Wednesday, September 28, 2011

Focus on Political Hocus Pocus

September 28, 2011- I’ve been reading in Politico about the Secret Service and its code names.

This is about politics and hocus-pocus.

Potus is President of the US.

Flotus is First Lady of the US.

Sotus is Senate of the US.

Hotus is House of the US.

But so far I read nothing about,

Votus, Voters of the U.S.

who will decide about Potus,Flotus, Scotus, and Hotus

and precious little about,

Scotus, Supreme Court of the US,

who will rule whether Cotus-Constitution of the US

is to be the modus or a just a wild crocus,

and the next Potus, Flotus, Scutus, and Hotus

Tweet: The political hocus pocus about an early Supreme Court decision on Obamacre may determine fate of Potus, president of the U.S.

Family Insurance Premiums Up 9.5% in 2011: Who Is To Blame?

September 28, 2011 - A study released by the Kaiser Family Foundation yesterday found that the average annual premium for family coverage was 9.5 percent higher in 2011 than in the previous year. The family premium exceeded $15,000 for the first time.

This rise raises questions about the effectiveness of health reform. President Obama promised the health law would decrease premiums by $2500 per family. As Congress works to decrease the federal deficit by cutting health care programs such as Medicare and by shifting patients to Medicaid, policy experts say insurers, hospitals, and doctors will have to find money elsewhere, which could force private insurance premiums higher for 150 million Americans. The National Federation of Independent Businesses (NFIB) is calling for the Supreme Court to totally repeal Obamacare because of the uncertainties and fear of even higher health premiums.

This premium increase outstrips growth in workers' wages and creates more uncertainty for the Obama administration and employers who are struggling to drive down an unrelenting rise in medical costs.

According to Kaiser Family Foundation data, this 9.5% spike reverses an eight year downward trend in premium percentage increases.

• 2003- 13.5%

• 2004- 9.7%

• 2005 – 9.3%

• 2006- 5.5%

• 2007 – 5.4%

• 2008- 4.7%

• 2009 -5.5%

• 2010- 2.9%

• 2011- 9.5%

Who to blame for this sudden increase?

• Insurers, who say they are just compensating for provisions in Obamacare that, among other things, now cover pre-existing illnesses and children up to 26 under their parents policies.

• Employers, who are shifting costs to employees through higher premiums, co-pays, and $1000 deductibles?

• The health care law, which imposes more rules and regulations and calls for switching to plans that meet expensive government standards.

• The stagnant economy, which causes more depression and sickness, among the unemployed and uninsured.

• Hospitals and doctors, who are raising rates to make up for government cuts and increased expenses required to comply with government regulations.

• Drug companies, medical device manufacturers, and other medical supply chain companies who are aising prices in anticipation of over $500 billion new taxes.

• Reduced payments to doctors for Medicare and Medicaid.

Wait just a moment? You were doing all right until the last bullet point. How can cutting payments to doctors and hospitals raise private premiums? That doesn’t make sense. It’s counter-intuitive. Cutting doctors’ pay for Medicare and Medicaid, both of which are rapidly expanding, should cut costs.

Look at it this way.

On average, physicians treat Medicare patients at 70% to 80% of private pay. For Medicaid recipients, it’s about 56% of private pay. As a result, about 20% of primary care patients do not take new Medicare patients. For Medicaid, that figure is approaching 50%.

Medicare and Medicaid patients who can’t find a doctor to treat them often go to the ER. For most common illnesses, the typical charge for seeing a primary care doctor averages $166. In the ER, that same treatment is $570, 3.4 times that charged by a primary care doctor.

Hospitals are legally obligated to treat patients entering the ER and absorbing the losses for the uninsured. Medicare and Medicaid patients often make up 50% or so of a hospital's patient load. Yet Medicare and Medicaid patients payments often do not meet the cost of care, say hospitals.

So what happens in the real world? Hospitals engage in tougher negotiations with private insurers rise rates to pay for Medicare and Medicaid losses. Concurrently, physicians are rushing into hospital employment to escape hassles of Obamacare, costs of installing EHRs , rising malpractice premiums, and the troubles of running a practices with rising expenses and lowering reimbursements.

Rampant consolidation between hospitals and physician organization is well underway. Hospital outpatient care is much more expensive than private physician outpatient care, partly because of “facility fees,” which allow hospitals and their employed doctors to charge more for hospital-related services.

Who is to blame for health care premium spikes? in the complicated world of cost shifting to make up for losses, there’s plenty of blame to go around. Blame is a convenient way to make sense of things you can’t explain or control.

Tweet: Family premiums for health insurance spiked by 9.5% in 2011, more than 3 times the 2.9% 2010 rate - not what Obamacare promised.

Tuesday, September 27, 2011

Supreme Court to Decide Obamacare Fate in June 2012

The Justice Department on Monday declined to ask a U.S. appeals court in Atlanta to reconsider its August ruling that declared part of last year's federal health-care overhaul unconstitutional, a move that sets the stage for the Supreme Court to weigh in.

Brent Kendall, “Health Law Path to High Court Clears,” WSJ, September 26, 2011

September 27, 2011 - The health care end game is at hand. In June 2012, four months before the Presidential election, the Supreme Court will likely decide if Obamacare, in part or as a whole, is constitutional.

The Justice Department’s decision not to reconsider the Atlanta appeals court decision that the health law is unconstitutional is monumental. It’s as consequential as Bush Vs. Gore in 2000.

The Supreme Court may determine the fate of Obamacare and of Obama himself. A defeat would be hard to overcome. The health law is Obama’s signature achievement and his claim to fame.

Over the next nine months, between now and June 2012, awaiting the Supreme Court’s decision will likely suspend any actions for implementing Obamacare. For the health law it’s may day.

• The 26 states that brought the case to the appeals court in Atlanta may suspend actions on health exchanges, a pillar of Obamacare.

• The federal government may delay its push for initiatives like physician and hospital financial incentives for installing electronic health records or forming accountable care organizations.

• Physicians and their organizations may sit back and await further developments before restructuring or changing their practices.

• Businesses may continue not to hire or expand until uncertainties over the requirements of Obamacare begin to clear.

An Elephant Pregnancy

The whole scenario reminds me of an elephant’s pregnancy.

The usual symbol of the Democratic party is a donkey, while that of the Republicans is an elephant. But when the donkey converted itself into a health care elephant, that changed the symbolism. Democrats, acting alone, created the elephantine creature known as the Patient Protection and Affordable Care Act. The health law is an elephant of a law, turning 1/6 of the economy upside down and causing many businesses to delay hiring until they see the law’s financial consequences. The gestation period of an elephant is 22 months, the longest of any mammal.

In the case of the health law, the gestation period was preceded by grunts, groans, and other weird noises at elephantine high altitudes, before its conception. The gestation period, from March 23, 2010, to June 2012, would be 26 months.

Twenty six months is a little long for the gestation period of an ordinary elephant, but it is understandable in view of the United States as the world’s largest economic elephant and complications along the way – increased premiums, stopping coverage for 300,000 workers, waivering 1500 businesses from the law, electing a Republican majority in the House, and an increasingly wobbly economy.

Will Obamacare will be stillborn or viable come next June?

The answer will haunt or vaunt the Obama administration for years to come.

Tweet: In June 2012, the Supreme Court will likely decide if the health care law, in part or as whole, is constitutional. The decision may determine the outcome of the 2012 election.

Monday, September 26, 2011

Physician Creativity and Patient Collaboration

September 26, 2011 - While reading On Leadership, by Donald J. Palmisano, MD, JD, I ran across this passage in Chapter 9, “Creativity and Acquiring the State of Mind Necessary for Success.”

“You can’t limited by the way things are currently done. New discoveries and adoption of new technologies occur because some people elect to try a different way in the hopes of finding a different way.”

Palmisano goes on to say creativity requires the three C’s: Critical thinking, Communication, and Collaboration.

Nothing in medicine is usually accomplished without collaboration with the patient. Never has this been more evident in this age of patients empowered by the Internet who wish to participate in their own diagnosis and treatment.

The best example I can think of this phenomenon is the Instant Medical History, a set of computer algorithms developed by Allen Wenner, MD, a family physician in Columbia, South Carolina.

Over ten years ago, Allen saw a patient with vague symptoms and dry eyes. He referred her to a local academic center where a medical student with time to spare made the diagnosis of Sjogren’s Syndrome, now is in the news because the same diagnosis has been made on Venus Williams, the tennis star.

Allen pondered why he had missed the diagnosis. He had not had enough time to consider it and therefore the diagnosis had never crossed his mind.

Why Nots

So Allen asked himself a few why nots? Asking the question “Why not?” is an essential ingredient of creativity. Creativity is nothing more or less than challenging the status quo – the usual way of doing things.

Why not collaborate with the patient by having them enter their own medical history?

Why not program the medical history based on the patient’s age, gender, chief complaint, and symptoms?

Why not use this elemental information to create a systematic approach to differential diagnosis?

Why not have the patient enter their own demographic data, complaints, symptoms, and personal and family history?

Why not have the patient do this data entry from home on their personal computer or in the reception area on a laptop?

Why not convert this information into an easily read narrative?

Why not have the patient enter the exam room with this narrative in hand?

• Why not
have the doctor enter his findings, add them to the narrative with his own observations, and why not convert the collective information into electronic record of the visit?

Why not use this complete electronnic record as the basis for coding for the patient visit and for the content of referral letters to other doctors and to the hospital?

• Lastly, why not give the text of this electronic record to the patient before they leave the office?

Allen reasoned that this alternative approach to the medical record would save time – it does, about 6 to 8 minutes per patient. He further reasoned that this record would reduce the chances of misunderstandings and even malpractice suits by making clear what was done and why?

For more on this, Google the Instant Medical History or Prime Software. The website explains this creative, collaborative, communicative process in more technical terms as follows:

“Instant Medical History, patient interview software, interviews patients to begin gathering the subjective history prior to the encounter.

