishing), due out in two-three weeks, will debut in both in print and as an E-book.

• You encourage your previous publisher (I-Universe) to convert your 2009 book – Obama, Doctors, and Health Reform – into an E-book.

And while you’re at it, you mourn the passing of print and you proclaim that a new medium has been born.

Sunday, July 17, 2011

Health Savings Accounts: A Return of the Obvious

It requires an unusual mind to undertake the analysis of the obvious.

Alfred North Whitehead, Science and the Modern World

July 17, 2011- I have a dear friend, Donald Copeland, MD, a 77 year old family physician in Cornelius, North Carolina. Over his lifetime, Don has been in solo and large group practice. He has organized large groups . He has taught family medicine at Bowman Gray. He has been around the block. Don has a gift for the obvious. He believes in most situations - a solo primary care physician, teamed with a dedicated nurse, dealing with a patient with a health savings accounts – can effectively, efficiently, and inexpensively - deal with common clinical situations. He believes in a close patient-nurse-doctor relationship, and he believes most patients, armed with an HSA, will make the right choices for themselves.

Given this context, I am pleased to note Congress has began to return to its senses by removing some of the restrictions placed on HSAs by the ACA on March 23, 2010.

Here, in brief, as reported by Kaiser Health News, is what is going on.

Bill Offered To Undo HSA Health Law Provision

July 15, 2011

Bipartisan legislation was introduced Thursday to remove restrictions on tax-exempt health spending accounts — a revenue-raising provision of the health law that was estimated to garner $5 billion over 10 years.

The Hill: Another Provision Of Health Care Reform Law Comes Under Bipartisan Assault

Lawmakers in the House and Senate introduced bipartisan legislation Thursday to remove restrictions on tax-exempt health spending accounts, the latest provision of the health care reform law to come under attack by Democrats. The bill would nix a provision that since January has required a prescription for buying over-the-counter medicines with medical savings accounts such as Flexible Spending Arrangements and Health Savings Accounts. The language was added as a way to keep the bill's costs down because it was estimated to save $5 billion over 10 years by cutting down on unnecessary drug purchases (Pecquet, 7/14).

Kansas Health Institute News: Kansans In Congress Offer Bill Repealing Part Of ACA

U.S. Sen. Pat Roberts and U.S. Rep. Lynn Jenkins, both Kansas Republicans, have partnered on legislation that would repeal a portion of the Affordable Care Act. As of Jan. 1, the federal health reform law disallowed the purchase of non-prescribed medications with money from tax-free medical savings accounts such as Flexible Savings Accounts, commonly known as FSAs. Roberts and Jenkins joined U.S. Sen. Ben Nelson, a Nebraska Democrat, and U.S. Rep. Shelley Berkley, a Nevada Democrat, in introducing legislation today that would repeal that prohibition (7/14)

And here is an interview I conducted with Doctor Copeland for my 2009 book, Obama, Doctors, and Health Reform (I-Universe).

CHAPTER THIRTEEN, View of a Family Physician from Rural North Carolina

It’s much more important to know what sort of patient has the disease than what sort of disease the patient has.

William Osler, MD, 1648-1919

The family doctor was an institution. If there has been a change, the physician is not primarily to blame. On the contrary, it’s a tribute to the profession that the older idealism persists in such an unfavorable environment. The fault – if fault there be – is that the profession is now practiced in an industrial world dominated by business.

Walton H. Hamilton, MD, Medical Care of the American People, 1932

There’s no other profession as personal as the medical profession. If physicians continue to allow non-physicians and businesses such as hospitals and insurance companies to control them, they will lose their patients and will be nothing more than over-educated, hired technicians.

Donald Copeland, MD, 2006

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

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

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

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

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

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

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

Strong Views Backed by Experience

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

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

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

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

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

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

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

Rural Physicians, Urban Internists, and Health Savings Accounts

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

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

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

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

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

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

Increasing Primary Care Visit Codes

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

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

Providing Comprehensive Care for Medicaid Patients in North Carolina

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

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

$50 Billion for Electronic Medical Records

Q: President Obama has recommended the government spend $19 billion over the next five years to make electronic medical records mandatory, and there’s underlying threat to restrict payment only to those doctors with electronic records. What do you think?

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

Organization Overkill

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

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

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

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

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

Practicing Primary Care

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

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

Personal Relationships Paramount

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

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

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

A: Of course. Who would think otherwise? The problem with outpatient clinics in academic medical centers is that they’re impersonal. That’s a terrible way to teach doctors how to practice medicine. I want medicine to be personal - between the doctor and the patient – not some third party. Besides, my granddaughter is going to medical school, and I want to do what I can to preserve the personal element. That’s what makes medicine such a great profession, and the lack of the personal element is what’s wrong with corporate medicine and third party care.
A family doctor Donald Copeland,
copes by taking a principled stand.
Inside-out he knows primary care,
And what he hasn’t seen is rare.
For him medical homes come down
to doctors and nurses in command.