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Friday, July 31, 2009

CAT scans for your cat

Tonight's 20/20 Exposes Single-Payer Health Care

ABC News "20/20" is planning to air a segment tonight with John Stossel about the health care systems of Canada and Great Britain. We understand our friend and colleague, Grace-Marie Turner of the Galen Institute, will be on the program. "20/20" airs tonight at 10 p.m. Eastern, but please check your local listings for the exact time.

Stossel gives us this teaser on his blog: "We did find places in Canada where patients have quick and easy access to cutting edge technology like CT scans, endoscopy, thoracoscopy, laparoscopy. The clinics make these treatments available 24 hours a day, seven days a week, so patients rarely have to wait. But patients have to bark or meow to get that kind of treatment.

"Do you want a CT scan? Canadian veterinary clinics, which are private, told us that they can get a dog in the next day. For people, the waiting list is a month."

The health care segment is scheduled to air toward the end of the program. Be sure to watch and let us know what you think.

For more information about the program, please visit the 20/20 Web site.

Now it's ACO

Dear Mrs Jones;

I am sorry that I no longer am responsible for your healthcare and you will not be able to pay me for services. I am now a member of the ‘accountable care organization’ of my regional health system.

After much studying and implementing mandatory health insurance coverage in Massachussetts (they discovered there were not enough doctors, nor enough funds to provide the coverage that was promised.

ACO was invented….this is a super large HMO.

1. The development of Accountable Care Organizations (ACOs). (Health delivery entities that can work as a team to manage the provision and coordination of care so that they are accepting responsibility for all - or most - of the care for their enrollees.)

2. Patient choice. Patients will be able to choose their primary care physician, and will not be restricted to only clinicians in their ACO - but may have to pay more for services outside of their ACO.

3. Patient-centered care and a strong focus on primary care. Each patient’s selection of a primary care provider will direct their insurer’s payments to their ACO, which will receive technical support to help develop/create medical homes.

4. Widespread adoption of the medical home model. (The Special Commission concluded that “medical homes overlaid on the current FFS system cannot achieve its vision for a high-value health care system.”)

5. Pay-for-performance (P4P) incentives to ensure appropriate access to care, and encourage quality improvement, evidence-based care, and coordination of care.

6. Sharing of financial risk between ACOs and insurers. ACOs will be held responsible for performance risk—including cost performance and meeting access and quality standards. Insurance companies, (and self-insured companies), will retain the insurance risk for the insurance contracts written to groups and individuals.

7. Strong and consistent risk adjustment. Global payments will be adjusted to reflect providers’ clinical and socioeconomic case mix, and, as appropriate, geography, so that ACOs will not be financially harmed by accepting high-risk patients with complex or chronic health care needs.

8. Cost and quality transparency. ACOs will report performance against common metrics measuring health care quality and access to appropriate care.

9. Participation by both private and public payers to ensure consistent alignment of care delivery incentives and to minimize administrative complexity and costs.

According to this well thought out proposal by legislators and higher ups in the food tree of health care administration, the ACO will provide the ability for global payments. (they don’t define what this is, nor how it is determined)

Real Reform in Massachusetts This report is generated from The Massachusetts Special Commission on Payment Reform recently issued its  recommendations for shifting the state’s health care system from Fee-For-Service (FFS) to Global Payments over a 5 year period.

It’ simple, really !!


So Mrs. Jones, the above diagram shows you how to obtain your health care. I see one box for health care providers on the lower right portion of the diagram. Where are you, the patient??

Thursday, July 30, 2009

Wisdom on the Health Train Express


Technology isn’t a quick fix. Just ask General Motors. In the 1980s, the auto giant spent $50 billion to automate and computerize its plants in an effort to compete with Toyota. Today, GM is emerging from bankruptcy while Toyota still leads in producing high quality, fuel-efficient vehicles.




What happened? “The Japanese have a great way of describing the error that General Motors made,” said Thomas Kochan, co-director of the Institute for Work and Employment Research at the Massachusetts Institute of Technology Sloan School of Management. “It’s workers who give wisdom to these machines.”

(underlining, mine)

The analogy between the auto industry and health IT is obvious.

Will the Obama administration’s $20 billion push to flood the nation’s physician offices and hospitals with electronic medical records (EMRs) suffer a similar fate?

“Technology doesn’t change lives,” Riley said. “It’s the process around the technology that brings results.”

I think this is what doctors are talking about in their reticence to accept EMRs into their practices. What is good for the goose, is not necessarily good for the gander.  Small practices (group, or otherwise) are different administrative animals than large and even huge integrated health care systems.

