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Saturday, July 31, 2010

Social Media ROI

Information Technology gurus often talk about Return On Investment or ROI. The term is used to assess the worth of IT investment, it's increase in productivity, or efficiency and it's long term ability to save on costs. 

It often is focused on the fixed capital investment and ongoing maintenance cost of purchasing and maintaining such systems.

Web-based Health 2.0 offers an immediate ROI.  ROI should be analyzed on the basis of what it does for you, the physician and your patient, not just a number based on dollars spent/dollars returned.  The numerator in that equation is close to if not zero.

If you substitute time as the numerator and results as the denominator it becomes even more apparent what health 2.0 offers you in your office or clinic.

Without notice the physician is able to lookup detailed specifications of medications, cross reactions,  in a fraction of the time compared to textbooks, and paper journals.  Google search or Pubmed search is an actual  world wide search.

Health 2.0 is driving advances in medicine and healthcare.

It is not a fad, and those who ignore it for much longer will be left in the dust.

The Mayo Clinic, an institution known for it's acumen in adopting new technology that has proven it's worth, has established a social media  presence.  May already has a significant presence on You Tube as a patient teaching media, and even on Twitter followed by 60,000 followers.

Admittedly this is a paltry following compared to more prurient interest sites such as Lindsay Lohan, Paris Hilton or Mel Gibson.

Twitter and Facebook have become more than social networks for communicating with friends.  It now presents a powerful platform for marketing and branding of products and services. It is more powerful than Google in that it provides an elective means of synchronous communications if chosen by participants.

And according to the Mayo Clinic, Social Media Networking presents substantial dangers due to it's inherent exponential Viral spread, much like a pandemic. 

What percentage of patients discover you via the yellow pages?

It is much more likely that they have found you on an online service via superpages, or an online listing in their health insurance website.  The classic paper yellow pages have become an indecipherable listing. The internet search engines allow a focused search for the individual patients. 


Thursday, July 29, 2010

Coalitions of Collective Intelligence

Thanks to the marvels of the internet and webinars I was able to attend the ACE  2010 event in Chicago from my well worn desk chair in my  den here in California.  Glen Tulman, CEO and extrovert of Allscripts was very good at analogizing much of health care with other industries, for example, Education.

Mr. Tulmann led off with the well worn exclamation that "Health is not a Commodity", but rather a "Community", which he compares to a coalescence of a collective intelligence.

During the webinar I was interrupted by a telephone call from "Dr Chronos", a new iPad EMR vendor.

I will return to that a bit later.

Mr. Tullman compared the manufacturing of a pencil with that of a computer.  It seems the pencil requires a significant amount of 'collective intelligence to bring it forth from a tree, deliver it to a manufacturing plant, grind it into a pencil along with the graphite core, apply the eraser with a band of metal and label it correctly as a No. 2  pencil, or whatever. Also don't forget the distribution process, packaging, marketing, etc.

He readily admitted the increased complexity of the computer and it's coalition of community involving Microsoft, Google, Wikipedia, You Tube, and Facebook.

While most computers have a common operating system, he correctly observes that Health Care does not have a common operating system.  He implies that what health care needs is an Operating System.

Mr. Tulmann also pointed out the disparity between professionals such as doctors and administrators, or business people, and compared to our teacher educators and their administrators.

Mr. Tulmann presented several projects where large dysfunctional or non functioning communities were revitalized block by block, one at a time. As an example he discussed Mr.Geoffrey Canada, a black American who was an instrumental leader in re-vitalizing Harlem in this same manner.  I can see this analogy as it applies  to  healthcare.

The presentation was broad, general and not very specific, although it seemed to be pointing toward the latest well-spring of governmental largess, health information exchanges.

He outlined several health systems goals in San Diego to integrate health data information retrieval. These are Scripps and Sharp Health System......

ACE 2010 was mostly a media event for Allscripts personnel, the marketing and sale force.  There were no really innovative ideas. It does however give one the sense of how the HITECH act has 'enabled' vendors' to sell their products.  Users are still skeptical...

US Healthcare vs UK N.H.S.


Recent reports from the UK indicate changes that will decentralize control from it's present organization and distribute accountability and decision making authority to physicians.

This story represents when individuals have little or no control over their working environment.


Oxford hospital child heart ops 'should stay suspended'

Caner Salih The report cleared consultant Caner Salih of any wrongdoing

Child heart surgery should remain suspended at Oxford's John Radcliffe Hospital where four babies died until improvements are made, a report says.

Surgery was suspended when four children died between last December and February, after being operated on by consultant surgeon Caner Salih.

The report found the deaths were not due to errors of judgement but Mr Salih was not given appropriate supervision.

Mr Salih was cleared of any wrongdoing by the report.

The independent report, commissioned by the South Central Strategic Health Authority (SHA), found there were problems in Mr Salih's induction and mentoring when he began work at the hospital.

All four deaths occurred shortly after his appointment.

He subsequently decided to stop operating and told the trust of his concerns, including a lack of support.

The SHA's chairman Dr Geoffrey Harris has apologised to the families of the babies who died.

"We offer our sincere condolences and we apologise that, in the cases, the standards of care were not what was expected," he said.


Continue reading the main story

Fergus Walsh

Fergus Walsh, BBC Medical Correspondent

At first glance this report has worrying echoes of the Bristol inquiry a decade ago.

Both dealt with the deaths of babies following heart surgery.

Both listed failings in the management of surgery and the poor culture of reporting concerns.

But the Bristol inquiry was on an altogether bigger scale and dealt with failures stretching over a decade during which time 29 babies died.

Doctors were struck off and a radical overhaul of paediatric heart surgery ordered.

In this case it was the surgeon who performed the operations who raised concerns and there is no suggestion that he performed poorly.

Action was taken within three months of the first death whereas at Bristol the high death rate continued for years.

Aida Lo, whose daughter Nathalie was one of the four babies who died, told BBC News: "It makes me angry because if they were not ready to do the operation they should have waited to do it.

"It's about human life.

"I can't believe it. It makes me sad. I have been crying, it has been very painful."

Mr Salih complained about the age of equipment and poor working practices at the paediatric care unit, asking for operations to cease, the report panel found.

The report does not criticise his care, saying "all the cases were complex and surgery was high risk".