Branching logic enables patients to progress quickly through adjustable questionnaires from an extensive medical knowledge base. Sophisticated technology enables this information to transfer to EMRs. Physician productivity increases because as much as sixty percent of the medical data necessary to complete the visit note can be provided by patients and automatically documented in medical terminology through the Internet, in exam rooms, or in waiting areas before the visit.

Our vision is to become an indispensable part of the way patients and physicians communicate. Our solutions are used by physicians each day to facilitate physician-patient communication in a variety of practice settings. Our software has been recognized by vendor associations, consultants, and industry peers as an invaluable component of medical history software and the future of health care.”

Tweet: Doctors: To make your time more productive and your diagnoses more accurate, have the patient enter their own information and history.

Sunday, September 25, 2011

Obamacare in 2012: Political Calculus

The theory of probabilities is at bottom nothing but common sense reduced to calculus.

Pierre Simon de Laplace, (1748-1827)

September 25, 2011 - Intrade, the world’s leading market predictor, puts President Obama's odds of being reelected at 48.4%. That’s as good a prediction as any in this 50/50 nation of ours evenly split between Democrats and Republicans.

Personally I tend to rely on the polls of Real Clear Politics, a middle-of-the-road, online site that lists daily polls on politics. Its readers are split – 41.5% Democrats and 41.0% Republicans.

Its polls today show a 51.6% Obama job disapproval, a 83.3% Congressional job disapproval, with 72% of Americans saying the country is headed in the wrong direction. Of Obama and the Democrats health reform plan, 51% disapprove and 38% approve, and of health reform repeal, 50% favor repeal and 39% oppose repeal.

For President Obama, not a favorable national poll in the bunch.

At this stage, 408 days before the elections of November 2012, these numbers may be meaningless. On the other hand, Nate Silver, a New York Times political analyst, says poll numbers are political calculus and more to be trusted than the opinions of political talking heads.

Suppose these numbers translate into President Obama’s defeat and loss of the House and Senate.

Suppose, as Charlie Cook, author of Cook Report and a respected political analysts , speculates that such a Democratic debacle spells the end of Obamacare(Charlie Cook, “If the GOP Wins, Cook Report, September 23, 2011).

Suppose the Republicans lose 10 to 15 seats, but still control the House – a likely outcome says Cook.

And suppose the GOP picks up 4 to 5 Senate seats, giving them a 51-49 or 52-48 majority, and Obama loses.

What then? Cook says the first piece of legislation might be H.R.1, effectively repealing Obamacare.

So then what happens to provisions already in effect and being worked upon – changes in benefit designs for health plans, work and money expended on health exchanges, coverage for those with preexisting illnesses and children up to age covered by their parents’ plans, and additional discounts for part D recipients in the doughnut hole?

Well, as one GOP health expert notes, the Republicans could end up "looking bad." “Their best hope, “ he says, “is for the Supremes to do their dirty work for them.”

Cook adds. “While no one doubts the importance of next year’s elections, the stakes are even higher than one might think.”

As for me, I am a half a glass full guy. I agree with Mark Twain, who said of Richard Wagner’s music, “It’s not as bad as it sounds.” I second the notion of Tom Friedman, the New York Times columnist, who says. surely we will come to our senses and have a “Grand Bargain” to clean up the mess. Friedman goes on to say, “It is easy to be an optimist in America if you stand on your head because the country looks so much better from the bottom up than from the top down.”

Given current odds, it is conceivable the GOP could win the Presidency and both houses of Congress. They might then repeal Obamacare. What then?

Saturday, September 24, 2011

Doctor Donald J. Palmisano Update

September 24, 2011 - Go to my website,, click on my favorite links, and you will find a link to DJP Update – the blog of Donald J.Palmisano, MD, JD, AMA president in 2003-2004. More than 2300 physician leaders read his blog for insights into health reform.

Here is his current blog, in which he praises the current chair of the AMA. This is significant because Dr. Palmisano has been critical of the AMA for its support of the PPACA, the health reform law.

DJP Update 9-23-2011 Some good news despite economy woes, investigations in Congress etc

Our beloved Land of Liberty, America, has some real challenges: Economy sinking, stock market dropping, unemployment rising, investigations in Congress and other federal agencies for Solyndra, Fast and Furious, LightSquared, etc. If you have been too busy caring for patients to hear the depressing news, here is a link explaining the named investigations above.

THE GOOD NEWS: AMA Board Chair Dr. Robert Wah did a great job advocating to Congress about medical liability reform and the right to privately contract with Medicare patients without penalty. You must watch video on C-Span (see below) to hear and see the testimony of Dr. Wah to House Health Ways and Means Subcommittee on Health. (Wow! My first testimony to that committee was Thursday, May 20, 1976 in the hearing on "NATIONAL HEALTH INSURANCE chaired by Rep Dan Rostenkowski of Illinois - The years go by but the subject remains!)

As you know, I have been critical of AMA's decision to support PPACA. And many have advocated that AMA change its position. One group, The Coalition of State Medical Societies and National Specialty Societies (all seated in AMA House of Delegates) advocate strongly for AMA policy of private contracting and worked with AMA to get a bill into Congress. That is progress. And the great performance of Dr. Wah for private contracting is another good sign that AMA is listening. So let's give credit when due. It is due now.

Price-fixing,whether SGR or some new clone, has not worked and will never work.
Health panel hears pros, cons of extending payment exceptions
Read this article to get names of all witnesses

Focusing on these several extended payments ignores the real problem of a broken Medicare physician payment system, according to hearing witness Dr. Robert Wah, chairman of the American Medical Association board of trustees. Wah likened the problem to a leaky boat. “All of the patches we have to maintain because we can't just pull them all off at this point because the boat is too leaky,” Wah said. “What we need is a new boat.”

But go to this link to watch and hear the testimony of Dr. Wah:
and click on "Medicare Provider Payment Policies" on right with small camera icon to go to C-Span video.

Then go to time mark about 1:06 (one hour 6 minutes of meeting). Congressman Dr. Tom Price is talking at that point and there are good comments immediately after by Dr. Wah regarding medical liability reform and the right for Medicare patients to privately contract. Do note that "independent consultant Mr. Bruce Steinwald", another witness, wants to think for 2 weeks regarding private contracting!

Go to 1 hour 11 minutes 16 seconds and hear Dr. Wah answer Congressman Dr. Tom Price question about private contracting: Dr. Wah says: it is AMA policy; I support it as an American...fundamental freedom.. Very supportive of your bill...

Dr. Robert Wah did an excellent job pointing out the need for medical liability reform and the need to pass the Medicare Patient Empowerment Act.

Let's give applause to Dr. Robert Wah, AMA Board Chair. Anyone can give prepared testimony by reading from a page. But the sharp people shine in the Q & A. Dr. Wah proved again he is one of the sharp people. Maybe there is hope that Congress will get on board and allow private contracting regardless of what Medicare pays. That act would keep access to care for patients.

And big applause too for Congressman Dr. Tom Price of Georgia who continues to advance bills supporting patients and physicians.

"Rep. Tom Price, MD introduced H.R. 1700, the Medicare Patient Empowerment Act, on May 3, 2011. This bill, in line with AMA policy, would allow Medicare patients and their physicians to enter into private contracts without penalty to either party. On May 22, Sen. Lisa Murkowski (R-AK) introduced S. 1042, the Medicare Patient Empowerment Act, in the Senate."

Stay well!
P.S. Stop by and sign up for DJPNEWS to get tweet alerts that may not make it into DJP Updates. Twitter is free and takes minutes to join. Put email in and pick password. Great source of breaking news and you don't flood your email with it. You can get free app for BlackBerry or IPhone etc and you check on tweets when you want. With newer operating systems, such as SNOW LEOPARD on Mac, you can put Twitter apps on your notebook or desktop.

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Carlson's Law

September 24, 2011 - In That Used Be Us: How America Fell Behind in The World It Invented and How We Can Come Back (Farrar, Straus, Giroux, 2011), Thomas Friedman and Michael Mandelbaum argue that most innovations occur from the bottom-up, from people on the ground who deal with real issues, rather than from the top-down, from Washington, D.C. or executive suites, from those who deal with problems from a distance.

To make their point, the authors cite Carlson’s Law. Curtis Carlson is CEO of SRI International, a Silicon Valley Innovative Laboratory, that advises major corporations and governments on what to do in a computerized, hyper-connected, rapidly evolving world in a driven by globalization and IT technologies.

Carlson’s Law is:

Innovation that happens from the top-down tends to be orderly but dumb. Innovation that happens from the bottom-up tends to be chaotic but smart.

The intent of the health reform law is to introduce order into the health system, but it is dumb because of its unforeseen consequences, which include increased costs and premiums, employers dropping health plans, and job-killing effects based on the uncertainties of its effects.

Meanwhile bottom-up chaotic market driven changes are underway - messy consolidations of hospitals and doctors, doctors not accepting new Medicare and Medicaid patients, abandonment of primary care, health plans leaving markets and raising premiums, doctors dropping out of third parties to form concierge practices, and states and business organizations calling for repeal of Obamacare.

Physicians are trying to innovate to adjust to the new economic and social realities by joining together with other practitioners, becoming hospital employees, and aligning with large hospitals and other health systems for capital, administrative, and technological resources and to meet compliance and legal obligations.

Practicing physicians are seeking to make changes that keep them in business. Much of what they are doing focuses on bottom-up changes - they are asking their office staff, “How can I do this better?”’ they are appointing a member of their staff as a Chief Innovation Officer; they are fine-tuning their information technologies to communicate better with patients ; they are sharing resources and expenses with other doctors.

