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Monday, June 30, 2008

We got their Attention

Quote of the day:
Finance is the art of passing money from hand to hand until it finally disappears. - Robert W. Sarnoff

Congress knew in advance that GWB would intervene prior to the new session of congress, by executive order.  GWB ordered that the 10% medicare fee reductions be suspended.  HHS Secretary Mike Leavitt also took administrative action to place a hold on changes as well.

"WASHINGTON (AP) - The Bush administration said Monday it is freezing a scheduled 10 percent fee cut for doctors who treat Medicare patients, giving Congress time to act to prevent the cuts when lawmakers return from a July 4 recess.

Physicians have been running ads hinting that as a result of the cuts, patients may find doctors less willing to treat them. The administration's delay in implementing the cuts spares lawmakers from having to use the recess to explain to seniors why they didn't do the job before leaving town.

Kevin Schweers, a spokesman for the Department of Health and Human Services, said Monday the Centers for Medicare and Medicaid Services will hold doctors' Medicare claims for services delivered on or after July 1. Claims for services received on before June 30 will be processed as usual, he said.

Congress, not willing to face millions of angry seniors at the polls in November, will almost certainly act quickly when it returns to Washington the week of July 7 to prevent the cuts in payments for some 600,000 doctors who treat Medicare patients. The cuts were scheduled because of a formula that requires fee cuts when spending exceeds established goals.

HHS Secretary Mike Leavitt had promised Friday that his agency "will take all steps available to the department under the law to minimize the impact on providers and beneficiaries." On Monday, the department used its administrative tools to delay implementing the scheduled 10.6 percent cuts."


It seems that outrage expressed byAARP and the projections by physicians that this could be a near final blow to the economiic survival of providers, both large and small.

It seems an opportune time for physicians to group together other high priority items for the upcoming new congressional session.

Friday, June 27, 2008

Personal Health Records and the Markle Foundation

Quote of the day:
Nothing is as simple as we hope it will be. - Jim Horning


Today I need to get down to more serious issues. I inject humor from time to time to maintain equilibrium.  I have had some commentary that my mind is "blown".  That may or may not be true......Nevertheless, here we go.

Medinnovation has a very comprehensive analysis of what and where medicine has gone and will go further, if the current entrenched medical power complex starts thinking out of the box.

Personal Health Records have been promoted in the past couple of years as a means of maintaining personal and family medical history for future provider visits.  The issue of privacy and confidentiality are probably a bigger issue here than in institutional settings.  Some people will want the personal security of using a hand carried  memory stick in one form another to carry in to their doctor's office. 

Others will want to rely on one they have available from their employer. 

HIPAA rules  may or may not apply to these PHRs.  The Markle Foundation has developed a 'Common Framework for Networked Personal Health Information', and how it would apply to a PHR, and a comprehensive view of their vision is at Connecting Consumers.

This is a good thing provided it is enforceable. A number of large organizations are endorsing it, and they can be found in the 'Common Framework'

However Matthew Holt   makes some cautionary remarks about this whole area of regulation as to how it applies to PHRs.

"There is, though, one tricky problem regarding disclosure of health information, and that is of course the impact it has on your wealth. So I asked the tricky question. They have AHIP, Aetna and BCBS Association (and Dossia) on their list of endorsers. They also have a separate policy about Discrimination and Compelled Disclosures (PDF is here). But as I asked, given that insurers (and some employers) already do discriminate based on health history, and thereby greatly impact people's wealth and their own of course, what’s the point in them saying that they won’t go fishing in the PHR. The answer is in the policy document (and to be fair it’s all they can say.)"

Well, my head is beginning to hurt, again.

Wednesday, June 25, 2008

Don't Stop Thinking about Tomorrow

Or never look back!!

Quote of the day:
The only paradise is paradise lost. - Marcel Proust


HMOs and where it all began..

Encore Presentation

Due to multiple requests (1) I am re-posting "Pirates of The Carribean" which was up two weeks ago.

Tuesday, June 24, 2008

How many cars can the express pull?


Some executives at California health insurance providers paid themselves handsomely while their companies were raking in more than $4.3 billion in profits in the last year.