It found that arrangements for clinical management were "less than adequate".

"In Mr Salih's four cases, we found no evidence of poor surgical practice, but that he would have benefited from help or mentoring by a more experienced surgeon; and that it was an error of judgment for him to undertake the fourth case," the report found.

It recommended an overhaul of the way the hospital deals with serious incidents, better clinical and managerial leadership and to develop ways to identify adverse trends in surgical outcomes earlier.

The hospital's children's heart unit is the smallest in England, carrying out just 120 or so operations a year.

The report also recommended that there needed to be an adequate caseload so surgeons "can maintain their expertise", by a mix of expanding the trust's service and forging links with another centre.

Sir Jonathan Michael, chief executive of the Oxford Radcliffe Hospitals NHS Trust, which runs the hospital, said the hospital had improved its procedures since the deaths.

Continue reading the main story

Aida Lo with daughter Nathalie

Aida Lo, whose daughter Nathalie was one of the babies who died, said the report was "very painful"

But he added he did not believe child heart surgery should remain suspended, saying the unit had "a lot to offer the NHS".

In a statement, the trust said it understood the past few months had been "difficult for the families of the children whose deaths resulted in this investigation".

"Children's heart surgery has been carried out at Oxford since 1986, with good outcomes," it said.

It said a review of clinical governance and risk management had begun in April to "streamline our internal systems and reporting lines".

"We recognise that in such a large organisation, processes can become over-complex and we are working to address this issue and ensure that we adopt a more uniform approach across the whole trust in the future.

"We want to be clear that where there are things to learn from the report published today, we will develop plans to tackle those issues as a matter of urgency."

It has until 17 September to report back to the SHA with an action plan.

The Care Quality Commission, which independently regulates health and social care in England, said the hospital was being monitored and its quality and safety standards were to be reviewed.

Meanwhile a helpline has been set up by the hospital trust for patient inquiries: 01865 572900.

More on This Story

Related stories

Competition for Medi-Cal Patients


Although many physicians do not accept medi-cal as compared to private insurance, there is a trend toward accepting medi-cal patients.

Strange as it may seem, a recent analysis of the number of physicians accepting Medi-Cal is on the rise.

Physician Participation in Medi-Cal, 2008 (1.12Mb)

Physician Participation in Medi-Cal, 2001 (800k)

Physician Participation in Medi-Cal, 1996-1998 (402k)

Read more:


Although these statistics seem to fly in the wrong direction, especially since physicians are so opposed to government intrusions into medical care there may be reasons this is occuring

1.The development of Managed Care Medi-Cal programs. This affords much easier billing and reimbursement guarrantees.

2. The shift from private small practices to larger medical groups, which afford more administrative support..

3. The real impact of decreased reimbursement by medicare and private carriers. 

4. The increasing number of patients who rely only on medi-cal for insurance. 

5. The increase in premiums for private insurance

6. The expansion of the CHIP program, and HealthyFamilys program.

Health Reform and the APPA will tilt the balance even further, if the states can even afford it. 

Wednesday, July 28, 2010

It Takes a Village.....

Recently I was sent an email regarding the development of "Healthy Howard".   No, it's not the "Truman Show".


Tech Firm, Howard County Partner to Help Uninsured

BETHESDA, MD (July 22) -- Howard County, Maryland, has enlisted local technology firm Healthcare Interactive to help manage its Healthy Howard program for uninsured residents.

"We're thrilled to count Healthcare Interactive among our partners in delivering critical healthcare services to Howard County residents who need them," said Liddy Garcia-Bunuel, Executive Director of Healthy Howard.

The program -- the first of its kind in the nation -- provides basic medical services at low cost to Howard County residents who cannot afford or obtain health insurance. For a small monthly fee, participants have access to primary care, discounted prescription drugs, emergency treatment, and inpatient hospital care, among other services. Concierge nurses and health coaches work with participants in their own homes and help them create personalized action plans for achieving their health goals.

Healthy Howard will serve as a model for the state-based co-ops and insurance exchanges that will soon be set up as a result of federal health reform legislation.

With Healthcare Interactive's innovative point-to-point (P2P) software, Healthy Howard administrators will be able to interact with beneficiaries as they receive care. The technology will also support the program's health coaching initiatives by connecting participants directly with healthcare professionals.

"It's critical that Healthy Howard's participants take steps to lead healthy lifestyles," said Dr. Peter Beilenson, Howard County Health Officer. "Healthcare Interactive's software will help us engage members directly and support their efforts to stay healthy."

"With Healthy Howard, we're working to build a model public health community right here in Howard County," said County Executive Ken Ulman. "Healthcare Interactive's technology will help us reach that goal."

"The Healthy Howard Plan is an exemplary way of expanding access to health care," said Henry Cha, President of Healthcare Interactive. "We're proud to help Howard County extend low-cost health services to those in need."


Howard County Executive Ken Ulman, Howard County Health Officer Dr. Peter Beilenson, Health Howard Executive Director Liddy Garcia-Bunuel, and Healthcare Interactive President Henry Cha are all available for interviews.

For more information or to set up an interview, please contact Melissa Garner at 202-471-4228 or  

About Healthy Howard

Healthy Howard Health Plan is a new program designed to connect Howard County residents to affordable health care services and help our community overcome barriers to healthy living. The Plan is not insurance, but offers basic medical and preventive care to eligible residents who would otherwise not be able to afford or obtain health insurance.

The Plan was created to address the Howard County administration’s goal of creating a model public health community. Even though the Health Department has been involved since its inception, the Plan will be administered through Healthy Howard, Inc., a non-profit organization.

About Healthcare Interactive

Healthcare Interactive is a software development company that has created a platform called Healthspace®, which is a development and integration platform for creating seamless healthcare applications. Healthspace has been used to create applications for employers, third-party administrators, PBMs, and disease management within both the private and federal industries.


Tuesday, July 27, 2010

What tha !?



Seems like Don Berwick was preaching to the wrong choir several months ago when he addressed an audience in the U.K.

Today, The New York Times announced,


LONDON — Perhaps the only consistent thing about Britain’s socialized health care system is that it is in a perpetual state of flux, its structure constantly changing as governments search for the elusive formula that will deliver the best care for the cheapest price while costs and demand escalate.