Above all else, they are making up new bottom-up arrangements with patients empowered by information garnered on the Net . These new arrangements include direct-pay arrangements, concierge practices, negotiating with patients on health savings accounts, private pay contracts with patients, and new modes of online communications such as Twitter, Facebook, and YouTube. Doctors are communicating more by email, encouraging patients to enter their own history and data, and tracking patients through embedded medical and direct audiovisual and telecommunication devices such as Skype.

In effect, these doctors are practicing constant innovation by taking advantage of every ounce of brainpower – their own and their patients - and in the process, bypassing some the “dumb innovations” imposed from the top-down.

Tweet:> Carlson's Law : Innovation that happens from the top-down tends to be orderly but dumb. Innovation that happens from the bottom-up tends to be chaotic but smart.

Friday, September 23, 2011

An Unvarnished View of How Physicians Can Adapt to Health Reform

It is not the strongest of the species that survive, nor the most intelligent that survives. It is the one that is most adaptable to change.
Evolutionary theory

September 23, 2011- Two events of yesterday shape this blog.

One, a invitation to speak next May before the Physicians Insurance Association of America (PIAA) about how to adapt to health reform pressures along with the title for my talk.

Two reading a book written by two intellectual elites – Thomas Friedman of the New York Times and Michael Mandelbaum of Johns Hopkins School of Advanced International Studies – authors of That Used to Be Us: How America Fell Behind in the World and How We Can Come Back. (Farrar, Straus and Giroux, 2011).

Tentative Title

My tentative title for my talk is “An Unvarnished View of How Physicians Can Adapt to Health Reform." The title is tentative for good reasons. It’s a long time, eight months- between now and when I’m scheduled to give the talk. A lot could happen in the interim, like a Supreme Court decision on the constitutionality of the PPACA, aka Obamacare, the give-and-take of the presidential campaign, and a double-dip recession.

But, as Friedman and Mandelbaum say in their book, four major challenges will still exist for America, how to adapt to globalization, how to adjust to the information technology (IT) revolution, how to cope with growing demands on government, and how to manage a world of rising energy consumption and climate threats. This challenges apply to physicians as well.

As a physician organization, the Physician Insurance Association of America, whose sister companies in various states offer malpractice coverage for the majority of American physicians, is concerned with the health reform law and its failure to address the issue of tort reform and its enormous impact of costs, not only through rising malpractice premiums buy through the common practice of “defensive medicine” to avoid future malpractice suit.

John E. McDonough, A Democratic insider and an unabashed admirer of the Health Reform law, just wrote a book Inside National Health Reform (2011). I reviewed it in my last blog. Nowhere in the book does McDonough even mention national tort reform. This means, I suppose, that either the Democratic party is a captive of the National Trial Lawyers Association, or it considers malpractice costs as inconsequential.

With regard to tort reform, my advice, and the best advice in my opinion, is to give no advice, is to follow the advice of Donald J. Palmisano, MD JD, founder and CEO of Intrepid Resources (R), a risk management and patient safety firm, who says in his book On Leadership (2011): Lead on tort reform, do your homework on its true costs, have the courage to highlight it at every opportunity, persist in your efforts to reform the legal system, be decisive in your beliefs and communicate those beliefs in every forum you can find (On Leadership: Essential Principles for Business, Political, and Personal Success), SkyHorse Publishing, 2011).

As we take the lead on tort reform , however, we physicians must keep in mind that globalization, IT, and debt forces are irrevocable and inevitable. We live in a competitive global economy, the fastest growing debt component is Medicare and Medicaid, and IT is profoundly effecting the practice of medicine, which will never return to the way it was before the health reform law passed on March 23, 2010.

As evidence of globalization, I would point out that 25% of our physician workforce is already foreign trained or born, that offshore care for high tech procedures is growing rapidly, and that international use of personal computers, cloud computing, and social networking already interconnect and empower us all.

As for IT transformation, physicians should take a leadership role. We should point out that Google self diagnosis has its pitfalls (“A little knowledge is a dangerous thing); that most Electronic health records are not ready for prime-time (most do not even talk to one another , are prohibitively expensive , slow productivity, and change the fundamental nature of medical practice).

As the same time, we should be honest ( IBM’s Watson, for example, can facilitate diagnosis, particularly of rare disease or in resolving difficult diagnostic problems with multiple treatment options).

In addition, we should be constructive in offering suggestions to improve EHRs. For example, we should encourage the inclusion of speech recognition in EHRs; we should foster the idea of Narrative Science, a fledging field in which masses of data are translated into narratives; and we should promote the idea of the Instant Medical History, wherein patients rather than doctors or medical staff enter their demographic, drug histories, allergies, clinical symptoms, and chief complaints before they enter the exam room on their home computers.

Tweet: Physicians should continue to lead on tort reform and start to offer constructive suggestions on how to improve electronic records.

Thursday, September 22, 2011

Book Review: Inside National Health Reform, by Dr. John E. McDonough, DPH, MPA, California/Milbank. Books on Health and the Public, 2011, 339 pages, $28

September 22, 2011 - This is the inside story, written by a quintessential Democratic insider, on how the Affordable Care Act, the Health Reform Law passed on March 23, 2011, came to be.

Its author, John E. McDonough, is a proud Democratic (“I was baptized a Democrat”). He was also a Democratic legislator in Massachusetts and is now an academic at Hunter College in New York City. McDonough dedicates his book to the late Senator Edward Kennedy.

As a professor at the Harvard School of Public Health, McDonough served as Senior Adviser on National Health Reform for the U.S. Senate on National Health Reform, and helped create and craft the 2006 Massachusetts health reform law.

No Apologies

There are no apologies there. McDonough is immensely proud of the health reform law. He is giddy about its accomplishments, even its warts and blemishes (“The ACA is a product of naked and enormous self-interest and an act of public-interest legislative politics of the highest order... a huge experiment that will harm or burden the lives of many, many Americans...On balance, in my view, the advantages and benefits of the law vastly outweigh the disadvantages and harm.”). He says the health reform law would not have been possible without Romney care, which showed reform was doable.

He is proud of the legislative shenanigans it took to get the law passed, of the legislative bribes (“The Cornhusker Kickback” and “Louisiana Purchase” to Nebraska and Louisiana Senators required to get their votes), of the roles played by Nancy Pelosi and Harry Reid in passing a partisan law against unanimous Republican opposition (Pelosiis quoted as saying,”We will go through the gate. If the gate is closed, we will go over the gate. If the fence is too high, we will pole-vault in. If that doesn’t work, we will parachute in. But we are going to get health reform passed.”)

McDonough’s heroes are Senator Kennedy, who kept alive the torch of national health reform for 40 years, and Pelosi and Reid, who kept its flames flickering, when they were threatened to be extinguished at critical legislative moments.

Virtues of Political Will

To McDonough, passage of the health reform law was an act of “sheer political will.” It was worth any price, any behind-closed-doors political maneuvering, any future government costs, no matter how high the taxes required or the debt incurred. He equates its passage to a massive civil rights law, a redistribution of wealth and social justice from the haves to the have-nots.

He believes the law will result in a high performing health system with better access, more affordable costs, improved outcome, and greater efficiency, in spite of growing evidence to the contrary in the first two years after its passage.

Historians will cherish this book. It is honest, not necessarily fair, but honest. It tells the inside story in detail – how President Obama stood up to close advisers, like Rahm Emanuel, who told him he should back off health care and focus more on the economy. It captures the complexity of the law – how it rolled ten pieces of legislation into one massive 2700 page bill, any piece of which may fail or be reversed.

No matter, it was the right thing to do. The health law is an enormously ambitious political act which runs the risk of being repealed or declared unconstitutional by the Supreme Court.

Physicians and the AMA

In the book physicians are given short shrift. Only 3 of its 339 pages are devoted to physician issues, of the AMA’s role in the scheme of things, and of the failure to reform the SGR (The Sustainable Growth Rate) formula, which is the basis for paying 570,000 physicians who bill Medicare. In McDonough’s words, “Physician-payment reform as part of comprehensive reform proved too heavy a challenge and financial lift.” By this he means Democrats could not fix SGR and still come under the $900 billion cost of the bill. As far as the AMA goes, it supported universal coverage and the individual mandate as well as many of the provisions of the law, at the heavy cost of loss of physician membership.

Tweet: Read Inside National Health Reform, an insider-book by a Democratic partisan of how the health reform bill came to be and what it portends for every American.

Wednesday, September 21, 2011

Hospital Marketing of Specialists

September 21, 2011- Eleven days ago, on September 10, Castle Connolly Ltd, ran a full two page ad in the New York Times, on 32 top prostate cancer specialists across the country with this headline:

“These physicians are among the Top Cancer Specialists as selected by Castle Connolly Medical Ltd, publisher America’s Top Doctors®…Physicians included in Castle Connolly’s Guides and on its website ( have been selected based on extensive surveys of physicians and health leaders nationwide. All physicians who are included undergo an extensive review of their credentials by Castle Connolly’s physician-lead research team. Doctors do not and cannot pay to be selected as a CCML Top Doctor.”

The ad carefully lists the physicians' credentials and the hospital affiliation of each of the urologists and radiation oncologists. The ad goes on say that September is national prostate cancer awareness month, that prostate cancer is the most common cancer, that it is the second leading cause of cancer related deaths, that each American man over 40 should get a baseline PSA and a digital rectal exam, and they could get free or low-cost PSAs and rectal exams at 200 different sites across the country.

In the interest of full disclosure, I am on the medical advisory board of Castle Connolly Medical Ltd.

To me, this ad illustrates several truths about America’s costly health system.

• America’s hospitals can market specialists in the name of cancer awareness and identifying top doctors, but specialists feel they cannot market themselves because of professional constraints that discourage self-promotion.

• Americans want to find some reliable means of finding the best hospitals and specialists who can best diagnose and treat such dire conditions as cancer.

There is another truth as well, which has nothing to do with this ad, America’s hospitals are struggling to make ends meet because of the growing numbers of uninsured, which by law they are obligated to treat, and because of the impending Medicare and Medicaid cuts imposed by growing national and state debts and by the Patient Protection and Affordable Care Act, aka, Obamacare.