An easily observed manifestation of this is what I call the 'walkaround"   Walk around a typical small group or solo practice and compare the square footage in a smaller practice  dedicated to clinical care space, and administrative space.  Where is the administrative space? In these large entities, those with the nicest offices with a 'view' are the nurse case managers, heads of departments, and executive administrators.  This is obvious when one tours a VA hospital, Army, Navy hospital and Kaiser Permanente. 

Are these administrators 'evil people"?  No, however the pecking order and corporate culture encourage this development of space allocation, especially since administrators control the purse strings.  I have even heard practice managers discourage allotting a comfortable 'thought room" because doctors don't see patients in their "personal office space".

More on this in my next post. I have a patient waiting and have to leave my 'personal space' (100 square feet).

Wednesday, July 29, 2009

The Art part of Health Care Reform?

M.D.: Where Is the Art of Medicine in Health-Care Debate?

Abraham Verghese MD discusses the objective of tying reimbursement to the time involved with seeing a patient. Attempts at this were made with the development of Evaluation and Management coding. (E/M coding). Unfortunately the criteria for these codes do not include many factors in patient management that have no relevant coding measures. E/M coding is strictly limited by body system evaluations, and depending upon the clinical focus are inappropriate. The coding measures have always been insufficient. There are no codes that reimburse for coordinating patient care with other providers, nor for administrative time involved in justifying payments to payers, including medicare.

Everybody’s got something to say about health reform, but nobody’s speaking up for the art of medicine, Abraham Verghese argues today in a column.

Many doctors’ groups and academic medical centers are too deeply entrenched in the business of medicine to speak up for the field’s noblest intentions, writes Verghese, a novelist, Stanford prof and practicing physician.

And he makes a case that a payment system that encourages doctors to practice the kind of medicine that leads to real relationships with patients could be more efficient in the long run: “Our esteemed medical societies and academies aren't speaking for medicine; they are lobbyists, defending their financial self-interests, lining up for or against the latest bill being proposed. Our great academic institutions and our esteemed medical schools have historically spoken for the cause of medicine, but these days many medical schools are more like big companies with complex financial interests in large hospitals and clinical practices. What about the large foundations dedicated to health care, such as the Robert Wood Johnson Foundation or the Kaiser Family Foundation? I think their voices have become more potent as they seem largely free of the kinds of conflicts of interest that bind many of us, but they are not quite the voice of medicine.”

Howard Dean meets SERMO

The power of the internet has become apparent in national and local political decision making. Politicians use the internet and watch bloggers and social networking sites to measure carefully their decisions. No longer do groups have to use expensive s elf serving lobbyists to get their point across.

Yesterday SERMO participated in a nationwide forum (debate) with Howard Dean on CNBC. Sermo put forth the concept that the AMA does not represent either the majority of physicians, nor their opinions.

Howard Dean himself indicated that he does not belong to the AMA. It was  a very contentious meeting. Dan Palestrant who spoke for SERMO and it’s 110,000 members focused on the need for tort reform and reimbursement reform. Howard Dean expressed his belief that doctors on salary would do away with the demons of our present system. Palestrant focused upon level of reimbursement being adjusted for level of training. Dr. Palestrant indicated the AMA has a self serving interest in reimbursement since it holds important copyrights to the CPT (current procedural terminology), which all insurance companies and Medicare, as well as DOD, and VA system use on a daily basis. (ie,insurance companies pay the AMA for their right to use CPT codes.) The AMA garners a great deal of income from that source. The interview was too short, abbreviated, and neither participants had sufficient time to give a coherent presentation to lay audiences.

I think the most important take away was that a large group of physicians had a national platform other than the AMA. Hopefully Congress has paid attention.

Tuesday, July 28, 2009

SERMO and the AMA

Daniel Palestrant MD of Sermo discusses health reform issues with Howard Dean, former Governor of Vermont

Health Health IT mandatory?

One of the greatest discoveries a man makes, one of his great surprises, is to find he can do what he was afraid he couldn't do.

Henry Ford


[Shades of the Past!


Jeff Marion of  EHR watch .com shares this commentary from Shahid Shah.

Guest Article: Why do Doctors Hate EMRs???

There is also an audio cast on the web site, for those who like to multi-task, listening and /or reading content.

Some interesting quotes regarding the appraisal of typical EMR software.

How do we know doctors hate EMRs? Look at anemic adoption rates.

When such features as e-prescribing, e-visit, and PHR integration are considered, it is likely than less than half of physicians use their EMR for little more than their own templates and a few favorite features. The majority of physicians have voted with their feet.

In the business community it is common to hear doctors referred to as computer-phobic and “in denial” about the benefits of computing. That is wonderfully ironic when heard alongside chronic complaints that doctors are overly eager to use expensive technology: lasers, cryro-probes, fiber optics, MRI and PET scanners, stents, and implants. The fact is that doctors love high-tech.