The new British government’s plan to drastically reshape the socialized health care system would put local physicians like Dr. Marita Koumettou in north London in control of much of the national health budget.

Even as the new coalition government said it would make enormous cuts in the public sector, it initially promised to leave health care alone. But in one of its most surprising moves so far, it has done the opposite, proposing what would be the most radical reorganization of the National Health Service, as the system is called, since its inception in 1948.

Practical details of the plan are still sketchy. But its aim is clear: to shift control of England’s $160 billion annual health budget from a centralized bureaucracy to doctors at the local level. Under the plan, $100 billion to $125 billion a year would be meted out to general practitioners, who would use the money to buy services from hospitals and other health care providers.

The plan would also shrink the bureaucratic apparatus, in keeping with the government’s goal to effect $30 billion in “efficiency savings” in the health budget by 2014 and to reduce administrative costs by 45 percent. Tens of thousands of jobs would be lost because layers of bureaucracy would be abolished.

In a document, or white paper, outlining the plan, the government admitted that the changes would “cause significant disruption and loss of jobs.” But it said: “The current architecture of the health system has developed piecemeal, involves duplication and is unwieldy. Liberating the N.H.S., and putting power in the hands of patients and clinicians, means we will be able to effect a radical simplification, and remove layers of management.”

The health secretary, Andrew Lansley, also promised to put more power in the hands of patients. Currently, how and where patients are treated, and by whom, is largely determined by decisions made by 150 entities known as primary care trusts — all of which would be abolished under the plan, with some of those choices going to patients. It would also abolish many current government-set targets, like limits on how long patients have to wait for treatment.

The plan, with many elements that need legislative approval to be enacted, applies only to England; other parts of Britain have separate systems.

The government announced the proposals this month. Reactions to them range from pleased to highly skeptical.

Many critics say that the plans are far too ambitious, particularly in the short period of time allotted, and they doubt that general practitioners are the right people to decide how the health care budget should be spent. Currently, the 150 primary care trusts make most of those decisions. Under the proposals, general practitioners would band together in regional consortia to buy services from hospitals and other providers.

It is likely that many such groups would have to spend money to hire outside managers to manage their budgets and negotiate with the providers, thus canceling out some of the savings.

David Furness, head of strategic development at the Social Market Foundation, a study group, said that under the plan, every general practitioner in London would, in effect, be responsible for a $3.4 million budget.

“It’s like getting your waiter to manage a restaurant,” Mr. Furness said. “The government is saying that G.P.’s know what the patient wants, just the way a waiter knows what you want to eat. But a waiter isn’t necessarily any good at ordering stock, managing the premises, talking to the chef — why would they be? They’re waiters.”

But advocacy groups for general practitioners welcomed the proposals.

“One of the great attractions of this is that it will be able to focus on what local people need,” said Prof. Steve Field, chairman of the Royal College of General Practitioners, which represents about 40,000 of the 50,000 general practitioners in the country. “This is about clinicians taking responsibility for making these decisions.”

Dr. Richard Vautrey, deputy chairman of the general practitioner committee at the British Medical Association, said general practitioners had long felt there were “far too many bureaucratic hurdles to leap” in the system, impeding communication. “In many places, the communication between G.P.’s and consultants in hospitals has become fragmented and distant,” he said.

The plan would also require all National Health Service hospitals to become “foundation trusts,” enterprises that are independent of health service control and accountable to an independent regulator (some hospitals currently operate in this fashion). This would result in a further loss of jobs, health care unions say, and also open the door to further privatization of the service.

  • Me?  I am moving to the U.K.

Thursday, July 22, 2010

More Transparency Hospital Comparisons


HHS has released the latest comparison of hospital statistics website with searchable data on outpatient surgical infections, heart attack treatment success and more." Data released Wednesday "appeared to bolster that argument, at least for heart attack patients," which showed "a drop in the national 30-day mortality rate for heart attacks of 0.4 percent to 16.2 percent for the three fiscal years of 2006-09." Also, the new healthcare law will "likely" give the comparison data "even greater weight" because some of the information may be used to calculate hospitals' reimbursements after 2013. 

The Hospital Compare website was created through the efforts of the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS), along with the Hospital Quality Alliance (HQA). The HQA is a public-private collaboration established to promote reporting on hospital quality of care. The HQA consists of organizations that represent consumers, hospitals, doctors and nurses, employers, accrediting organizations, and Federal agencies. The information on this website can be used by any patients needing hospital care.

Patients searching for a hospital will now be able to compare how much they rely on medical imaging procedures, which can carry dangerous levels of radiation.

Information on the procedures has been added to, an online tool that lets users analyze and compare data on patient care from more than 4,700 hospitals across the country.

I examined the website and it appeared to be well designed with easy and intuitive interface, and depending on your choice it will display results in either graphic or numeric results.

This tool will give patients a means of analyzing a hospital of choice.  Whether these statistics are accurate, and/or biased by the particular demographics of patient responses, which could vary significantly depending on the patient's expectations of care. The statistics are based upon the percentage.  of patients who rate the hospital at 8 or above. This particular chart did not rate outcomes. 

There are two tabs at the header, one for consumers (patients) and another for professionals. 

The professional tab offers an outcome rating, based upon PQRI requirements, found at QUALITY NET

These numbers are more objective, not based upon subjective assessments by patients.

These tools represent part of   The plan for Open Government, the details of which can be read here.

I believe most patients will select the hospital at which  their doctor chooses to practice , or by convenience, perhaps limited by distance and socioeconomics.

I'd like to hear your comments..GML


Monday, July 19, 2010

The Gloves are Off

The gloves are off!!  I have always been a moderate politically and at times liberal in my thoughts about improving society with some radical ideas about poverty, homelessness and other important human issues.  Despite the fact we are the most affluent country in the world we see signs of 'slippage' in our respect from the rest of the world. We have always been the most generous country offering aid to other countries in times of crisis.  That is why I am particularly disturbed that our administration refused aid from other nations at the beginning of the crisis.  What was that all about? Was it our pride about needing, or asking for help? The Norwegians who have much experience in deep water drilling in a much harsher environment offered help immediately.  Who ever was responsible for refusing their assistance was more than negligent in ignoring their offer.  Perhaps this rose to the level of  the 'philosopher king' of our country. 