(As reported by the San Francisco Chronicle)

In addition, HMOs spent $6 billion on administrative costs, which include hefty CEO salaries, according to a report by the California Medical Association, which said the money could have gone toward driving down premiums or better protecting the insured.

The annual report, which draws on expenditures reported to the state Department of Managed Health Care, will be released Tuesday.

It found that annual salaries topped $1 million for chief executive officers at providers like Aetna, Inc., CIGNA Corp., Health Net, Inc., UnitedHealth Group and WellPoint Health Networks, Inc.

The medical association is sponsoring a bill to require health plans to spend at least 85 percent of their annual income from the insured on health care.

"This report really underscores what we have been saying all along, which is there's massive waste in the insurance industry," said Sen. Sheila Kuehl, D-Santa Monica, who authored the bill.

"Californians are literally going into bankruptcy because of rising insurance premiums and having their benefits gutted simultaneously," she said.

The report found that if the bill were already in place, nearly $1.1 billion dollars would have gone back to providing health care.

Of major providers, Indianapolis-based Anthem Blue Cross' 4.1 million members see the smallest proportion of their premiums returned, with 79 percent of revenue used toward medical care.

"One of the worst ratios is Anthem Blue Cross," said CMA President Richard Frankenstein. "They sent more than $1 billion back to Indiana last year and I don't think that's where Californians want to see their premium dollars go."

Anthem Blue Cross said in a statement that as a for-profit business, it also pays more taxes than the nonprofit HMOs included in the study, which accounts for some of the difference in administrative costs.

"Anthem Blue Cross continually strives to reduce its administrative costs while also delivering innovative products to its members," the statement said.

The report highlighted four major providers who already put more than 90 percent of revenue directly toward medical care: L.A. Care Health Plan (97.1 percent), CIGNA HealthCare of California (94.3 percent), Inland Empire Health Plan (93.1 percent) and Kaiser Foundation Health Plan (90.6 percent).

"We're a not-for-profit so there aren't any shareholders who get dividends or bonuses, so any net revenue is invested right back into facilities, services, and keeping our rates affordable," Kaiser spokeswoman Kathleen McKenna said.


Bla bla bla. 

Monday, June 23, 2008

Junk Science and Carbon Footprints

Quote of the day:
He is one of those people who would be enormously improved by death. - Saki

Quote of the day:
I have come to believe that the whole world is an enigma, a harmless enigma that is made terrible by our own mad attempt to interpret it as though it had an underlying truth. - Umberto Eco


Today's early morning ruminations took me to FOX news where I was greeted by another analysis of how many tons of CO2 I produced this morning when taking my shower. It's been extremely hot here the past week, not cooling down at night. I follow Al Gore's example of being carbon "neutral" by cranking my thermostat down to 65 degrees each night to get a head start on what comes later in the day, 114 degrees.  Supposedly our A/C when maxed out will offset 40 degrees, brining it down to 74 degrees during the afternoon.  (we have a son who does  not sweat due to cystic fibrosis)

Well, I digress.   Have you figured out how much your hospital produces in carbon dioxide, or your medical building? How about those ambulances and EMTs running around in those supersize fire-engines? They always seem to come in pairs.  How about a hybrid fire engine, or more realistically smaller vehicles for the initial scout vehicles??

It seems Al Gore increased his 'footprint' by 10% last year following his "nobel prize'.  This despite the fact that he exchanged his incandescent lights for 'fluorescent' eco-green friendly lights.

How about a 'hybrid personal jet' Maybe one that runs on water?? I have such a deal for you......

Al Gore should be stripped of his Nobel Prize, and his Oscar for his movie, "An Inconvenient Truth".  Inconvenience does not seem to hinder 'Big Al" from his noxious C O 2  emissons.  The people who awarded him this prize are brain dead....

Several questions remain, that haunt me each night

1. Is a carbon footprint unique....can it identify the polluter?

2. Is Al Gore missing a chromosome?

3. Is there a relationship between DNA matching and CO2 content of your body?

4. How much carbon offsets do I need to buy if I bill 66984 to remove a cataract (phacoemulsifer and operating microscope.