They have reason to hate EMRs but not computers and iPhones.

Most physicians receive their first scars at the hands of hospital software. The truly unlucky have experienced a software installation with conversion from paper to EHR.

Physicians know that better exists. They have experienced Google, Amazon and e-Bay. Game lovers know that Electronic Arts’ “Tiberium,” now 15 years old, exceeds the capabilities of their professional health care software. They know from Yahoo and MSN the value of configuring a home page suited to delivering niche-information of their own preference. They know from using Word and Word Perfect that they can create precision documents merely by tweaking a template. They know they can use voice commands to make a phone call on their Blackberry.

They know that they can find drug information more easily on Google than proprietary software. They suspect that if their EHRs and EMRs had physician-specific home page functionality, that they could drop and drag orders, answer FAQs, dictate letters, and save time with templates with many fewer clicks. Ordering medications should be as safe and uncomplicated as using E*Trade.

Today most EHRs and EMRs are invasive both to workflow and finances. While high cost is a significant barrier to physician adoption, workflow disruption remains the killer deterrent.

An example demo patient, a return visit for an office visit, was typical enough: an obese, diabetic female smoker with a pulmonary problem. Everything was point and click: select, enter, click, read, post—again and again, over and over. The visit timed out at 30 minutes (their calculation, not mine) not including the time spent by a nurse’s clicks and front-office clicks. Allowing for physicians’ differing styles and based on difficulty, I’d expect this visit to take half that time. The record created was excellent. In private practice, at two patients per hour, and at this level of complexity—say 12 to 14 patients per day—one should expect bankruptcy. One would make a better living running a Dairy Queen.

A sign at a dry-cleaner’s shop reads: Low Prices, High Quality, Fast Service: Pick One. The point of EMR design is not to “pick one.” And, I am not advocating modeling medical practice after that in a remote mission clinic where the only record is a toe-tag, although I should recognize that mission outcomes are remarkably good. In the real world you get what you measure. If the metric is the chart, and you are willing to sacrifice time, then have at it. Also, in the real world, physicians are not usually on salary with no increment of production payment. Physicians do not hate high-tech and they do not hate computers. They hate wasting time; they cannot afford it, and neither can our health care system.

Monday, July 27, 2009

A Voice in the Wilderness

How many times do you or other specialists watch the current issues affecting medical care, and go back to seeing patients, either because of lack of interest, or more likely time pressures and patient care overwhelm your ability to deliver quality care to patients?

Specialists rely upon their societies to get the  news to the AMA via their specialty representatives or through their local and county medical societies and again through their state medical societies.  Is this effective?

CNBC Debate To Feature Sermo Physicians

Live survey results on CNN

Recently SERMO conducted a survey regarding physician opinions of the AMA's effectivenss in representing physicians. Does their public image and lobbying truly reflect the grass roots views.  SERMO's survey, although small seems to represent a far different view.  95% of the survey respondents said NO.  While there are some that this is  not a valid or scientific study, it does reflect a troubling issue brewing amongst physicians.  The study is biased toward physicians using "NEW MEDIA" , social networking and the internet.  Yet this is an important new vehicle which is more democratic than our previous organizational democracy. It also represents the young movers and shakers who will assume and be affected by health reform proposals.

For those of you unfamiliar with SERMO, it is a web based site with specialty sections.  It began with mostly clinical discussions about cases, and therapeutic interventions.   It grew over the past two years to include  practice mangement, political issues, ethics, philosophy, and medical issues. It is also a direct line to pharmaceutical companies, and others who can tap into the statistics developed from  comments on SERMO.

Be INFORMED, and render your opinions. !!

Thursday, July 23, 2009

The Nitty Gritty


The following is part of a series of original guest columns by the American Medical Association.

by J. James Rohack, M.D.

Physicians started this month with some good news from the White House. After intense AMA education and outreach, the administration announced that it would remove physician-administered drugs from the archaic formula used to determine Medicare physician payment rates.

This important development will significantly lower the costs of a permanent repeal of the current payment formula that projects yearly payment cuts to all physicians. This is key. There is no debate that the current formula is broken, but the cost of permanent reform has stood in the way of long-term action. Instead, Congress has stepped in at the eleventh hour for the last few years to stop yearly cuts to physician payments that would harm seniors’ access to care.

Over the years, spending on physician-administered drugs ballooned from $1.8 billion to $9.1 billion, growing three times faster than spending on actual physician services. When government number-crunchers add those figures into the physician payment formula, known as the Sustainable Growth Rate (SGR), overall physician volume appears to go up. The growth target in the formula is then reached sooner, sending payment rates down.