Hospital administrators, and everybody else for that matter, knows that the most profitable “lines of service” reside in high tech care, such as cancer, heart, orthopedic, and other specialty services, not in treating Medicare and Medicaid patients, which are treated at a loss for each government-subsidized patient.

In the future, I expect hospitals to focus more on specialized services for full-pay patients and on the specialists who provide them rather than on radio, television, and billboards featuring generic best care provided by its entire medical and nursing staffs.

Instead hospital marketing will concentrate on the specialty services offering the “latest and greatest technologies” such as robotic surgeries, gamma knife procedures, or personalized genomic-based treatment regimens.

Tweet: Hospitals are increasingly focused on marketing specialists for diagnosing and treating cancer and other chronic and rare conditions.

Tuesday, September 20, 2011

More Trauma in ObamaCare Drama

September 20, 2011

• A poll released this week shows that 82% of Americans say the federal government should not have the power to require Americans to buy health care insurance. Among politically important independents, 87% say government should have no right to require insurance; 95% of Republicans agreed.

• In a blow to the administration, the Mayo Clinic, the Cleveland Clinic, Geisinger Health System and Intermountain Healthcare – repeatedly touted as models for a new health delivery system – say they will not apply to participated in the new federal ACO program. The rules are just too onerous and the bureaucratic hoops too high for them to succeed.

• Labor economist Diana Furchtgott-Roth, formerly of the Hudson Institute and newly affiliated with the Manhattan Institute, has produced two new studies showing the impact of ObamaCare on two specific industries- medical devices and franchise businesses. These studies demonstrate in detail how ObamaCare is a job killer.

Source: Grace-Marie Turner, “A Rough Week for ObamaCare,” Health Policy Matters, September 16, 2011

Tweet: Bad news for Obamacare: Polls showing 82% opposition, big clinics declining to join ACOs, 2 studies showing reform law to be job killers.

Monday, September 19, 2011

What You Call Groups of Doctors

September 19, 2011

Here for your information
And for your exultation,
Is the straightforward goop,
On what to call a doctor group
Forgive the verbal inflation.

A palpitation of internists
A fibrillation of cardiologists
A handful of gynecologists
A stirrup of obstetricians
A family of general practitioners
A rash of dermatologists
A void of urologists
A pile of proctologists
A movement of gastroenterologists
A lump of oncologists
A staph of diagnosticians
A hive of allergists
A shot of pediatricians
A vocation of laryngologists
A passage of rhinologists
A herd of otologists
A retinue of ophthalmologists
A gout of rheumatologists
A vein of hematologists
A cast of orthopedists
A series of radiologists
A joint of osteopaths
An arch of podiatrists
A colony of bacteriologists
A plague of epidemiologists
A helix of genetics
A host of parasitologists
A batch of virologists
A resect of surgeons
A gross of pathologists
A burr of neurosurgeons
A bag of anesthesiologists

Source: An Exaltation of Larks, James Lipton, 1999

When you do not what to call your doctor and you don’t want to use his name in vain, read medinnovation blog September 19, 2011

Sunday, September 18, 2011

What is Health Reform All About?

September 18, 2011 - Last night I dreamt I had the answer to this question: What is health reform all about?

My answer? It’s systematists versus individualists.

A systematist is someone who develops, follows, or conforms to a system ; an individualist is someone who thinks or behaves individually.

Systematist Beliefs

A systematist believes in central planning, in guiding, expanding or narrowing options to achieve a goal, in reducing myriads of data to digestible bytes or swallowable whole.

A systematist believes in numbers, in using them to develop processes for continuous improvement to achieve six sigma with zero defects.

A systematist believes in protocols and checklists to guide people to a desirable and achievable goals.

A systematist believes data in hand, prior to or at the site of an action, is worth two in bush, i.e., viewed retrospectively.

A systematist believes the ideal tool for assuring conformity to system goals is the computer – a logical, impersonal, objective, programmable machine devoid of human emotions.

Individualist Beliefs

An individualist believes in freedom and flexibility ,of shaping individual actions at the point of a human transaction based on the situation, circumstances, and desires of the individuals involved in the transaction.

The individualist believe forcing conformity to a system is the road to serfdom, to being a servant of outside authorities.

Ironically, the individualist believes the computer, and its thousands of applications – embedded in Twitter, Facebook, YouTube, mobile apps on Ipad, Ipod, and Iphone, or any other mobile device– are the road to individual freedom, to connecting with other individuals , to bypassing the system.

The individualist believes you can use online tools to get your own information, ideas, products – to rate what’s available to you , to cut your own deals, write your own news, promote yourself.

The individualist believes you can use online technologies to get the things you need rather than going through traditional channels.

Homogenization Versus Humanism

In my dream, the issues between system and individual believers boiled down to homogenization versus humanism.

But when I awoke, I knew reconciling these views was not that simple.

Organized, purposeful, systematic approaches can improve health results for populations of people and for individuals. On the other hand, systems can handicap individualism, hamper innovation, invade privacy, enforce compliance, and limit freedom of action.

Maybe systems are the price we must pay for living in a civilized society. Conversely, maybe individualism is what makes life worth living, creativity worth pursuing, and practice worth practicing.

In human society, it’s always six of one and half dozen of the other. In health reform, on the national scene, it may come down to this: give me systems of care, give me individual freedom of action, or give me consequences - inequities, uneven quality, debt, or excellence engendered by competition and choice.

Tweet: In the real world of health reform, it's still the same old story - systematic approaches to improve care versus individual freedoms.

Saturday, September 17, 2011

It’s The Culture, What Works, Not Partisanship, in Health Reform

The inherent vice of capitalism in the unequal sharing of capitalism; the inherent vice of socialism is the equal sharing of blessings.

Winston Churchill (1874-1965), At a White House Luncheon, June 26, 1954

September 17, 2011 – When President Obama moved into the White House, one of his first gestures was to send the bust of Winston Churchill back to Britain.

This act showed President Obama’s ideological leaning. It is also showed its misunderstanding of the nature of American culture.

For good or bad, we are a conservative center-right nation that believes in capitalism, with all of its faults. We believe capitalism is a more productive economic system. We choose to be nation that believes in individualist free enterprise rather than elitist-dictated centralized planning.

I happen to believe President Obama’s fundamental problem is that he doesn’t understand American culture. This is not to say he is unpatriotic , lacks good intentions, or is engaged in some conspiracy to covert the U.S. into a quasi-European nation. I do not believe any of these things.

President Obama is a good and decent human being, a genuine intellectual, a nice man without a mean streak, and a solid family man.

Somehow, however, President Obama radiates a mistrust of capitalism and the business community, Those in business reactu to thismistrust by not hiring, by complaining of his high tax mindset, his penchant for heavy regulations, and the uncertainties of future profitability.

Is there a middle ground between President Obama’s beliefs and policies that would reform the health system without unduly punishing businesses and making their future profitability more certain?

I happen to think policies exist that would make the present system more sustainable without bankrupting the nation. And these policies would not require radical changes in political philosophies, which centrist America resists with a passion, as shown by a poll released last week that shows 82% of Americans who say the federal government should not have the power to require Americans to buy health insurance or for business to provide that insurance.

• We could move the eligibility of Medicare from 65 to 67 in two month increments over the course of 6 years and require more affluent Americans to pay more through means testing over the same period.

• We could make health savings accounts available to all in high deductible plans with catastrophic lids, require tax deductible credits to all, and by so doing sensitize patients to costs, allow them to set aside money in a retirement plan with money not spent on health care, allow them to have the same choices that federal employees(including Congressional Representative and Senators) have in Federal Employment Benefit Plans , remove the myth that health care is free, and in the process, give Americans the option of investing in private Social Security accounts.

These policies and options would be in keeping with American culture’s beliefs in capitalism, free enterprise, personal responsibility, and might strike the right balance between capitalism and socialism. In implementing these changes, we might just conserve the best aspects of capitalism, salvage Medicare, and preserve Social Security for future generations.

Tweet: Health Reform requires blending and balancing virtues of capitalism and socialism and more personal responsibility.

Friday, September 16, 2011

Joint Commission Absurdity

The privilege of absurdity, to which no living man is subject but man only.

Thomas Hobbes (1588-1679), Leviathan (1651)

September 16, 2011 – Any social movement or scientific undertaking, taken to its extreme, is capable of absurdity.

Take management science, defined as the use of statistical methods, such as linear programming and simulation, in order to analyze and solve organizational problems.

In health care, management science has come to mean the use, study, and application of data, measurements, protocols, guidelines, algorithms, and processes to achieve continuous quality improvement.

An article in yesterday’s New York Times , Joint Commission Report Excludes Top Hospitals, " opened with this paragraph,

“In the latest advance for health care accountability, the country’s leading hospital accreditation board, the Joint Commission, released a list on Tuesday of 405 medical centers that have been the most diligent in following protocols to treat conditions like heart attack and pneumonia. Almost without exception, most highly regarded hospitals in the United States, from Johns Hopkins in Baltimore to the Mayo Clinic in Rochester, Minn., did not make the list. “

None of the 17 medical centers listed by U.S. News & World Report on its “Best Hospitals Honor Roll” this year are on the Joint Commission’s list of 405 hospitals that received at least a 95 percent composite score for compliance with treatment standards.

The Joint Commission list, at, omitted the Cleveland Clinic; Massachusetts General Hospital in Boston; Duke University Medical Center in Durham, N.C.; Ronald Reagan U.C.L.A. Medical Center; and the University of California San Francisco Medical Center, among others. It did not include a single hospital in New York City, or the most prominent centers in Chicago and Houston.

This Joint Commission report borders on absurdity. To exclude 17 leading medical centers, which have earned their reputations over decades of efforts to achieve excellence because they are not sufficiently diligent in slavishly following protocols is the height of absurdity.