5. Is Al Gore missing a chromosome?

6. Is Al Gore the missing link?

7. How much CO2 would be saved if.........................

8. Is Al Gore missing a chromosome??

These things give me a headache.

Have  a great and blessed day!!!!!

Oh, I almost forgot...........what will HIT add to the carbon footprint and will HHS or CMS reimburse me for the carbon credits I must buy....are they tax deductible or will I get a tax credit.???

Saturday, June 21, 2008

Medal of Freedom

Today's express is upbeat. President GWB awarded the Presidental Medial of Freedom to 2 physicians.

The Medal of Freedom was established by President Truman in 1945 to recognize civilians for their efforts during World War II. The award was reinstated by President Kennedy in 1963 to honor distinguished service. It is given to those deemed to have made remarkable contributions to the security or national interests of the United States, world peace, culture, or other private or public endeavors.

_Dr. Benjamin S. Carson Sr.: In 1987, he performed the world's first successful operation separating twins joined at the back of the head. He is director of pediatric neurosurgery at Johns Hopkins Children's Center in Baltimore. Bush talked about Carson's mother, who raised Carson and another son alone. "Every week the boys would have to check out library books and write reports on them," Bush said. "She would hand them back with check marks as though she had reviewed them, never letting on that she couldn't read."

Dr. Anthony S. Fauci: An adviser to the government on global AIDS issues, he is the director of the National Institute of Allergy and Infectious Diseases. Bush said that Fauci still quotes what he learned from Jesuit teaching - "Precision of thought. Economy of expression." And the president quipped, "And now you know why he never ran for public office."

Both of these men come from the strength of our country, from families' who valued and prioritized education.

Many physicians lead largely unrecognized lives, except for the patients and families for whom they have cared. The thousands of physicians, radiologists, pathologists,anesthesiologists, who contribute much and without whose expertise clinicians would be back in the 19th century.   They receive little public recognition but are the lifeblood of medical care.

The gains we attain becoming MDs go far beyond our technical skills and clinical education.  Many physicians often feel they are unsuited for other vocations, however our pre medical, medical and post graduate training endow us with analytic abilities, a true comprehension of human abilities and disabilities.

We have become bogged down and enslaved to a system that suppresses originality, encourages following along blindly according to edicts of preferred practice patterns, which will never replace clinical judgment and acumen.  In fact some of the regimented patterns increase cost and waste medical resources.

It is like this also with continuing medical education which has spawned an expensive medical education-industrial complex upon which big Pharma intrudes.  More governmental intrusion and a system not unlike "No Child Left Behind".  NCLB.  I coin a new phrase  " No physician Left Behind NPLB, not to be confused with NPDB.

Friday, June 20, 2008

Getting a Seat at the Table

Quote of the day:
To invent, you need a good imagination and a pile of junk. - Thomas A. Edison

This from Consumer's Health  Care Choices

"There can be no more compelling testimony on what physicians are facing than the farewell address by Doctor Ian Bogle, when he stepped down as Chairman of the British Medical Association on June 30, 2003. The speech is really quite poignant because he indicates that physicians in Great Britain made the same mistakes that American physicians are in the process of making.

He says, "I accept, like all of us do, that national standards, quality markers and assessment of individual and team performance are essential in a modern, patient-centered NHS."

But this acceptance, the desire to get-along-by-going-along, the desire to "have a seat at the table," is precisely what brought about the bone-crushing regimentation of Medicine he bemoans in the rest of his talk.



Doctor Bogle goes on to describe what medicine is like in the UK Today -

  • Ministers and managers have muscled in on the doctor-patient relationship, and we now have a healthcare system driven not by the needs of individual patients but by spreadsheets and tick boxes.
  • Clinical decisions have been taken out of clinicians' hands and the fundamental NHS principle of care based on need and need alone has been superseded by the principle of care based on numbers.
  • Targets are set nationally without any appreciation of what they might mean for individual doctors sitting in consulting rooms with individual patients
  • If you set targets for the treatment of one group, you automatically disadvantage others whose clinical need may in fact be greater.
  • If you set targets for access to services, you encourage those providing the services to give more thought to throughput of patients than to what is actually wrong with those patients and what their individual treatment needs are.