The irony is that physician-administered drugs should never have been part of the formula in the first place. Payment rates for drugs are not determined by the formula, and utilization is primarily driven by pharmaceutical advances and government policies. The AMA has long argued that it is not equitable or realistic to finance the cost of these life-saving drugs through cuts in physician payments.

Permanent Medicare physician payment reform must be part of comprehensive health reform this year. Medicare payments should cover the increasing cost of providing care so that seniors can be assured of continued access to physician care.

Members of Congress on both sides of the aisle have stated that the Medicare physician payment formula is broken and should be repealed. President Obama’s administration has helped clear the way to Congressional action by removing drugs from the formula.

J. James Rohack is President of the American Medical Association.

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Pandora's Box, Covert Rationing,

Last week Health Care Reform took a brief break surpassed by the passing of Michael Jackson. The news cycle remained in that mode for an unprecedented 72 hours.

This week confusion, chaos, and indecision reigns once again.

Numerous bloggers, official and unofficial weigh in on “Pandora’s Box”.

Dr Rich posting on Better Health:


Even with the soaring popularity of our new President, and the general feelings of goodwill projected toward him by Americans and non-Americans alike, and despite the fact that the party he leads holds large majorities in both houses of Congress, and despite the general agreement by both political parties and by all the major stakeholders in the healthcare universe that the time has finally arrived for substantial reform, one gets the sense that Mr. Obama is losing some of the initiative on his healthcare reform plan.

Some of the leaders in the Democratic party (who, really, are the only ones who count) have balked at the price tag that has been attached to the Obama proposals (estimated currently at $1.5 trillion over 10 years, and most admit this projection uses the rosiest of assumptions), and now they’re balking as well at the much-desired (by the Obama administration, at least) “public option,” the Medicare-like insurance plan for all……more, click above.

To see why, one simply needs to consider for a few minutes those alternate reform proposals now circulating amongst policy wonks. DrRich will briefly describe three of these alternative proposals, ones that seem to have gained at least some traction, and which may on the surface seem to be quite good (and thus the most threatening to the Obama plan). Then he will demonstrate why these plans simply cannot work.

The Healthy Americans Act, sponsored by Sen. Ron Wyden (D-Oregon), requires that individuals buy private health insurance that at a minimum would offer “Blue Cross standard” care. Individuals would be able to afford this insurance (which will be available to all regardless of age or medical history) because everybody would get a big raise (by statute) when their employers no longer have to buy it for them. People earning less than 400% of the poverty level would receive government subsidies to purchase their own insurance. The Wyden plan has the great advantage of having been “certified” as being budget-neutral by 2014 - so “officially” it would be a trillion or two cheaper than the Obama plan over the next decade.

The Patients’ Choice Act, sponsored by four Republican Congressmen (Coburn, Burr, Ryan and Nunes), also places ownership of health insurance in the hands of individuals, instead of the employers. Individuals will buy their own insurance, which will be available to all, and which will be available through one-stop shopping via state-run “regional insurance exchanges.” Families will recieve a tax credit of $5700 ($2300 for individuals) to purchase this insurance, and those with low-income would receive further subsidies. Those who do not make an active insurance choice will be automatically enrolled in a private plan paid for by the tax credit.

And finally (finally for this blog post, at least), there is Bob Laszewski’s proposal, the Health Care Affordability model. Laszewski is a noted healthcare blogger and well-respected policy expert, and accordingly, his proposal is being taken quite seriously by some members of Congress. Laszewski is so smart and his proposal is so detailed that one with DrRich’s limited capacity has difficulty getting through the whole thing. But essentially he proposes to have the feds set formal cost-cutting targets which every private health plan must meet. Those who fail to meet these targets will lose their tax advantages (i.e., companies that continue to provide their products will no longer get tax deductions). Clearly, this will provide a strong incentive for insurance companies to meet those cost targets, and healthcare costs will, accordingly, eventually come under control. Lazsewski emphasizes that his proposal is not really a stand-alone plan, but can be attached to any other plan that’s out there. It will simply give insurance companies the added incentives they need to actually cut costs.

Health Care Reform: Putting Patients First

Elected Officials Join America’s Top Medical Bloggers to Discuss the Real,

Clinical Impact of Health Care Reform

WHAT: As the health care debate heats up on the Hill, join Representative Paul Ryan as he sits down with top medical bloggers from across the country to discuss health care reform and its impact on practicing clinicians. This keynote discussion will be followed by two panels of physician and nurse bloggers who will highlight the importance of putting patients first.  Topics covered will include key barriers to health care quality, affordability, and access as well as the potential pitfalls of a new public plan and ways to fix the current system without investing billions in a new one.


Friday, July 17, 9:00 a.m. to 12:00 p.m.