There is more to health care, indeed to any social enterprise, than management and linear channeling of statistical methods to improve outcomes according to the arbitrary dictates of its programmers. Reputation counts.

The Joint Commission's list of 405 top performers included a disproportionate share of small and rural hospitals, as well as 20 Veterans Affairs medical centers. I am sure these small, rural, and VA hospitals deserved mention and do exemplary work, but to exclude leading medical centers is absurd.

To conclude,

To call something absurd,

is not to give it the bird.

Its protocol the Joint Commission should reword,

If it wants its message to be believed and heard.

Tweet: The Joint Commission has issued a list of 405 top hospital performers, which does not include the nation’s leading medical centers.

Thursday, September 15, 2011

Sound of Obama’s Silence on Health Reform

Hello darkness, my old friend
I've come to talk with you again
Because a vision softly creeping
Left its seeds while I was sleeping
And the vision that was planted in my brain
Still remains
Within the sound of silence

Lyrics, “Sound of Silence,” Simon and Garfunkel, 1964

September 15, 2011
- The sound of silence of President Obama on health reform is deafening.

In a September American Spectator essay, Grace Marie Turner of the Galen Institute observes,

The White House is quietly implementing a shrewd new strategy of silence on Obamacare. Its goal: making sure the revolt against the unpopular health care overhaul that swept Republicans into power across the country in November 2010 isn't repeated in 2012.

After two years of nonstop focus on health care, the president has stopped talking about the law's far-reaching effects. Now he is concentrating on a few micro changes. Meanwhile the administration is working hard to dampen controversy by handing out buckets of waivers and attacking Republicans.

Grace-Marie has it right. President Obama has decided to stop talking about his health reform law, which has not yet delivered on its promises of lower costs, keeping our own plan and your own doctor, increased access to doctors, and higher quality.

His speeches are beginning to fall on deaf ears. His phraseology is redundant. Listeners get the feeling he has “been there” but he has not "done that.” His rhetoric lacks results. His words no longer calm the public, the business community, and physicians.

They remain deeply uncertain about Obamacare’s consequences, as evidenced in polls showing 51% to 40% of the public does not believe his jobs speech will create jobs.

After the disastrous November 2010 elections, when Republicans took over the House, his advisers told him the fundamental cause of the Democratic fiasco was his health reform law.

So, Obama is remaining silent on health reform.

This is hard for the President. For him to believe his speeches are not golden is a tough pill to swallow.

According to Grace Marie, the Obama strategy has become.

1. Stop talking about health reform - His main job is to get re-elected. Anyway, he can always veto any health reform or repeal legislation.

2. Focus on the small stuff – 26 years being covered under their parents’ plans, free preventive tests, coverage for pre-existing illness, new insurance regulations.

3. Calm the opposition - Pacify the governors on Medicaid, Give waivers to your political allies.

This may work for a while. But not for long. Victor Davis Hanson, a conservative classic scholar at the Hoover Institute, says:

“Obama’s rhetorical quiver is empty. He can only say so much. His address to Congress last week went nowhere. It was hyped well. It was delivered well. It was comprehensive. But Obama had nothing to say that we have not already heard from him — and that has not already failed or proved to be hypocritical.”

“When the quiver is empty, the archer puts his bow away. Silence, not ‘This is our moment,” is the wisest course for Barack Obama now that the arrows are all gone.”

In the case of health care, his speeches may be silver, but silence is golden.

Tweet: The health reform law is unpopular. Obama is listening to his advisers and remaining silent on health reform,

Wednesday, September 14, 2011

Health Stakeholders Uneasy about Medicare and Medicaid Cuts

September 14, 2001 – Lee Stillwell, an Inside-The- Beltway friend of doctors, writes the "Washington Report" for the Physicians Foundation. The Foundation is dedicated to defending and improved the private practice of medicine.
Here is his latest report, dated September 12. It shows the uneasiness among health care stakeholders contemplating consequences of Medicare and Medicaid cuts.

Well, the handwriting is on the wall. Medicare and Medicaid are on the budget chopping block big time as the deficit reduction super committee this week begins serious work on trimming federal deficits by more than $1.5 trillion by Thanksgiving.

Surprisingly, the committee now is being asked to target more cuts in programs like Medicare and Medicaid by members of Congress and President Obama.

Obama earmarked healthcare for even greater cuts in his speech last Thursday to a joint session of Congress and asked the 12-member bipartisan committee to increase its deficit-cutting goals by at least $447 billion to cover the cost of his proposed jobs bill with a mix of tax increases, spending cuts and reductions in the Medicare and Medicaid programs. The president promised next week to detail his proposed cuts.

“Now, I realize there are some in my party who don’t think we should make any changes at all to Medicare and Medicaid and I understand their concerns,” Obama said. “But with an aging population, and rising health care costs, we are spending too fast to sustain the program. And if we don’t gradually reform the system while protecting current beneficiaries, it won’t be there when future retirees need it. We have to reform Medicare to strengthen it.”

The super committee got a similar message from 25 centrist senators who urged participants to search for $3 trillion in cuts over a decade, twice the size of their current mandate! Sen. Joseph L. Lieberman (I-Conn.) said the centrists want to encourage the super committee “to reach for a higher number.” Quite frankly, even $3 trillion won’t do the job with the Congressional Budget Office (CBO) estimating the federal government will spend $4.69 trillion more than it collects in taxes the next 10 years.

Even though the committee is being told to be more ambitious, there are skeptics who question if the group even can reach consensus on the $1.5 trillion in cuts.

Matter of fact, there are healthcare lobbyists who are pushing for a stalemate because the alternative is a sequestration process that triggers automatic across-the-board reductions, considered less painful to health care programs. Medicaid would not be hit in the across-the-board reductions and Medicare only would take a two percent cut, amounting to $130 billion to $150 billion, much less than the committee is expected to do in an agreement.

Even a number of patient-friendly organizations favor the automatic cuts, believing it to be the lesser of two evils!

Meanwhile, numerous healthcare groups have moved quickly to implement strategies they hope will minimize cuts. Right now, the nursing-home industry has undertaken a multimillion ad campaign, claiming previous budget reductions already have crippled their effectiveness. TV ads now are running in Florida, Massachusetts, Michigan, Missouri, New Mexico, Nevada, Virginia and Washington. The Alliance for Quality Nursing Home Care and the American Health Care Association also are conducting a broad lobbying campaign.

The American Hospital Association (AHA) now is using its members to lobby Congress to change the Medicare eligibility age from 65 to 67 as a money-saving alternative that is estimated to save $124 billion. AHA officials, worried about additional cuts, estimate the triggered two percent cut in Medicare would cost hospitals $45 billion over nine years. They point out that this is on top of $155 billion in Medicare cuts hospitals face under the new health care law.

Not only do healthcare lobbyists face competition for the shrinking federal dollar from within their own industry, they must guard against a full frontal attack from defense industry lobbyists who face the same potential drastic cuts. The ongoing battle between both interests is being called a “Holy War” inside the beltway.

In the midst of all this intensity came the organization of the Joint Select Committee on Deficit Reduction with Democratic and Republican subcommittee members meeting separately behind closed doors on Capitol Hill last Wednesday. On Thursday, the committee successfully held an organization meeting and established ground rules. With Sen. Patty Murray (D-Wash.) and Rep. Jeb Hensarling(R-Tex.) as co-chairs, the group plans to hold its first public hearing tomorrow. Douglas Elmendorf, head of CBO, is scheduled to discuss the nation’s mounting deficits.

Meanwhile, behind the scenes, staff continues to look at ways to bring down Medicare and Medicaid costs which now make up 23 percent of federal spending. There are a number of options contained in staff memos for reducing cost, including increasing the Medicare eligibility age from 65 to 67, higher costs for seniors, cuts in provider payments, and a $120 billion reduction in payments to drug companies.

Not getting much attention, but in that pile of issues to be considered in the budget reduction process, are three issues crucial to the future of healthcare:

--Tricare, the Defense Department’s health insurance program which covers 9.6 million military personnel and dependents. The Administration for some time has looked here for potential savings.
----The Independent Payment Advisory Board (IPAB), a 15-member panel created in the new health law, which will have the power to make Medicare payment cuts that will take effect unless Congress overrules it. There are advocates who argue IPAB should be given more power to control spending while others, including most of the healthcare industry, argue for its repeal.

--The Sustainable Growth Rate (SGR), the method for Medicare payments to physicians, must be fixed by year’s end, or America’s doctors will receive a 29.4 percent pay cut! Organized medicine hopes for favorable committee action while many associated with the panel look at the issue as not part of their mandate.

Several boisterous protesters showed up at the committee’s organization meeting with signs which said, “Tax the rich!” and shouts of “Jobs now.” Committee members probably can expect more of the same as they proceed to cut programs valued by millions and millions of Americans, particularly in the healthcare area.

Tweet: The health care establishment – physicians, hospitals, and nursing home – are uneasy about impending automatic Medicare and Medicaid cuts.

Tuesday, September 13, 2011

WellPoint and IBM’s Watson: Why I Am Respectful but Skeptical

September 13, 2011- When WellPoint and IBM announced yesterday the two would be conducting pilot studies in 2012 to test the usefulness of IBM’s supercomputer Watson to “help” doctors make diagnoses and courses of treatment, I was respectful but skeptical.


• Respectful because WellPoint is a giant health plan with 42,500 employees covering 34 million Americans directly and 70 million through its subsidiaries, right up there with UnitedHealth care with 78,000 employees covering 70 million Americans.

• Respectful because IBM is the world’s largest computer powerhouse already deeply enmeshed in health care issues, especially in its promotion of the Medical Home concept through the work of Paul Grundy, MD. IBM Corporation's Global Director of IBM Healthcare Transformation.

• Respectful because computers are logic machines, capable of digesting and summarizing millions of articles and studies from the medical literature and suggesting diagnoses and best practices.