It is an eloquent statement that should be must-reading for anyone in health policy today. But it must be said that all this was brought on by the naiveté and credulousness of Dr. Bogle and the British Medical Association that persists today. They continue to "accept national standards, quality markers and assessment of individual and team performance." And that is what enabled the bureaucrats to tell them how to practice medicine. It is the exact same mistake the AMA is making today - sacrifice your principles to "get a seat at the table."

British Medical Association.

Readers will find much more at Consumer's Health Care Choices

Thursday, June 19, 2008

A Repeat Post

Quote of the day:
I have a new philosophy. I'm only going to dread one day at a time. - Charles M. Schulz


It's been awhile since I published this message.....time for a "rerun"

Fellow bloggers:

When I first began “blogging” about three years ago I intended it to be a newsletter for a RHIO that I was heading up in my area of the country. About a year ago I chose to rename it “Healthtrain Express”. The term recently coined by others came to my mind in 1989 (that definitely dates me) It was in the pre-DRG, pre RVU, pre managed care (ie, the “golden days”) that my residents often wistfully mention..

I often tell them that no “age in medicine” is trouble free. It’s the nature of the “beast”.

Healthtrain express conjures up the rapid changes that constantly occur in medicine. For those of you who have read “Future Shock “ by Alvin Tofler , this has always applied to medicine. I highly recommend this reading.

It also denotes a vehicle with a tremendous amount of inertia, barreling down a “track” . If you are on the track you had better be moving fast enough to stay ahead of the train. If you are stationery, then you must either move aside or be “smashed”.

Returning to more specifics of our “age in medicine” we see the predictions and evolution of pay for performance and reporting, health information technology, the methodology of reimbursement change, including CMS intention to not reimburse for “poor outcomes” or those due to “poor care”. Medicine will continue to be increasingly directed by third parties, consumers, and political and social planners. Most of whom have never treated a patient. This one issue frustrates most physicians, although it has become a fait acompli, I know it continues to “gall” most doctors.

Physician-hospital relations continue to be in a state of flux. Gone forever in most areas is the leadership of the medical staff as it pertains to the board of directors, or trustees of the hospitals. In some rural areas this may remain intact, unless the hospital is part of a larger financial “holding company”. Creative financing has allowed many hospitals to continue operations with “leaseback arrangements” for management, and other issues.

Looming on the horizon is radical change in hospital accreditation organizations.

The JCAH authority is about to be undermined by pending legislation and some hospitals chose to use alternative accreditation sources This may or may not be a good thing, given that operating requirements have radically changed for hospitals.

For those of my readers you may notice on the sidebar the expansion of medically related blogs. Over the next month this list will be expanded. This is going to involve a significant amount of my time selecting and moderating my personal favorites.

I am also extending a personal invitation for co-authors for “healthtrain express”.


Tuesday, June 17, 2008

It's Not all in the DATA

Quote of the day:
For a list of all the ways technology has failed to improve the quality of life, please press three. - Alice Kahn

I was sent a survey last week from the Harvard Business School, by Julia Adler-Milstein, of the Harvard Business School.  It was a query on the status of the Inland Empire HIE, or RHIO.

It was an online 'Survey Monkey' which one the surface looked nice, simple format and was enjoyable to fill out. My first, second and third attempts resulted in an error message. I gave up in frustration, but did email JAM that it didn't work. (no reflection of  HIT, here.  I was sent another link which did work well.

At the end of the day  I sent along an email with some attached comments.... I appreciated her response to my 'footnotes'.


"Thank you Gary. I'm relieved that it worked and very much appreciate you taking the time to add "footnotes", which, for those us in the academic world, are very helpful to understand some of the details that aren't easily seen in the data. I'll check out your blog too!"