The National Press Club, Broadcast Operations Center 4th Floor, 529 14th St. NW, Washington, DC


Keynote: Representative Paul Ryan, (R-WI), House Budget Committee Ranking MemberModerator: Rea Blakey, Emmy award-winning health reporter and news anchor, previously with ABC, CNN, and now with Discovery Health

Host: Val Jones, M.D., CEO and Founder of Better Health

Policy Expert: Robert Goldberg, Ph.D., co-founder and vice president of the Center for Medicine in the Public Interest (CMPI)

Primary Care Panelists:

Kevin Pho, M.D., Internist and author of KevinMD

Rob Lamberts, M.D., Med/Peds specialist and author of Musings of a Distractible Mind

Alan Dappen, M.D., Family Physician and Better Health contributor

Valerie Tinley, N.P., Nurse Practitioner and Better Health contributor

Specialty Care Panelists:

Kim McAllister, R.N., Emergency Medicine nurse and author of Emergiblog

Westby Fisher, M.D., Cardiac Electrophysiologist and author of Dr.Wes

Rich Fogoros, M.D., Cardiologist and author of CovertRationingBlog

And Fixing American Healthcare

Jim Herndon, M.D., past president of the American Academy of Orthopaedic Surgeons and Better Health contributor

clip_image002When the biggest retailer in the country says employers should be required to contribute to their employees’ health-care costs, even as business groups are pushing hard against such an idea, there’s sure to be a fight.

So, two weeks after Wal-Mart backed an employer mandate as part of health reform, the National Retail Federation has written an open letter, attacking the position. Here’s the WSJ’s story; here are a few choice lines from the letter itself:

Seeing the company in lock-step with the unions on this issue was troubling to say the least. Although the move may provide a short-term public relations boost to Wal-Mart, it could have long-lasting, devastating consequences to retailers throughout the country.

The letter’s core argument is that if employers were required to spend money on their employees’ health care, they would be forced to raise prices or reduce payrolls.

Wal-Mart’s own letter from two weeks earlier, co-signed by leaders of the union SEIU and a left-leaning think tank, argued that the current system, which leaves millions uninsured, is economically inefficient. The letter continued:

Not every business can make the same contribution, but everyone must make some contribution. We are for an employer mandate which is fair and broad in its coverage …

Health Blog Question of the Day: Should employers be required to help fund health insurance?

Speak to Me

by Rob on July 12, 2009

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The name of the conference is “Putting Patients First.”  So how can we have the audacity to say that we stand for patients without having patients on the panel?  Aren’t we just going to beat the drum of our own self-interest but do it in the guise of speaking on the behalf of the patient?

The danger is there.

I won’t pretend that I don’t have some selfish reasons to enter the healthcare debate.  I make my living off the system and a seriously flawed plan could significantly decrease my income.  I don’t want to earn less.  Is that selfish?  Of course it is!

So to make sure that I don’t go too far in that direction and so that I don’t have mistaken ideas of the patients’ perspectives, I want to open the floor for discussion.  I want to hear from patients, doctors, patient advocates, economists, llamas, mascots, and anyone else with opinions on the subject.  I will only say what I believe, but I am very open to change what I believe, understanding that what I think is based on my own limited experience.

I am very happy that folks like Duncan Cross will be at the conference and e-Patient Dave and others are wanting to contribute their opinion (this post stemmed from a Twitter conversation with Dave and others).  This is what keeps us honest.  I do intend on representing patients and feel that I have a lot to contribute on this issue.  I see thousands of people each month and have a wide range of experience with people’s problems with our system.  I really get angry when I see suffering as a result of the stupidity of our system; I have enough to deal with from the usual causes of suffering.  Our system is supposed to make things better, but it often does the opposite.

If you want to know where I come from, you can read the following:

  • Contrary to what you may hear, Medicare is highly flawed.  Dear Mr. President, Medicare Stinks
  • Healthcare is about doctor-patient interaction.  The system must maximize this.  The Oncoming Train.
  • Uninsured patients are a huge problem.  The Uninsured, Since You Asked, The Uninsurable (3-Part)
  • We need to stop paying for what doesn’t work.  Evidence
  • Not paying for unproven and/or ineffective treatments does not equal rationing.  Rationing
  • The current system makes docs decide between good care of patients and a better income.  All of us have compromised on this, and most of us feel very uncomfortable with that fact.  Temptation
  • The lack of communication within our system is killing people.  Blind Medicine
  • We can’t leave decision-making to politicians and special interest groups.  We will all need healthcare at some point, and we need to shape reform based on people, not politics.  Radical Moderation
  • Those who represent us are not like us.  They won’t be hurt if they make the system worse, and they don’t really know what goes on in real life.  We need to advocate for ourselves.  Why Blogging Matters
  • Trusting the insurance industry to fix the problem is the pinnacle of stupidity.  Rabid Wolves
  • Primary Care is central to reform, but usually gets left out.  Can I Play?
  • Epileptic emu farmers from Canada sometimes fret over windmills.  Return of the Llamas

That’s a lot of reading, I know.  Pick and choose.  The bottom-line is that I don’t care how the system gets fixed; I just want that fix to be what is best for the patients I take care of – one that lets me take the best care of them possible.