• Skeptical because of the nature of the American culture, which Garry Orren, a professor of political science at Brandeis, just outside Boston, who polls for the New York Times and Washington Post, said, “A good place to start is to remember we are pro-democracy and anti-government. It comes down to ideas that are essentially anti-authority and tend toward self-regulation.”

• Skeptical because of the profound limitations of the computer as a diagnostic and treatment tool Jerome Groopman, MD, a professor of internal medicine at Harvard, said it best in his book How Doctors Think,
“Clinical algorithms can be useful for run-of-the-mill diagnosis and treatment – distinguishing strep throat from viral pharyngitis, for example. But they quickly fall apart when a doctors needs to think outside their boxes, when symptoms are vague, or multiple and confusing or when test results are inexact. In such cases – the kinds of cases where we most need a discerning doctor – algorithms discourage physicians from thinking independently and creatively. Instead of expanding a doctor’s thinking, they constrain it.”

• Skeptical because it is one small step from using the computer for “helping “ doctors to monitoring them, judging them, dictating to them what to do, and withdrawing payment for computer non-compliance. The use of computer data is a multi-edged sword. It can be used for the “good,” facilitating diagnosis and treatment and making it more accurate and up-to-date, and for “evil,” invading privacy, inviting security breechs, and making decisions based on the opinions of remote authorities rather than those present at the patient-doctor encounter. Being victorious at “Jeopardy” does not necessarily translate into success at managing the patient-doctor relationship and improving its outcomes. Most clinical decision-making is gray, not black and white. What I would like to see is a comprehensive study is how computers affect issues in the gray world - how computers impact or improve the totality of decision-making on sociological and psychological problems, which may be more subjective rather than objective.

Tweet: WellPoint and IBM will conduct pilot studies to see if IBM’s supercomputer can suggest diagnoses and treatment. This has +’s and –‘s.

Monday, September 12, 2011

Economic and Health Reform: America’s Strength and Weakness

America’s Strength: A Sprawling, Brawling People

Title of Editorial, Detroit News, September 11

September 12, 2011 - Pardon this verse.

Adam Smith said people acting in their own self-interest could best lift the economic boat.

Alexander Hamilton asserted only federal elites know what makes the economic boat float.

Thomas Jefferson countered only common people understand the common interests.

Writers of the Constitution understood both sides wear different economic Mae West vests.

James Madison wrote in 1787: “As long as the reason of man remains fallible, different opinions will be formed.”

By design we’re a nation formed by arguments, proposals, and counter proposals, some informed, some Ill-formed.

Lively disagreement is our strength, as well as our weakness.

The pursuit of freedom shapes and defines our uniqueness.

Let us debate loudly the merits of health reform,

And how to best the health system transform.

Without deriding or denigrating the other side.

Or treating our own solutions as cut and dried.

Let us disagree about the unforeseeable.

without being disrespectfully disagreeable.

Tweet: As we vigorously debate solutions for the abysmal economy and the dismal state of health reform, let us disagree without being disagreeable.

Health Information Technologies – Potentials and Threats to Privacy

An American has no sense of privacy. He does not know what it means. There is no such thing in the country.

George Barnard Shaw (1856-1950), Speech in New York

If the right of privacy means anything, it is the right of the individual, married or single, to be free of unwarranted government intervention.

William Joseph Brennan Jr. (1906- 1991), Eisinstadt v. Baird (1972)

September 12, 2011 - This week the Sunday edition of the New York Times contained three articles that caught my attention.

• “Court Case Asks if “Big Brother” Is Spelled GPS.

• “Tracking Vital Signs, Without the Wires.”

• “In Case You Wondered, A Real Human Being Wrote This Column”

GPS Surveillance

The GPS (Global Positioning Satellite) addresses the propriety and legality of planting GPS devices in suspect’s cars to track their activities. It asks the question; do such uses of the GPS have Orwellian Big Brother overtones? One judge says such use makes the Big Brother approach “seem clumsy”; another judge writes “1984 may have come a bit later than predicted, but it’s here to stay"); Yet another opines, “Technology has progressed to the point where a person who wishes to partake in the social, cultural, and political affairs of our society has no realistic choice but to expose to others, if not to the public as a whole, a broad range of conduct that would previously have been demme4d unquestionably private.”

Epidermal Electronic Monitoring

The second article on wireless technologies describes a new field “epidermal electronics,” mHealth, wherein researchers attach mobile devices to the skin to monitor vital signs, in such conditions as cardiac rhythm disturbances. Electronic monitoring could reduce medical costs, as proven by a large study of patients with congestive heart failure and chronic obstructive lung disease. These patients showed a 25% drop in bed days of care, and 19% drop in hospital admissions. Hospitals, the article goes on to say, “Have some fear about the financial implications.”

Algorithms as Translators of Data into Narratives

The third article – on how programmers have been able to translate financial data in readable narratives. Computers, it turns out, given the proper algorithms, can write some pretty decent prose. This research now goes under the name of “Narrative Science.” This is not the same speech recognition, which may make EHRS more useful and readable. Oren Etzoni, a computer scientist at the University of Washington, says “The quality of the narrative produced is quote good” and sees this application as pointing to “the increasing sophistication in automatic language understand and now, language generation.”

Will this application spill over into the practice of medicine? It already has. The use of the Instant Medical History, now more than 10 years old is widely used. Clinical algorithms in the Instant Medical History take age, gender, chief complaint, and symptoms, supplied by the patient from a home computer or a laptop in the reception room, into account and types out the medical history in the form of a narrative before the patient enters the exam room.

Does this threaten privacy? It might if someone hacks into the doctor’s EHR or the patient’s home computer. But is also enhances productivity, saving, on average, 6 minutes for each patients, and it adds to the comprehensiveness and accuracy of the patient’s medical history.

Tweet: IT advances include surveillance of suspects with GPS, skin devices monitoring vital signs, algorithms translating data into narratives.

Sunday, September 11, 2011

Mourning and Honoring Victims of 9/11

September 11, 2011
– Joseph Nardone, the now retired Battalion 9 Chief of the New York City Fire Department, is a friend of mine.

What follows is a speech he gave today at a memorial ceremony for firefighter victims of 9/11/2001. That day firefighters on duty under his command died. Joe was not among the dead because 9/11 was his day off. By the time he arrived at the Towers collapse scene, most of the 343 firefighters who died had already perished. Joe will never forget their sacrifice or their families' fate.

Good morning.

I thank Lt. Pat Brady for this opportunity to speak to you. I consider this a special honor and privilege.

This morning Firehouses across the city are conducting memorial services, just like this one.

For good reason. This is a day for remembering broken hearts and unspeakable horrors.

That Day

On September 11, 2001, radical Islamic terrorists murdered over 3000 innocent people, including 343 New York City Firefighters lost while rescuing thousands of civilians from the Towers.

On that horrible day, all Battalion units (E-23, E-40, L-35, L-4, E-54, and Battalion 9) responded to calls for help from the World Trade Center. Tragically – too many on- duty members made the supreme sacrifice – including 15 from E-4, L-4, and Battalion 9.

Never Forget

For ten years now, we have come together to honor the memory of brave men who died in the line of duty on September 11, 2011.

We have vowed to “Never Forget,” and we never will.

Our friends who have come to this memorial park for the last ten years have not forgotten. On behalf of Engine 54, Ladder 4, and Battalion 9, I want to express our deepest appreciation and to say “thank you.”

At my age, ten years is an insignificant bump in the road. Yet when I look at the children, your children, I realize ten years is a significant mile marker. The children have grown into teenagers and young adults. In our firehouse, 28 children have grown up without fathers in their lives since 9/11/01.

We Firefighters are always mindful of the mothers and grandparents of these children. They have carried the heavy burden of raising these children while suffering endless grief.

We will never forget your grief and sacrifice. You have our profound respect and love. Your husbands and sweethearts would be proud of you.

What is it about these anniversaries?

As for me, as this 10th anniversary approached, I began to feel a weight upon my emotions. The closer the date, the heavier my emotions become. I am sure this holds true for you here today.

I remember the first anniversary. While driving into the City, my cell phone rang. It was 6:30 AM. My youngest son, Jim, the 22, was on the phone. Upon hearing my voice, he burst out crying.

I struggled to explain it was a tough day for everyone. I tried to reassure him it was OK to feel as he did.

It is hard for me to describe in one all -encompassing way how I feel about the scope of the destruction and loss of life with the collapse of the Towers. I have never seen the Grand Canyon, but I doubt if you can grasp its vastness and its details in just one visit or one viewing.

So it is with events surrounding the World Trade Center tragedy. At first, America was shown on TV the now iconic images of firefighters and other rescuers working endlessly to find everybody alive and then later recovering the victims.

Behind the scenes, others were at work. At pier 4, many of our members were working on a massive family assistance program for every family that had lost loved ones, offering medical, counseling, and legal services.

Some served hot meals to Firefighters and other rescue workers. Some scrubbed the soles of our boots before we sat down to eat so we didn’t contaminate the eating area.

Still other Firefighters had the vital and difficult role of attending to the needs of families.

In the days, weeks, and months that followed, hotels and car rental companies donated to families. Donated food covered the firehouse kitchen tables for months. Thousands sent well-wishing cards.

We all remember flowers and candles that covered the front sidewalk and adorned the Statute of Liberty. We remember the lady who attended the flowers, keeping them fresh, organized, and respectful. We knew her simply as “Flower.”

Then there were local groups – friends in the theatre community and folks in the immediate neighborhood.

Finally, people in the hundreds, including many celebrities , came from across America, including First Ladies Laura Bush and Libby Pataki. It was not just our tragedy, but America’s tragedy as well.

Gratitude to Fellow Firefighters

I shall be forever grateful to Captains Ray Ziegler of Ladder 4 and Barry Mead to Ladder 35. They had left their respective units before 9/1l, but requested to return and take command of their decimated companies.