On another front, near and dear to most of us as physicians, Docs4PatientCare is on a new campaign to inform our patients the sheer 'chutzpah' of the administration regarding Don Berwick's appointment to Head of CMS.

After reading this post and watching the VIDEO, please comment and write your representative that you want Berwick's appointment rescinded  pending a thorough mandated confirmation hearing.

Docs4PatientCare's message warns of "Medical Dark Age"

Sunday, July 18, 2010





Doctor 2.0

The recent Health 2.0 conference in June of 2010 had a diverse collection of participants.

The comments from these younger physicians emphasizes the true basic nature  of medicine, and the common thread of passion and enthusiasm of these internet ennervated physicians to use these tools to practice medicine.

Doctor 2.0 is a video dialogue with several physicians and how they have transitioned their practice(s) into the modern era.

Dr Jay  Parkinson

Dr. Enoch Choi

are well known enthusiasts for blending their medical expertise, caring manner with the tools of the time.

We need to look at adopting these ideas in all our practices, be leaders to move forward, and stop looking at all the negatives. My favorite saying has been "build it and they will come" (Field of Dreams).  

I like to say use it, and it will happen.  If we wait for our 'government ' to write rules and regulate, nothing will ever happen, and when it does it will self destruct.

Health 2.0 OnScreen  offered many interesting comments from physicians and non physicians.

The Next Generation of Doctors



The Next Generation of Doctors, is a topic which is timely for all of us who are past the age of 55, or so.  Whether we like it or not, we are on the 'way out'. Given the average age of 28-30 when we completed our training (if we did not stop along the way to breathe, or entered medicine as a second career, our days are numbered.

Like it or not I noticed when I reached age 55 I was definitely not the human being I was at age 25,35,or 45 years of age.  Despite the best of my intentions the last ten years and especially the last five  years gave me a clue that things had changed.


The development of information technology and EMR as one example sharply punctuates generations of  physicians. B.EMR, and A.EMR (before & after) clarifies the pre-internet and post internet era for me.

There would be no Health 2.0 were it not for the information highway and html. 

Looking at the introductory video from Health 2.0 conference in D.C. in June it will be obvious except to the dedicated luddite that 'we ' are on the way out....As an active practicing clinician I want to  help  prepare the next generation to do a much better job than we have done.  They are learning what has been done wrong.

The practice environment has changed drastically with dramatic increases in the elderly, and new expensive diagnostic and therapeutic choices.  We cannot use the old paradigm and business methods if we expect the system (and us) to survive.

In my next blogpost I will bring you another video from Health 1.0, It is named  Doctor 2.0

Friday, July 16, 2010

Bundle your cable TV, Internet and Phone Service with Health Information Exchange





See full size image

It ran through my mind about six years ago when this whole thing about RHIOs , EMR and Health Information Exchange began.

There were multiple attempts at forming business entities which were sustainable. Millions of dollars were spent setting up 'pilot programs'.  Attempts were made to reinvent the wheel.  There was more time and money expended setting up committees, seeking stakeholders and the like. Redundant non profit entities were required to access precious grant money to start some of these entities. Most failed miserably.

Even now in California there are multiple entities circling the wagons around each other.  (CAEC, eHealth, CALIPSO) I sit in on many of these meetings via webinars.  There are a lot of well meaning advocates , and 'techies' in these calls.

An intense feeding frenzy has developed around ARRA, HITECH and other governmental eponyms. Government has become a four or five-letter word.

Any fool should have been able to figure out reinventing a network was not necessary. We already had a great network, call it Verizon, Comcast, AT&T or whatever.  Plug in your EMR and off you go.  The key was and is software.  These networks are already technically capable of providing HIPAA security as needed.

The key is interoperability and that has been established by CCHIT certification. It's been around for four years. Of course now the federal government wants to usurp their developmental success and supplant it with an "equal opportunity" organization that is appproved by some governmental regulatory agency, like the NIST. 

The reward for all the hard work of EMR vendors, and voluntary industry people is cancelled out by the 'do-gooders' in D.C.

Negative reward is always the fallout from governmental -come- lately- to the table, initiatives.  They sap entrepenurial initiative, investment and commitment to success rather than 1000 page documents  written by the government. 

So what happens now to the 40 or more vendors who have CCHIT certification, and the thousands of medical practices already invested in these ' legacy systems"?  Undoubtedly they will be grandfathered in in order to satisfy medicare requirements for meaningful use to meet the governments (read medicare) requirements for incentive payments.  44,000 dollars is not a great incentive, nor adequate for someone to discard a system that perhaps cost 100,000 dollars last year or the year before.

Well, back to my comments on the 'original network(s) Verizon,Comcast, or Charter.

Verizon has publicized it's involvement with MedVirginia. It is co-labelling it's HIE product with several other EMR vendors..

MedVirginia and Verizon have already partnered using the NHIN to link with Social Security for processing Disability Claims and medical records

Actually when one thinks about their 'offering' HIE, and/or Regional networks become superfluous and redundant.

Any practice EMR can 'plug in their cord and 'dial up" anywhere Verizon or a like system is in place.

Keep it Simple, Stupid !!!!  K.I.S.S.

As for me I am buying  VZW .  I thought of this five years ago, where is my cut?

Thursday, July 15, 2010

If Lawyers worked like Doctors

Dr. Wes in a column from October 2009 writes a 'parody' on attorney billing. If you read it, you will chuckle....

I have a few other 'regulations' for attorneys.

Pass the Affordable Plaintiff and Defendant Act.

Establish legal preferred practice patterns

Establish evidence based legal decision making

Establish quality review and payment guidelines for outcomes.

Establish "never events" which allow clients to refuse payments to their counsel.

Incentivize attorneys to utilize legal information technology with decision making algorithms.

Encourage further the development of 'managed judicial organizations (MJO) and/or accountable judicial organizations (AJO)

Establish a sustainable growth rate formula (SGR).   This would include a built in 5% a year decrease in reimbursements, subject to a six month hold while waiting for congress to delay the changes.

Establish and publish on the internet a directory of all attorneys and a rating by clients. Call it "Legalgrades" Post uncorroborated complaints from clients about the attorney or the firm.