What do YOU think I need to address when in Washington?  You don’t have to agree with my opinions.  I want to know.

Physician Burnout Is The Biggest Threat To Healthcare Reform

by DrWes


It was supposed to be delayed gratification.

After all, that’s the American way: work hard, put your nose to the grindstone, get good grades, be obsessively perfectionistic, then you’ll be rewarded if you just stay with it long enough. It’s the myth that perpetuated through medical school, residency and fellowship, and our poor residents, purposefully shielded from the workload they’re about to inherit, march on.

But then they graduate and find that just as the population is aging, chronic and infectious diseases are becoming more challenging, health advances and potential are exploding. Just then, we decide to launch a full scale attack on physicians and their patients with increased documentation requirements, call hours, larger geographic coverage of their specialties, reduced ancillary workforce, and shorter patient vists.

Physicians get it - burn out and dissatisfaction are higher now than ever before. This is probably the greatest real threat to the doctor-patient relationship and health care reform discussions don’t even put it this on the table.

At the same time that we expect our doctors to be devoted, available, enthusiastic, meticulous and at the top of their game with perfect “quality” and “perfect performance,” while simultaneously cutting their pay, increasing documentation reqirements and oversight, limiting independence, questioning their professional judgment, and extending their working hours. We must become more efficient!


*This blog post was originally published at Dr. Wes*

Is Laughter the Best Medicine??

How important is blogging? Well, according to our American Academy of Medical Bloggers, it is essential to the survival of medical care as we would like it to be. (The AAOMB has just been founded by myself). The membership has expanded rapidly in the past week from 0 members to 1 member. Board certification is NOT required, and would actually place one at a disadvantage. I am the sole voter, and hold immediate veto powers over myself. I am inviting you to a tea party, during which I hope to be overthrown.

Were it not so serious our present condition is laughable. If laughter is the best medicine, (Norman Vincent Peale) would be hard pressed to apply our situation to better health.

AMA flip-flop

As I stated in one of my recent blogs, The American Medical Association recently did a 180 degree turnabout to support HR 3000. The American College of Surgeons today sent a letter also supporting HR 3000 .

The text of it’s support:

The American College of Surgeons has endorsed the House’s healthcare reform bill, joining the American Medical Association in backing the Democratic initiative.
“On behalf of the more than 74,000 members of the American College of Surgeons,” Executive Director Thomas Russell wrote in a letter, “I write to express the College’s support.”

What is not apparent in their letter of support is:

The house of medicine is far from unified in support of the House Democrats’ bill, however.
The American Association of Neurological Surgeons and Congress of Neurological Surgeons issued a statement opposing the legislation, citing their stances against the creation of a government-run health insurance plan and in favor of medical malpractice reform measures rejected by Democrats.
Likewise, a letter opposing the House Democratic bill is circulating among state-based medical societies. The missive could land in Capitol Hill inboxes on Monday. Apparently the “grass roots” is fed up with being mis-represented by their ‘societies’. Perhaps this too is a sign of the populaces’ opinions of their congressional representatives, who are so busy they don’t have time to read the very bills they vote upon.
Like the American Medical Association, the surgeons’ support is strongly tied to provisions in the House bill that would replace the formula that calculates how much Medicare pays physicians. This very narrow focus of the ‘societies’ would imply that physician interest is mainly tied to their pocket books.

Like so many issues the ‘devil is in the details:

“The current Medicare payment system, universally regarded as flawed, has called for pay cuts every year for nearly a decade, forcing Congress to enact short-term fixes. For 2010, the formula would establish a 21.5 percent cut without legislative intervention.
“One of the greatest threats to our health care system is the uncertainty facing physicians in Medicare, and H.R. 3200 takes important steps to address the problems posed,” Russell wrote in a letter delivered Thursday to House Ways and Means Committee Chairman Charles Rangel (D-N.Y.), House Energy and Commerce Committee Chairman Henry Waxman (D-Calif.) and House Education and Labor Committee Chairman George Miller (D-Calif.).
The new physician payment formula in the House bill would cost up to $300 billion over 10 years. The Senate Finance Committee is not considering a permanent fix to the payment issues, meaning that physician groups' endorsement of the House’s bill does not necessarily mean they will support the final healthcare legislation.”

1 x 10 to the ninth

A trillion here, a trillion there. In the words of Governor Bobby Jindall of Louisiana fame,

“This here is a fine pot of gumbo”.