Tuesday, June 10, 2008

The Failure of RHIOs and ONCHIT


Quote of the day:
In a time of universal deceit, telling the truth is a revolutionary act. - George Orwell

Today' iHealthbeat reveals why government is inept in many regards.  What starts out with innovative ideas quickly becomes bogged down on internal machinations, politics and the inability to adapt to rapidly changing market forces.  As I stated fouryears ago HIT and RHIOs could not be produced from the top down, rather it would develop from the bottom up as we are witnessing now. Ihad compared the development of our national telephone network as an example.  The many 'Bell' companies eventually merged into one company serving the majority of the United States.

Perhaps the most important item to come from ONCHIT was it's stimulus to develop CCHIT standards.  David Brailer's vision may come true but in a different manner than proposed.

As I had stated and predicted it would not be necessary to 'reinvent the wheel', that many of the requirements already existed in the market place.  ONCHIT chose to ignore this fact and became involved and invested in it's own thought process.

During the last four years I became the principal involved in an attempt to develop a "RHIO" in Southern California. The outcome was less than devastating.  The REPORT  written by David Kibbe and published on The Health Care Blog (Matthew Holt) articulates the absolute failure of RHIOs except for one or two which existed prior to ONCHIT' arrival on the scene.

During the past three years I worked with a multitude of vendors at the grassroots level.  Except for large to medium sized groups and IPAs the market remains very fragmented. 

ONCHIT has largely ignored the present market.

"It's as though these people and institutions never heard about medical search, health social networking, wikipedia, Google Health, Microsoft HealthVault, or the Continuity of Care Record standard. To read the ONC Strategic Plan you would never know of the existence of HealthGrades and the other quality and transparency reporting sites on the Internet; the SureScripts network that was used for 100 million ePrescriptions last year,; the hundreds of  thousands of lab results delivered to medical practices over the Internet using Web applications every day; or the thousands of medical practices that have deployed Web-based technology for billing and claims administration, Web portals for communications with their patients, and clinical systems for helping with care management. " (from the report)


"The second biggest misstep taken by ONC has been to entirely remove the consumer from the equation, and to ignore the force of the analogy that is powering consumer/patient impatience, even anger, at the calcified hairball our health care industry has become. That is the analogy with consumer experiences of convenience, affordability, and service excellence from companies across a wide spectrum of industries that have effectively integrated the Internet and the Web into their DNA, from FedEx to NetFlix, from Southwest Airlines to L.L. Bean, and from CNN to iTunes. Education, commerce, banking, the financial services, and personal communications are all online.

Too much of health care is still offline, and nothing in ONC's obsolete strategic plans reflects this reality or recognizes the progress that is being made despite ONC's befuddled time warp.

Will somebody, please, push the "reset" button on health IT policy inside the Beltway?"

June 10, 2008 in Policy, Technology, The Industry, Web/Tech | Permalin

What Doctor's Think

Quote of the day:

Three may keep a secret, if two of them are dead. - Benjamin Franklin

Here is what fuels our "health train"

Doctor Insights

Doctors directly influence more than a third of the entire USA health care economy. Consider these important facts:

  • 902,000: number of physicians in the USA in 2005
  • $2.1 trillion: USA healthcare expenditures in 2006
  • $274 billion: sales of physician-prescribed medications in 2006
  • $587 billion: cost of various patient services and devices ordered by physicians and healthcare providers in 2004

These figures are from  What Doctor's Think.

Monday, June 9, 2008

Health Train Express -- Derailed

“It is better to know some of the questions than all of the answers.”
James Thurber (1894 -1961)


When I named my blog several years ago I did not quite realize the analogy would have so many applications to health care.

Our "train" is certainly not travelling a straight line on the track. In fact at times the train seems to have left the track.

One unfortunate observation is that like our country overall there is no  ten year or twenty year cohesive plan. Healthcare has become a hodge podge of entities and chaos.  In fact if we can plan beyond next month  running our medical practices we are lucky.

A train with a locomotive at each end pulling in opposite directions won't move very far.

Sunday, June 8, 2008

Hijinx 101

Enough gloom and doom with healthcare, medicare, universal care, dental care, heart care, bone care, who cares, an NO CARE for this week.