Establish 100 not for profit foundations and/or study groups to make recomendations to improve efficacy and safety of legal judgments. 

Establish a National Lawyer Database (NLB) to report the win/loss statistics and any disciplinary actions (to be posted on the internet) and other untoward events.

Require a search of the database prior to any legal actions posted by any attorney.

Require attorneys to become credentialled annually at the BAR for individual courts, and charge them annually for this privelege.

Washington and the Parasitic Economy

Following in the distinguished footsteps of Microsoft and Google, Apple is the latest innovative company to be targeted by politicians and regulators for being too successful. Will it be sucked into Washington's "parasite economy"?  Has medicine become a part of the government's parasitic economy?

David Boaz of the CATO Institute explores the history of success in America.

For more than a decade, Microsoft went about its business, developing software, selling it to customers, and — happily, legally — making money. Then in 1995, after repeated assaults by the Justice Department's antitrust division, Microsoft broke down and started playing the Beltway game — defensively at first.

Washington politicians and journalists sneered at Microsoft's initial political innocence. A congressional aide said, "They don't want to play the D.C. game, that's clear, and they've gotten away with it so far. The problem is, in the long run they won't be able to."

And Microsoft got the message: If you want to produce something in America, you'd better play the game. Contribute to politicians' campaigns, hire their friends, go hat in hand to a congressional hearing, and apologize for your success.

A decade later, it was Google. After a humble start in a Stanford dorm room, Google delivered a cheap and indispensable product and became the biggest success story of the early 21st century.

Politicians, seeing an opportunity to extend their power and rake in some campaign cash, are circling like sharks. When both Apple and Google declined to attend a Senate show trial on Internet privacy, Sen. Jay Rockefeller (D., W.Va.) growled, "When people don't show up when we ask them to . . . all it does is increases our interest in what they're doing and why they didn't show up. It was a stupid mistake for them not to show up."

And that's what politicians and regulators are costing America: The brilliant minds of Silicon Valley and Redmond, Wash., are going to waste time and energy on protecting their companies instead of thinking up new products and new ways to deliver them to consumer


Does any of this sound familiar? For the past fifty years our patients enjoyed the best of healthcare and incredible advances in science and health. The miracles of antibiotics, vaccines and advanced cardiac treatments have  extended life to the point where degenerative diseases have replaced infectious disease as the major end of life events leading to death (in an extended manner)

This measure of success is discounted and totally ignored as the source of increased expenses for health care in America.

In the past physicians have largely ignored this parallel in general business and health finances. However the interest in pandering to political expediency peaked during the past debate on health reform.  Medicine showed up at the hearings and for several decades have attempted to 'lease' representatives interest with PACs and lobbying efforts.

Well, medicine is now wasting it's time and energy protecting itself and patients. Brilliant minds are also leaving patient care and clinical research to pursue other less stressful and more innovative methods to treat  patients. 

This sounds very familiar with Dave Boaz's analysis of the " Beltway Game."

It would be interesting to find out how you think about this analogy??

Wednesday, July 14, 2010

Bad Medicine

In a white paper written by The Cato Institute, Bad Medicine...A Guide to the  Real Costs.....elaborates on the true cost of the health reform act, and it's secondary consequences:

Simply having insurance is not enough to satisfy the mandate.

More than 2/3 of companies could be forced to change their insurance coverage

Some of the mandated changes may have unintended consequences.

As many as a million workers could lose their health insurance coverage they have now.

Tennessee's experience with TennCare gives a precautionary tale.

The phase-out of these benefits imposes a high marginal tax penalty

All together these changes produce an enormous increase in the welfare state

Plans offered through the exchanges must meet minimum federal standards

President Obama has been hostile to consumer directed healthplans

The fate of HSA's depends upon ruling by the Sec'y of HHS.


The Cato Institute was founded in 1977 by Edward H. Crane. It is a non-profit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of libertarian pamphlets that helped lay the philosophical foundation for the American Revolution.

In order to maintain its independence, the Cato Institute accepts no government funding. Cato receives approximately 75 percent of its funding from individuals, with lesser amounts coming from foundations, corporations, and the sale of publications. The Cato Institute is a nonprofit, tax-exempt educational foundation under Section 501(c) 3 of the Internal Revenue Code. Cato's 2007 revenues were over $24 million, and it has approximately 105 full-time employees, 75 adjunct scholars, and 23 fellows, plus interns.


The Cato Institute’s nationally and internationally recognized Centers and Projects tackle a wide range of topics, including health care, education, environment and energy, foreign policy, and international human rights. Scholars in these Centers and Projects vigorously apply America’s founding principles to key issues of the day, and are committed to countering the continued expansion of government beyond its constitutional constraints, and to confronting escalating attacks on individual rights.

Center for Constitutional Studies
Center for Educational Freedom
Center for Global Liberty and Prosperity
Center for Representative Government
Center for Trade Policy Studies
Downsizing the Federal Government
Project on Social Security Choice

Tuesday, July 13, 2010

Health Train Express Resumes Publishing

Things seem to be working again. I spent the greater part of the past two days getting things back up and running.

After my blog platform disappeared from my menus and a number of dead desktop icons, several freezes, virus scans, and other disconnected events, and after removing several programs, re-installing several programs, which failed to load, defragmentations, etc I did a restore to several weeks ago and all is fine. It interrupted my writing schedule and diverted my attention, worrying all the while if it could be fixed, how much data I would lose, etc and  even the fear of having to replace it with  a new system.  '


Fortunately for me I had a disaster plan....I had an external drive with backup and also an online backup.  My onsite backup runs automatically twice a week, and my online backup is continuous as needed. Onsite backup has it's own dangers, and at times fails. An online insurance backup is not expensive, (about $ 100/annum)

It is a great sense of comfort, and I lost no data.

I bring this up because it really relates to developing total dependence on electronics.  Sooner or later it will go 'south'

If  you are in a significant size group  you probably already have expert IT support, if you are solo or a small group it can be a challenge to keep backups and disaster plans implemented and more important used on a regular schedule.  It might even be worthwhile to have disaster drills, just like fire drills.

An EMR disaster abruptly changes the focus of the practice for the manager and the doctor.