He continues in his comments for the WSJ

“I honestly do not know one single individual who is happy with this situation. Not one. Not a Republican, a Democrat or an independent. These actions are all problematic individually, but taken as a whole, they are devastating. So against that backdrop, we enter the health care reform debate. I honestly do not know one single individual who is happy with this situation. Not one. Not a Republican, a Democrat or an independent. These actions are all problematic individually, but taken as a whole, they are devastating. So against that backdrop, we enter the health care reform debate. I know a little something about health care policy, and I can tell you exactly the game that is currently afoot. If the House Democrats’ plan were to become law, the president’s statement that “if you like your health care now, you can keep it” will not be true. This is not an opinion, this is a fact.”


I could not resist plagiarizing this from Dr Wes' blog.

An Open Letter To Patients Regarding Health Reform

By DrWes

Dear Mr. and Ms. Patient,
It has come to my attention that in order for you to enjoy success as patients in the new era of health care reform, you must start working now to prevent illnesses that might befall you. Do not, under any circumstances, eat or drink too much. Fast food might as well be considered illegal. Exercise three, four, five times a day, even if it means take time off from work. It goes without saying that you should not smoke. The government has data that demonstrates how you have become fat, lazy, and a huge burden on our health care system. Your non-compliance threatens the very fiber of our economy. Even employers realize this, and are using calculators to figure your financial burden to them.
Now, in the unfortunate circumstance where you might become sick, you will need to develop symptoms that follow a few simple rules. Do not, under any circumstances, develop symptoms that fall outside federal protocols developed based on comparative effectiveness research data. If you do, your doctors will face pay cuts, litigation, limited resources due to lack of funding for cost-ineffective technologies, and the scourge of discharge planners. Does the term "leper colony" mean anything to you?
Rest assured, if you fall into one of the areas studied under the guise of comparative effectiveness research and I apply all of the 153 quality care measures deemed necessary, according to the President I will not receive a cut in pay and you will receive exemplary care. Further, my nurse coordinator will be more than happy to answer your calls, see you in the hospital, answer all your questions and service your symptoms. After all, Mr. Peter F. Orszag, an economist and Director of the Congressional Budget Office feels they are equivalent to my specialist care and will serve as "productivity enhancements," saving $110 billion. See how patriotic you'll be?
Also, do not be a surgical case that has any risk of failure. After all, "Complicated Patient" is the new scarlet letter as we work to cut even more costs. Fortunately, thanks to the new multitudes of guidelines for care that we must follow, I will be carefully interviewing you to assure that you fit into one of several pre-determined renumeration bins called "bundles." Please don't confuse me with more than one major disease since there is currently no way to handle this circumstance. I would suggest you pick the disease that bothers you most.
Unfortunately, after years of clinical practice I have observed several clever patient stunts, like failure to respond to medications, unusual unforeseen infections, having an rare disease, and the like. I strongly recommend against these shenanigans as we move forward. It is in your best interest to not require long hospital stays, dear patient, or else.
I wish you the best as we move forward in this exciting time. Please feel free to contact my automated pool of nurse coordinators if you have questions. They'll each open your message, play a little "hot potato" with each other, and then contact you as our information technology system streamlines communication.
Stay healthy!


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Senator Tom Coburn's Bill SB 1099

I received an email from my good friend and colleague this morning. Jim Rowsey MD, a now retired academic physician (fellow ophthalmologist) has been working with Senator Tom Coburn (Okla), also a physician for the past several years. Dr. Rowsey, in response to one of my recent blog posts refreshed my memory on alternative proposals spearheaded by Dr. Coburn for health reform. It is published below:

“I am still teaching every state medical society that I can reach, or their Board of Trustees, and the subspecialty societies the value of Tom Coburn, MD's legislation Senate Bill 1099, (and House companion bill 2025) which covers tort reform, Medicaid reform, HSA, and a Patient Driven Health Care system. It the the point of action for physicians to take back control of health care. Jim Rowsey, MD cell 727-642-7017”

The WSJ Blog has this to say about reform:

Is closing military bases the model for health care reform?


Massachussetts has some “ less than original ideas”


Last evening I watched the whitehouse news conference, during which President Obama outlined his 'vision" for healthcare in America.  Unfortunately his speech had little specifics other than how wonderful life would be with his reform measures.

As in most political campaigns the message was what would happen if we did not adopt these changes. Surely the sky would fall. It sounds a bit like "Chicken Little".

The message from Congress is becoming quite clear. SLOW DOWN!

Providers, both in small practices and in large integrated health care organizations, such as the Mayo Clinic have exposed some basic flaws in reform measures being considered in Congress.