Norman Vincent Peale decided for the rest of us that "laughter is the best medicine".  Now that is not on  medicare part D., so Idon't know how to order it, or if it requires a special RX pad.

The sad fact is that most of you "intelligient" docs got where you are due to you ability to adapt, work hard, and check off the boxes that your teachers wanted you to check off.   Creativity has been smashed beyond recognition in clinical care.

So, to cheer you all up I am including some links to stimulate the "other" side of your brain. 

I am saddled with being left handed, which it turned out has been a boon to my career as an ophthalmologist. ( I never could play the ukelele.)

Sit back, relax on this fine Sunday morning and enjoy the hijinx of the Y and Z generation.  There  is still hope if we "old guys" get out of the way.  This one's for you....Buckeye Surgeon, Surgeons blog,Panda Bear ( I miss your blogging), Kevin MD, THCB, and more.

Revision 3.0

Future in Biotech


I am a Twit

You Tube--Healthcare

Pirates of the Healthcare-I-bean  (very funny)




Marrying for Healthcare

Remix Mayday

Light up Your Lighter

The Future (may load patient)

There is hope!!!!

Saturday, June 7, 2008

The Flawed SGR Formula

When more is less...............

Quote of the day:
Democracy means government by discussion, but it is only effective if you can stop people talking. - Clement Atlee


Usually before I start my blog writing I do some surfing around for current news in the blogosphere. Buckeye Surgeon has a few interesting links that are germane.  The Wall Street Journal blog cuts right to the Chase.  It's not difficult to see how payors enjoy playing us against one another....divide and conquer techniques which have been demonstrated to be quite effective thus far. No specialty or primarycare physicians should take glee in reaping benefits as a result of these tactics.  Remember, first they came for "them" then they came for "me". 


To quote Buckeye Surgeon,

"There's plenty of money to go around. The discrepancy in pay between the GI doc and the PCP is not the reason why health care is so expensive. The giant HMO's and the pharmaceutical conglomerates would love to have you believe that. There's a reason both are multi-billion dollar industries. Let's not nickel and dime each other. A united front is our only hope of ensuring that the backbone of the American health care system, i.e. the physicians, does not deteriorate into a collection of second- rate, infighting, backstabbing special interests."

Monday, June 2, 2008

Conductors for the Health Train Express

Quote of the day:
Politicians are the same all over. They promise to build a bridge even where there is no river. - Nikita Khrushchev


It's been a very long time since I have been on a train. I remember them as walking down the aisles of passenger cars punching your ticket.  Do they still exist?

I think "Health Train Express"  needs fewer ticket punchers.

When was the last time you thought about a Surgeon General?

The last one I remember was  David Satcher , before that the memorable  C. Everett Koop .   I am not certain why but the most memorable Surgeon Generals  had beards.


The complete List of Surgeon Generals is here.

Another Surgeon General was Jocelyn Elders,  who I like to call the "equal opportunity"  Surgeon General.  She was both a woman and an African-American . General Elders was a very outspoken leader....she was however politically incorrect, a proponent for sex education, introducing Condom in public school.  She was summarily drummed out...

Condom rolled

Some of these "Generals" actually were Admirals...but I have not heard of any called "Surgeon Admirals".

Whatever  has happened to our current  surgeon general?

Rear Admiral Steven K. Galson, M.D., M.P.H.

photo of RADM Steven K. Galson, M.D., M.P.H., Acting Surgeon GeneralSince October 2007, Rear Admiral Steven K. Galson, M.D., M.P.H., has served as the Acting Surgeon General of the United States. As the nation's top public health physician, the Surgeon General communicates the best science, evidence, and data to the American people in order for them to make healthy choices that impact their health, safety, and security. Additionally, he serves as the operational Commander of the Commissioned Corps of the United States Public Health Service, a uniformed force of 6,000 health professional officers dedicated to promoting, protecting, and advancing the health and safety of the people of the United States.

I am sure he is an excellent Surgeon General, but why has been "acting"  for so long.  Is this a rehearsal, or Audition for the part?

Now you ask what does any of this have to do with caring for patients.....???Nothing, nada...............just like most of what we read, or hear about medical care.