I have had it happen to me, despite  best intentions.  My staff was not performing regular backups, my vendor was unreliable, and often unavailable.  I learned a lot about computers, software as a matter of necessity. Besides losing income and losing time, it created havoc in my mind. Having a system in place is the first step, testing and using it is also vital. In todays' much harsher reimbursement environment a small blip can rapidly unravel into disaster financially.

Many of us are being diverted by all the talk about 'incentives' and meaningful use for EMR.   Another important issue is  whether your system works for 'your practice' and if it is designed to be reliable,have fail safes and totally reliable tech support from your vendor or a reliable local source.

Remember, the introduction of EMR and HIE will mean more complication...eventually.

However I think the horse (or is it cow) has left the barn.

Monday, July 12, 2010

Non Publishing Notice

Due to technical difficulties Health Train Express will not be publishing for the next 48 hours.  I know you will all be broken up about missing one of my rants.   Blame it on 'Windows'.

Friday, July 9, 2010

Re-distribute the Wealth


Don Berwick's commandered appointment to be head of CMS seems to have only caused a flicker of congressional shock.

Some of this may have been their own reticence to start the confirmation process, because Max Baucus had not yet scheuled the hearings.  Perhaps the Republican leadership should learn that political stalling and meandering only lead to surreptitious acts. The Republicans are not alone in this form of political extortion and deal making.

Berwicks' candid and open opinion that health care  reform should 'redistribute wealth, and that is one of it's primary missions".  (See The Video, below)

That statement  is one that neither I nor most doctors have ever heard from a highly appointed M.D.  I can accept that health reform should 'transform, and perhaps open access to those who are not yet covered. "   If this is a true 'redistribution of health care, or wealth, then someone else will get less access or treatment.

Redistribution of wealth or health care is a euphemism for 'rationing'.....'with your eyes open'. 

Essentially Don Berwick has become the 'lap-dog' for the socialist agenda of Barak Obama.  Dr. Berwick has been a respected member and head of many organizations that are held in high esteem by the government for advice.  [the Institute for Healthcare Improvement (IHI)[1], a not-for-profit organization]He has been awarded many  titles, and is a professor of pediatrics.

Obama's actions in health care is juxtaposed to his bail our of financial markets and the automotive industry.  In those cases the wealth was 'redistributed' toward the already wealthy barons of finance and industry.

Never before has the head of CMS (who is basically supposed to be an administrator, and not a policy maker), a function which should be left to the congress acted in such a manner.

The combination of the Affordable Patient Care Act and it's mandates for the Head of HHS to do certain things and the appointment of Don Berwick to CMS  are a double pronged attack on the freedom of patients and physicians to make choices. Make no mistake about it we all have lost much.


Hopefully when and if confirmation hearings do occur when the Congress resumes they will oppose the nomination.  Hopefully public opinion and backlash from those in the trenches will keep this issue in the headlines.  I doubt it....the attention span of the media today is about 24 hours.

A sad day for the American Dream

Richard Reece MD in his Blog Medinnovation asks;

"How should physicians respond??"

Thursday, July 8, 2010


Finally, a Medicare/Medicaid Chief

Published: July 7, 2010

The New York Times  Op - Ed, today


"President Obama made a sensible move Wednesday when he bypassed the Senate and appointed Dr. Donald Berwick, an expert on reducing health care costs, to oversee Medicare and Medicaid. Republican senators had made it clear that they would use confirmation hearings to distort his record and rehash their arguments against the recently enacted health care reforms, mostly to score political points for the November elections.

By using his power to make recess appointments while the Senate is on vacation, Mr. Obama put Dr. Berwick in a position of vital importance in implementing the new reform law. His appointment will run until late 2011, giving him time to get things moving before he would have to be renominated. The Centers for Medicare and Medicaid Services, which Dr. Berwick will run, has been without a permanent administrator since 2006.

The obscure but influential agency runs two huge public insurance programs that will play central roles in health care reform. The new law requires Medicare for older Americans and the disabled to become more efficient and to serve as a testing ground for innovations to improve the quality and lower the cost of health care, the core of Dr. Berwick’s professional interests. Reform will also entail a big expansion of the state-federal Medicaid program for the poor, requiring strong guidance and leadership from Washington.

Dr. Berwick’s major credential for the job is that he leads the Institute for Healthcare Improvement, a consulting group that promotes measures to improve the quality and safety of health care while reducing its costs. He has been enormously successful at getting health care professionals and institutions to work together to reform their practices — exactly what the agency needs.

His appointment is backed by the American Medical Association, the American Hospital Association and scores of other health organizations and patient advocacy groups. He has been endorsed by three predecessors who held the same job in Republican administrations.

Even so, some Republican senators have portrayed Dr. Berwick as a proponent of socialized medicine because he has expressed great admiration for Britain’s National Health Service. They also call him an advocate of rationing care and even suggest he favors “death panels,” a politically potent falsehood.

Yet Dr. Berwick spoke an obvious truth when he declared that “the decision in not whether or not we will ration care — the decision is whether we will ration with our eyes open.” Care is already rationed by insurance company decisions about what services to cover and by high prices that make insurance and medical care unaffordable to millions of Americans.

Senators jealous of their prerogatives in confirming presidential nominations are grumbling about being bypassed. But there is no telling when or whether the Senate would have been ready to confirm Dr. Berwick. The job is too important to leave open any longer. "

For the record, a serious conversation about Berwick’s qualifications and plans would have been worthwhile. I’ve heard even people sympathetic to Berwick question whether his administrative experience is adequate. But, again, it’s hard to have a serious conversation when one of the two political parties refuses to be serious.

The Dems were well within their rights to use the recess appointment mechanism (as the Bushies did hundreds of times in their day), just as they were to use the reconciliation mechanism to pass the healthcare reform bill. Of course, the GOP is now completely free to paint the Berwick appointment as unacceptably anti-democratic. Who’s right? Who cares? The voters will ultimately decide.

Some or all of the above may be true, but why the rush to the appointment.  Some of those recommendations come from previous temporary heads of CMS. So, why didn't they keep their job?

The American  People deserve to hear the questions from their elected representatives, and answsers from Dr. Berwick, both about positive and negative attributes of this highly achieved and touted academician.

It has been shown the AMA represents only about 115,000 physicians out of over 800,000 physicians, most are students,  and academicians.