They boosted morale tremendously, and Firefighters desperately needed their experience.

In addition, Engine 54’s Captain Parenty, Engine 23’s Captain Bendict, and Engine 40’s Captain Gorley were the bedrock of unit cohesiveness and morale. They were indispensable during this difficult period.

These captains had a huge burden placed upon them. They were the major sources of contact for grieving families. They arranged for funerals and memorial services, trained new members, and responded to fires among other pressing duties.

And who among us will ever forget the unwavering steadfastness of Lieutenant Bob Jackson, LBJ as his men called him. For me, Bob was my right hand. For families, he was their best friend and supporter. Bob was totally committed.

He would say, “Let’s circle the wagons for the families.” Nothing came before that principle.

America and the world saw the true character of our New York City Firefighters – their unwavering determination and resolve to bring home the remains of brother Firefighters and civilians so that families could conduct proper funerals.

Day after day, week after week, month after month, Firefighters returned to the site to search for lost brothers and other victims, exposing themselves to dangerous conditions and toxins.

I shall never forget, and I stand in awe of the nobility and brotherhood of the New York City Fire Department as I would see our members recover a brother from Ground Zero, then proudly and with dignity carry the remains up a long ramp to the street, then stand as uniformed honor guards at the funerals, act as pall bearers into and out of church, and then return to work to answer fire alarms.

This forever will be the legacy other fire departments will have to live up to.
In the weeks, months, and years that followed, you, the officers and Firefighters who were members of 54, 4, and Battalion 9 on 9/11 and who are still working there today, you are an inspiration. You have lived up to the vow we made to “Never forget.”

After 9/11, we have had several notable events to help us with our grief and to help to “Never forget.”

In March 2002, we dedicated this Firefighter Memorial Park. You may recall that moving rendition of the song, “On Angel’s Wings,” as sung by MaryAnn Regan.

In May of 2003, on board the Intrepid, we dedicated that beautiful Bas relief by the noted sculptor Arcard Kotler. It is mounted in front of our quarters. The relief depicts all the units in the 9th Battalion. It was here that Young David Wooley gave his eloquent and inspiring speech.

Later our lost members’ names were placed on the nose cowlings of F-18 Super Hornets for the air craft carrier Abraham Lincoln. In addition, “Tail Hooks” had a fly-over at Steward Airport.

Captain Paranty commissioned the outstanding mural on the firehouse front door.
Firefighter Keith Kerns built the beautiful memorial display walls inside the fire house.

Last September 10, Darrel Lynn kicked off project “Hero Portraits” from our firehouse. Darrell intends to paint oil portraits of all 343 lost Fire Department members. Those in the audience had the opportunity to hear the composer Judy Gold sings her beautiful song, “From a Distance.”

And most recently President Barack Obama visited our quarters to have lunch with our members and to recognize the huge sacrifice our members made on 9/11.

Today, in the spirit of “Never Forget, “we honor the members of our lost Firefighters but also the men and women of the Armed Services and the thousands who have lost their lives in Iraq and Afghanistan in the wake of 9/11.

They are all heroes. Thucydides, the Greek philosopher, said “But the bravest are surely those who have the clearest vision of what is before them, glory and danger alike, and yet notwithstanding go out to meet it.”

Although our lost loved ones’ absence is felt today, we should not feel hollow because they are gone. We should be filled with the inspiration their example has given us.

The memory of their valiant service and sacrifice will help us move forward. The brave souls who gave their lives in the line of duty are too great to die.
We will not let them. They are part of our own lives, and they will always be part of our Department’s proud history and honorable traditions.

Their lasting legacy will be found in the way we honor all those who have been lost by striving everyday to live up to their example of duty, honor, courage, and sacrifice.

God Bless the New York City Fire Department, and their families and remember: “Never Forget.”

Tweet: 343 New York City firefighters perished on 9/11/2001. We must never forget their sacrifice and the impact of 9/11 on their families.

Saturday, September 10, 2011

Promises and Consequences of Obamacare

September 9, 2011 - I would like to talk to you today about the promises of Obamacare, The Patient Protection and Affordable Care Act. There are some who say the term “Obamacare” is demeaning. But President Obama has assured us he likes the term Obamacare because it shows he cares.

Using questionable last minute tactics and bribes , Democrats passed Obamacare March 23, 2010 against unanimous Republican opposition. That was the first time that had happened with a major piece of social legislation affecting every American. Many ardently supportive legislators admitted they had not even read the fiendishly complicated 2700 page Act, and House leader Nancy Pelosi infamously said, “We will have to pass it to see what’s in it.”

Four Promises

Basically the law promised four things to the American public.

Promise One - Your personal health costs will go down by $2500 per couple by 2016. Instead, your premiums grew by 10% to 12% in 2010 and 2011. Medicare’s Actuary says costs will exceed costs if nothing had been done. By 2024, costs may amount to $2.5 trillion, 2 ½ times original estimates of $950 billion by 2020.

Promise Two
- You will be able to keep your present health plan and your current doctor. Period. Instead, large and small companies are shedding coverage for millions of Americans, and 1500 have been granted waivers to wiggle out of costs of Obamacare. Early on, Fortune 500 companies announced they would have to drop drug coverage for retirees. Some 80 to 100 million Americans may have to switch to more expensive plans that meet Obamacare standards, leaving their existing plans and doctors in the process.

Promise Three
- Coverage for care will be expanded for some 12 million Americans with pre-existing illness, young adults up to 26 covered under their parents plans, children – and 32 million uninsured. These are good things, and I applaud them. But there are at least six catches here – 1) insurers are dropping coverage because of increased expenses; 2) the majority of states are saying they cannot afford increase Medicare expenses; 3) employers are shifting costs to employees to meet mounting Obamacare-induced costs; 4) the Supreme Court may decide in the summer of 2012, to declare Obamacare unconstitutional ; 5) as many at 80% of Americans like their present plans and do not relish the idea of being placed on Medicaid; and 6) A present and future doctor shortage means that increased coverage may be meaningless if there are too few doctors to care for the newly insured.

Promise Four - Under government scrutiny and mandates the quality of your care will improve. Yet, in large surveys, 60% of doctors predict quality will go down. And Americans themselves are skeptical, By a current margin of 52% to 38%, national polls indicate they disapprove of Obamacare.

Think and Ask

Think of these promises, as the Presidential campaign kicks off and heats up.

Watch for the Supreme Court decision on the constitutionality of the individual mandate and the accompanying health reform law.

Ask yourself: Is my health care better than it was four years ago? Is it less or more expensive? Are the benefits greater or smaller? Do I have greater access to doctors? Does the doctor I want to see accept Medicaid or Medicare? Do I have to wait longer to schedule an appointment? Indeed, do I have difficulty finding one? Will I have to go on Medicaid? Who can best decide how to care for me? A government official or my doctor?

Thank you for reading this. If you want to learn more, google, or read my book The Health Reform Maze, which can be ordered on

Tweet: Obamacare's promises- to cut costs, keep health plans, expand access, and increase quality - have not been met, but it's not yet 2014.

Friday, September 9, 2011

Obamacare Repeal Will Not Reverse Reform Pressures

September 9, 2011 - I received this September 8 e-mail from Doctor Donald J. Palmisano’s DJP Update.

“Now we have heard from the Sixth Circuit(2:1 say PPACA constitutional): Eleventh Circuit(2:1 say individual mandate unconstitutional); and today the Fourth Circuit (Dismissed for lack of jurisdiction… the case will go to the Supreme Court. I predict it will be heard in next session of Supreme Court, and we will know decision by end of June or sometime in July 2012. And now, I know I repeat myself; individual mandate and most likely the entire PPACA (lack of severability clause) will be ruled unconstitutional. Uncertainty is destroying practice of medicine. That is my opinion).”

I respect Dr. Palmisano’s opinion. He is a lawyer as well as a surgeon.

But, you opponents of Obamacare, don’t get your hopes up. Life for physicians will never be the same again. We will not return to the status quo.

As a group of analysts assembled by the Physicians Foundation in 2010 observed in a 73 page White Paper, Health Reform and the Decline of Private Practice,

This time, reform will not be a ‘false dawn,’ analogous to the health reform movement of the 1990s, but will usher in substantive and lasting changes…Most physicians will be compelled to consolidate with other practitioners, or align with large hospitals and health systems for capital, administrative, and technical resources.”

There will be no return to yesteryear. Societal and economic trends to lower costs and restructure practice will continue unabated. These will include pressures to install EHRs, curtail high tech procedures, lower specialists’ fees, end fee-for-service, consolidate care and coordinate care, comply with rules and regulations, monitor care, and calls for improved quality, real or imagined.

Tweet: The Supreme Court will probably hear Obamacare case in summer of 2012. Even if overturned, its measures will still bedevil physicians

Thursday, September 8, 2011

The Power to Prescribe and the Power to Influence Prescribing

Sell when you can, you are not for all markets.

Shakespeare (1564-1616). As You Like It

September 8, 2011
- Perhaps the greatest power of being a physician is the power to prescribe. The Supreme Court diluted this power in 1997 when it ruled drug companies could directly advertise to consumers. Now, with the ubiquity of pharmaceutical marketing, physicians must cope with patient demands for drugs they saw on television.

You can scarcely spend an hour before the television tube without seeing a series of ads for drugs.`

Today while watching TV to assess the aftermath of the Republican debate at the Reagan Library. I saw ads for Pradaxa (atrial fibrillation), Lyrica (fibromyalia), Viagra and Cialis (erectile dysfunction), Embrel (rheumatoid arthritis), Bayer aspirin (coronary prevention), Boniva (osteoarthritis), Plavix (prevention of coronary thrombosis, and Freestyle and other diabetic supplies.

I do not object to these ads, but I as I witnessed them, I grew a little weary of the time they consumed away from the news. I’m aware television programming must be paid for, and drug advertising and promotions is one of the greatest sources of television advertising.