This from the WSJ Health Blog:

Mayo Clinic CEO: Medicare Payment Model Is a ‘Catastrophe’

Mayo Clinic, along with 18 other health care organizations around the country, sent an open letter to Congress on July 22.

Posted by Jacob Goldstein

Health ReformDenis Cortese, the doc who runs the Mayo Clinic, swung by the Health Blog’s office today to talk health reform. His bottom line, which he’s been repeating in public in the past few days: The big health-care bill unveiled last week in the House of Representatives misses a key opportunity to change the way Medicare pays for health care.

What’s more, Cortese argued, adding a new public plan that covers more people and pays for care the same way as Medicare won’t work, because the rapid rise in health costs will …continue. “A Medicare model is a catastrophe,” he said.

The basic argument Cortese and the Mayo Health Policy Center have been making for a while now is a variation on a familiar theme: Doctors and hospitals should be paid on the based value they provide rather than simply paid a fee for every procedure they do. Those who have better outcomes with less risk and fewer costs to the system should be rewarded.

Yes, it’s tough to value care for some conditions, but there are others where there are solid, risk-adjusted measures to evaluate patient outcomes. And Medicare could go a long way by starting with a few common conditions, such as diabetes and heart disease, Cortese said.

“Why don’t we give instructions to the Health and Human Services Secretary to start value-based purchasing right now in Medicare?” he said.

The message is clear: We must fix medicare first.  Any reform is doomed to fail based upon the flaws in medicare payment methodology.  Who  regulates medicare?  Congress supposedly does with advice from a number of groups, some  physician groups and many others such as AHRQ.   If medicare is any indication of how well Congress makes decisions. ?????

Friday, July 17, 2009

HR 3200

My conclusion regarding health reform was confirmed by the congressional budget office today. With the present plan there will be no savings. The plan as proposed does nothing to eliminate the parasitic bureaucratic insurance environment, nor the regulatory environment, In fact the plan would merely transfer these costs to the government. Unfortunately the AMA in an effort to boost it’s credibility came out today to support the House Bill. No surprise there….just when most sensible people rose up and told congress it’s too expensive.

Obama is creating a ‘health care crisis’ much as he did with the fiancial markets promising to pull it out with ‘stimulus funding’. Congress is begiing to say “enough is enough’.No one is going to be panicked into a hasty decision. Obama wants all or nothing at all.

It seems saner heads are prevailing, as well as the skeptical response of the public in general.

Unfortunately health care will have to wait further to see just how our economy will (if) recover. As evidenced by the state of affairs in California even those well established programs such as SCHIP are being curtailed or eliminated, and this in the largest and perhaps most affluent state in the country.

Nevertheless changes do need to be made, and sooner rather than later. The cry of ‘emergency’ and crisis are beginning to sound like crying ‘wolf’. That only goes so far….banks, equity firms, mortgage crisis, credit crisis, and financial scandals . Obviously all those responsible were not playing with their ‘own money’ This too would be an enormous problem with a universal, or public program.

The most imminent medical issue is that there are a lot of providers who are about to quit, retire, or find some other less stressful financial vehicle, even if it means living under a bridge.

The Death of the SGR

Way back in the early 90s the Sustainable Growth Rate was introduced to us by Congress and Medicare.  This would result in an annual reduction of physician's fees annually, unless congress took action to either eliminate that year's adjustment or postpone it until the next fiscal year.  After 4 years of 'deferrals' the amount  pending is 20%. In the midst of heated congressional examination and proposals for health reform, this 'adjustment' has not publicly been discussed.  It however is a major bone of contention amongst providers of medicare services.  It becomes more important in the face of other payors who base their reimbursements upon Medicare's fee schedule.

The SGR  includes the costs of drugs and other items billed by the      provider, and also the payments made to ambulatory surgery centers. These numbers are included in the calculation of provider expenses. Claims that provider payments have increased are largely due to these two amounts.  As we all know ambulatory surgery centers have literally exploded in volume, and pharmaceutical expenses have risen sharply as well.

In the past, not much has been made of this item.

Wednesday, July 15, 2009

HR Discussion Bill

I began reading the 850 page draft discussion bill for health care reform that the House of Representatives is now considering.

The bill is now in committee.

The contents of the proposal are frightening, and impacts not only reimbursements but also how, and what type and numbers of residency programs will be offered.  It usurps the role of established specialty boards and overides the goals of program directors. Every academic physician must read this document, and react immediately.  The content of the entire bill  goes beyond my limited time to discuss it's entirety here, but can be found at:

HR discussion Draft. Considerable length is given to the formation and administration of a "Health Care Exchange".  The extent of regulation and enforcement dwarfs the already present insurance company bureaucracy.  It is difficult to surmise how this will play out in terms of costs to the taxpayers of the United States.