Senators are not 'jealous of their prerogatives" they have the sworn duty to represent their constituents.

As  usual the NY Times is highly biased in favor of liberal social agendas, rather than expressing any discontent with President Obama's wanton disregard of procedural matters.


Your Health on the Ballot Box

So, how are you going to like your health care on the ballot?

Would you like a Republican diagnosis, A Democratic diagnosis, or perhaps the Libertarian or Independent opinion?  Worry not, no matter what the decision it will take months to implement, if it is funded, at all.

The situation in Massachussetts is dire.


Mitt Romney signs health-care reform into law as Ted Kennedy (third from right) looks on, April 2006.

U.S. President Barack Obama (C) is applauded after signing the Affordable Health Care for America Act during a ceremony with fellow Democrats in the East Room of the White House March 23, 2010 in Washington, DC. The historic bill was passed by the House of Representatives Sunday after a 14-month-long political battle that left the legislation without a single Republican vote.

U.S. President Barack Obama (C) is applauded after signing the Affordable Health Care for America Act during a ceremony with fellow Democrats in the East Room of the White House March 23, 2010 in Washington, DC.

 And in large measure Obamacare is on the same path.

Rago of the Wall Street Journal has this to say:


President Obama said earlier this year that the health-care bill that Congress passed three months ago is "essentially identical" to the Massachusetts universal coverage plan that then-Gov. Mitt Romney signed into law in 2006. No one but Mr. Romney disagrees.

The state's universal health-care prototype is growing more dysfunctional by the day, which is the inevitable result of a health system dominated by politics.

In the first good news in months, a state appeals board has reversed some of the price controls on the insurance industry that Gov. Deval Patrick imposed earlier this year. Late last month, the panel ruled that the action had no legal basis and ignored "economic realties."

Sure enough, the five major state insurers have so far collectively lost $116 million due to the rate cap. Three of them are now under administrative oversight because of concerns about their financial viability. Perhaps Mr. Patrick felt he could be so reckless because health-care demagoguery is the strategy for his fall re-election bid against a former insurance CEO.

The deeper problem is that price controls seem to be the only way the political class can salvage a program that was supposed to reduce spending and manifestly has not. Massachusetts now has the highest average premiums in the nation.

Liberals write off such consequences as unimportant under the revisionist history that the plan was never meant to reduce costs but only to cover the uninsured. Yet Mr. Romney wrote in these pages shortly after his plan became law that every resident "will soon have affordable health insurance and the costs of health care will be reduced."

One junior senator from Illinois agreed. In a February 2006 interview on NBC, Mr. Obama praised the "bold initiative" in Massachusetts, arguing that it would "reduce costs and expand coverage." A Romney spokesman said at the time that "It's gratifying that national figures from both sides of the aisle recognize the potential of this plan to transform our health-care system."

Perhaps Mr. Obama never took Economics 101 at Harvard. He has certainly never run a business.

What do you think?

Tuesday, July 6, 2010

Wellness Wiki.....What is?

About five years ago I was asked to participate in the founding of the "Wellness Wiki".  This was during the dawn of the age of HIT.

Several luminaries participated in this early talk about wellness, and health care transformation.


Welcome to the Wellness Wiki! We offer this wiki to help clarify the complex problems plaguing the U.S. healthcare system and develop sustainable ways to improve the health and well-being of all people. This virtual encyclopedia of the healthcare crisis and potential remedies. We welcome your comments! To become a contributor, please contact Dr. Beller

The program of which I was privileged to have my name put on it (with little real contribution, other than an enthusiastic "go for it" from me) now is on  and is available for purchase at the web site.

It is well worth the read, from two experts well ahead of the curve.

Hospital Staff Priveleges:

Why I no longer belong to hospital staffs:

The Happy Hospitalist explains the byzantine maze required to see and treat patients.

Bill Gate’s web experience: Byzantine, idiotic logic

A medical license has always been an earned privilege. We are given the privilege of hospital staff memberships. However things have taken a terrible turn for the worst. At this point the hospitals should consider it is their privilege to have me on their staff. I agree with Happy that there is now a lot of “crap” in the system. Someone has made or is making a lot of $$$ producing software, and/or meetings for medical staff offices to ‘automate” their credentialing system. A great deal of information requested is repetitive and could easily be stored in a central location for medical staff credentialing purposes.




In their own words;

“CAQH, an unprecedented nonprofit alliance of health plans and trade associations, is a catalyst for industry collaboration on initiatives that simplify healthcare administration. CAQH solutions promote quality interactions between plans, providers and other stakeholders; reduce costs and frustrations associated with healthcare administration; facilitate administrative healthcare information exchange and encourage administrative and clinical data integration. provides the same type of services for physicians to become credentialed by health insurance companies.”

It just keeps on getting crazier. Physician credentialing software is out of control. Physicians now pay hundreds of dollars a year in government regulatory licensure fees. Doctors pay thousands of dollars to take the test. The test is a board exam documenting the physician's expertise in a field of medicine so they can hang a certificate on their wall that most patients will never see.

Physicians who take the test are supposed to be certified as experts in their field of practice. So why are physicians forced to jump through miles and miles of expense and complicated credentialing processes for every hospital they would like to see patients at?

For physicians to do a hospital admission or daily visits or procedures inside a hospital they must first obtain hospital credentials. In other words, if there are five hospitals in town and a physician wants to be able to see patients at all five hospitals, they must apply for the right to practice medicine within all five hospitals.

* It's not good enough to pay your money to your state licensing authority every year for the right to practice medicine.

* It's not good enough that most states require physicians to complete at least 50 hours of uncompensated continuing medical education (CME) every two years just to apply for a state medical license.

* It's not good enough to pay $500 every few years to the federal government for the right to prescribe medications.

* It's not good enough to pay several thousand dollars and spend hundreds of hours of uncompensated study to get your board recertification every few years.

Nope, none of that is good enough. To practice medicine inside the walls of a hospital, the hospital must then grant you the privilege of seeing your patients at their hospital. Every hospital has their own set of rules. Every hospital has their own credentialing committee that meets to give the yeah or nay to new staff appointments. Every hospital has their own physician credentialing software that guides them in their search for red flags.