I know too that most drug companies are for-profit enterprises and require marketing to survive and to please investors.

Basically pharmaceutical companies have two audiences to whom to market_- physicians and consumers. To reach these markets they use the follow methods, which in 2005, were said to be 56% free samples, 25% detailing to physicians, 12.5% direct-to-consumers marketing, 4% hospital detailing, and 2% hospital detailing.

The United States and New Zealand, I am told, are the only two companies that allow direct-to-consumer marketing. This has its good aspects - informed consumers – and its bad – misinformed consumers and pressures on doctors to prescribe drugs that may not be needed, and the medicalization of the American public.

I cannot help but notice two things about direct-to-consumer advertising – one, the exclusive marketing of expensive brand name drugs to the exclusion of cheaper generic drugs, and two, the creation of diseases or syndromes that require drugs to treat. An example of the latter is Lyrica for fibromyalia, a “disease” that may or may not exist. I have doubts about the prevalence of erectile dysfunction, which from the volume and nature of its advertising, you would think runs amuck among handsome middle-aged males and their beautiful wives. As a doctor, I wonder how I would handle a male with a four hour erection.

Tweet: U.S. and New Zealand allow direct drug advertising to consumers. Drug firms may create diseases and overstate conditions to sell drugs.

Wednesday, September 7, 2011

MDs as MBAs

Healing is an art, medicine in a profession, health care is a business.

John Prescott, MD, CEO, Association of American Medical Colleges

September 7, 2011 - I see by the New York Times that more doctors are getting their MBAs "Adjusting, More MDs add MBA" - 500 in all. This is not new news for those of us following the evolution of health care as a powerful economic force to be reckoned with. Health care is the fastest growing economic sector, is the biggest employer in many communities, and the single greatest expense for many businesses.

This should come as no surprise. Americans admire those with specialized knowledge in any field - be it law, business, medicine, finance, technology, computers, or economics. This may be why the number of MD-MBA programs have grwon form 5 to 65 in the last 10 years, and why Mitt Romney with joint degrees from Harvard in law and business, is a finalist in the Republican Presidential sweepstakes.

I do not bewail this trend. It is the conseqnece of our culture's belief in specialized knowledge. I sometimes wonder if this belief is overdone and whether a general liberal arts education, steeped in a general knowledge of the culture and the humanities, might do as well.

I know health care has become so big, it must be managed. Perhaps doctors who have mastered two fields of knowledge are better qualified to manage the business of health care than jack-of-all-trades politicians. But most doctors resist the MBA trend. You get the feeling that we suspect MDS with MBAs have passed over to The Other Side. This is not what most doctors signed up for. To them practice is almost a priestly function, between them and their patients.

If physicians had wanted to go into business they would have. If they had wanted to save Medicare's bacon, they would have gone into politics. But many of us do not think in these terms, which may be why in national poll of 111, 000 physicians (with 1611 responders), released yesterday by Jackson and Coker, only 15% agree the AMA, a supporter of Obamacare, spoke for them, while 77% disagreed with the AMA's position.

Tweet: More MDs are getting MBAs. But most doctors resist this trend. The regard medicine as an art and not a business.

Tuesday, September 6, 2011

Denver Health System and Community Health Plans

September 6, 2011 - Yesterday I was speaking to a Duke University Medical School classmate, and he was praising mile-high the accomplishments of the Denver Health System, the largest community health clinic in the nation.

These clinics, established about 10 years ago under President Bush and supported by President Obama, cover about 20% of Americans. Unfortunately, as Rodney Dangerfield might say, they get little respect or recognition among pundits and policy makers.

Still, they are a powerful force for care for those without a doctor, for the uninsured, Medicaid recipients, the poor, immigrants, and particularly for children.

The Denver clinic has 24 outlets, half of them school clinics, which provide immunization and pregnancy, sexually transmitted disease counseling, and routine pediatric and adolescent care. In addition, the Denver system has centers of eating disorders, minimally invasive surgery, complex fractures, occupational safety, and trauma. Its health professionals are dedicated to their work and have been awarded 24 black belts for meritorious achievements.

The system cares for 42% of Denver residents. Denver, a city with 2.5 million resident, is racially diverse with large Hispanic and Russian populations. The "mile-high" city takes great pride in its system, which serves its many citizens from the bottom-up, with top-down support from federal grants.

Monday, September 5, 2011

Two Crystal Balls

I look into my crystal ball. I see a tall, dark person coming into your life. Perhaps I see a light person coming into your life. I see that you will travel. I see you will not travel. I see I have a dirty crystal ball.

Milton Berle, American comedian, 1908-2002

I tote and tout two crystal balls.

Just in case one breaks and falls.

In the first, I see government health reform winning out.

In the second, I see market reform winning without doubt.

I don't mind which one drops, both are dirty and need overhauls.

Tweet: My 2 crystal balls tell me,1, government reform may prevail,2, market reform may sail, but both could fail.

Health Reform: I’m OK- You’re OK, Opening Closed Doors

September 5, 2011, Labor Day - Since my book The Health Reform Maze (Greenbranch Publishing) was published in August, I’ve been asked to write or speak about the present status of health reform and what lies ahead before three national audiences.

I puzzle how to do this.

Unpredictability of Health Reform

He who thinks he can predict health reform’s future has a fool for a prophet.

Current political and reform uncertainties make predictions foolhardy. Given the current climate of joblessness, hopelessness, and unhappiness, there’s a 50/50 chance President Obama will not be re-elected, a 50/50 chance the Supreme Court will declare Obamacare unconstitutional, and a 50/50 chance the present health law will not remain intact.

Two Physician Foundation Surveys

Whatever and however one thinks, the new health law and private reform pressures mean private practice will never be the same again. According to a Physicians Foundation October 2010 survey of 100,000 doctors, “Health Reform and the Decline of Private Practice,” the clear majority of physicians do not approve of the health reform law, believe reform will increase patient loads while decreasing financial viabilities of their practices, will reduce patient access to their practices , will cause doctors to retire, not accept third party payments, or work part-time, locum tenens, or in concierge practices, and will harm quality.

A subsequent survey June 2011 “A Roadmap for Physicians to Health Reform” was even more pessimistic, It forecast physicians would be forced to care for populations, not individuals; compelled to join networks, groups, or organizations; make them unable to carry on a “private” practice; require them to comply with a host of new rules and regulations , assume financial risks for outcomes beyond their control ; and end in a physician shortage, with older physicians retiring or cutting practices with other physicians seeking refuge in hospital employment with shorter hours.

Not a Pretty Picture

This is not a pretty picture. This demoralizes physician community. This portends more unwanted government intervention.

But this has not left us without options. We can still take a leadership role in shaping reform. No reform is possible without physicians to deliver care, no matter what the system.

But How?

In the course of writing 11 books and creating 1936 Medinnovation blogs on reform and innovation, I like to think I have done my homework and have something to offer physicians on how to right the reform ship.

But how? Health reform is devilishly complicated. Reform does not lend itself to simplistic solutions.

Then I thought of the 1969 book I’m OK, You’re OK by Thomas Harris, MD (1910-1995), a Sacramento and former U/S. Army psychiatrist who promoted the concept of I’m OK-You’re OK approach, a form of transactional analysis. He insisted this technique made feelings more accessible, guilt less oppressive, results more productive, and dealing with issues easier. The book is a perennial bestseller and is still in print.

Opening Closed Doors

That said, maybe I’m OK, You’re OK will help open the behind Closed Door Approach with questionable deals (Louisiana Purchase, Cornhuster Hussle, and UConn Conn) that rammed through Obamacare and poisoned the political process responsible for the bitter partnership we now see.

Here’s what I might say to physician audiences.

1) It’s OK for me and you to disapprove of Obamacare. So does the majority of the American public, who would like to see it repealed.

2) It’s OK for you and me to say: Yes, we need reform, but we prefer bottom-up to top-down reform, led by doctors and patients, not by government.

3) It’s OK to say we believe in patient, physician, and business friendly reform based on a American competitive model of free enterprise, free choice, tax credits for all, shopping across state lines, tort reform, and personal responsibility engendered by health savings accounts and private contracting between patients and doctors rather than a a quasi- European model based on conformity to government standards, micro-management of physician practices, and covert rationing.

4) It's OK to object to backdoor government strategies for control of practices such as financial penalties for not installing EHRs or prescribing electronically, "Independent" unelected Payment Advisory Boards, and SGR formulas for controlling physician pay.

5) It’s OK for use to say repeatedly that the hidden costs of Obamacare and the uncertainties of meeting universal government health plan standards has caused businesses, large and small, to stop hiring until they see the final costs and consequences of the health reform act.

6) It’s OK to push ahead with disruptive practice innovations – such as telemedicine, Skype connections with patients, remote patient monitoring apps, and patient entered histories before seeing doctors in the exam room, and to promote innovations at the grassroots that make medicine more personal, more decentralized, and more responsive to the needs of individual patients rather to an overreaching government.

7) It’s OK to say we believe in the will of the people rather than the wisdom of government experts.

8) It’s OK to say that electronic medical records are not up to prime time, are too expensive, slow productivity, are often useless as communication tools, distract from the doctor-patient relationship, are designed by and for managerial and government nerds rather than physicians, and can be improved by introducing voice recognition apps that turn doctors into relevant story tellers and recorders rather than mindless data entry clerks.

) It’s OK to take every opportunity to remind the public, policy wonks, and politicians in private and public forums that the present health reform law has not and probably cannot deliver on its promises to cut costs, to salvage Medicare and Medicaid, to allow one to keep one’s health plan and one’s doctor, and to improve the quality of medicine. Meeting these goals will require persistent physician input and physician efforts to deliver patient-centered rather than government-dictated care. Take the lead, Open the doors wide.

Tweet: Physicians can take a leadership role in promoting grassroots reform changes by adopting I'm OK-You're OK dialogue.