I recently applied for hospital privileges to another hospital. Happy's billing company takes care of all the credentialing requirements for insurance companies and hospitals. In this case, they sent me a packet of information almost 40 pages long. They mark everything I need to sign with tiny little sticky pads. About 10-15 tiny little sign and date here sticky pads dotted the hospital credentialing paperwork. Forty pages of legal mumbo jumbo.

A lot of this physician credentialing software delves into your past history. Where did you train? What are your previous practice experiences? What procedures can you prove proficiency in? What procedures would you like to be credentialed to provide? What are your last three residential addresses? Have you ever been charged with a crime? Have you ever been convicted of a drug or alcohol related offense? Have you ever been sued? Not lost a lawsuit, just sued. Have you ever been treated for depression? There is some pretty personal information that gets requested on these hospital credential applications. Next thing you know, they'll want to know my sperm count.

Imagine the legal fallout hospitals must be worried about by allowing doctors who have been sued from seeing patients? Could they be held liable for allowing a bad apple to practice medicine in their walls. A physician who has been licensed by the government and certified by their specialty society as an expert capable of providing excellent care?

There are many ramifications for settling a lawsuit because it's cheaper just to make it go away than to fight for what you believe in. Would that prevent you from obtaining hospital credentials or perhaps even cause a hospital to revoke them?

Physician credentialing software these days must be based on an overwhelming mountain of legal fear. One of my partners failed to disclose a minor in possession ticket (MIP) during her teenage years. After failing to disclose this ridiculously unimportant legal request, her hospital credentials were delayed for weeks, perhaps months in order to send letters and appear in committee meetings to explain herself.

One local physician even told me that another colleague at another hospital had failed to disclose that he got a ticket for fishing without a license. That's right folks. A ticket for fishing. When he failed to disclose this dastardly deed on his hospital credentialing paperwork, his approval was denied and delayed. Unbelievable.

This is what the legal environment of doctors and hospital credentialing has become. MIPs and fishing licenses. The fear in medical credentialing is out of control.

In a new one for me, physician credentialing software asked me how many children live in my home and if I'd ever lived with any children in the past. The title of the document I was to sign had to do with any previous allegations or arrests for child abuse or sexual assault. Now the hospitals want to know if I have any children in my home. What has this world come to?

With such a large volume of legal detective work being done on every physician credentialed at every hospital, one has to wonder how is it even possible for a bad apple to fall through the cracks. If you have a hospitalist seeing you at your hospital, you can rest assured their past has been raked through the coals and their history and credentials have been picked apart by government agencies, specialty societies and even the hospital you find yourself in. And absurdly so.

HAPPY HOSPITALIST, I hear your angst.........and there is hope

Credentialling Solutions

which offers this service.

Blogs | Reporting on Health

Blogs | Reporting on Health

Friday, July 2, 2010

Happy Independence Day

The freedoms to practice medicine...........................

4_july_independence_day.gif image lucky_thir13en

It's that time again, the anniversary of the "birth" of our nation. The 4th of July means many things to many people. For our warriors away from home it memorializes what our country is all about. "FREEDOM" 

When I was younger I did not appreciate fully how challenging it is to establish and maintain "FREEDOM'  The seed must be planted in  fertile ground, watered and fertiilzed.  Neglecting the plant and not watering it will result in withering and death.

One of the best fertilizers for "FREEDOM" is the diversity, discourse, and  strong disagreements among it's citizens.  Just like the first law of thermodynamics, organizations tends to descend into chaos without  adding more energy. 'FREEDOM' will always require energy to maintain.

And while our economy is suffering, "FREEDOM" remains strong. It however is endangered by the crisies, real or manufactured.

Governments may be induced to suspend "FREEDOM" in the interest of public safety, and disasters.

Our leaders must be attentive to this emperative and not lose focus dealing with the daily challenge of meeting health care needs, fixing economic markets, and sustaining productivity.

Our founding fathers were true geniuses, establishing a tri-partite government, with each body carrying equal weight in the equation.  It is the duty of the congress to regulate and challenge the executive branch.  The Judicial branch serves to analyze and apply law to certain conflicts with it's opinion(s).

The President is supposed to lead the people,  but not the congress.  Congress is supposed to have a mind of it's own.

Freedom and health care go hand in hand. It's always been a lightening rod for disagreement in the United States, when governments steps in.

Are our leaders who are sworn to defend the constitution and our borders violating their oaths for political  purposes?

As we all enjoy our hamburger's hot dogs, ribs, chicken and other barbecue goodies,  think of the marinade as the "freedom" we have the fortune to live in. Think of the ketchup as the  blood shed to guarrantee our freedoms. Think of the mustard as the gold or riches of our freedoms.

God Bless America,  my home  sweet home.

Thursday, July 1, 2010

Primary Care--What are the Barriers?

Last week I was invited to join Hope Street Group 2.0 which is focused on economic opportunity for professionals and practitioners. It covers a variety of areas.  One of them is health care.

They posed this question:

Re: What do you think is the biggest barrier to innovation in primary care?

Aaron Doty and Sarah Steinhofer  enumerated the following: (Hope Street 2.0)

"It is possible to point to a  number of barriers that limit the spread of innovation in primary care  (see some examples below).

Examples  of barriers to innovation in primary care

  • Variations  across states in scope of practice regulations
  • Reimbursement  rules and lower earnings overall limit the attractiveness of primary  care specialties
  • Current training and practice in silos does not  support team-based work
  • Malpractice insurance rules discourage  part-time work, especially for retirees
  • Inadequate  access/utilization of health IT – telemedicine, electronic  communication, EHRs – restricts access in rural/underserved areas
  • Administrative  burden of care coordination
  • Design of new payment models is  complex
  • Payment models (such as pay-for-performance) may  incentivize shedding of sickest patients, or penalize those providers  with more chronic & complex patients
  • Lack of data analysis  capacity

Barriers  to the spread of particular models:
Retail clinics – concern  about fragmentation of care coordination, concern about loss of revenue  by other providers, lack of shared electronic record with PCPs
Accountable  Care Organizations – limited number of demonstration projects – new and  unproven payment mechanisms, lack of consistent specifications,  antitrust: perceived risk of collusion in the guise of care  coordination, loss of revenue from emergency presentations.
Patient  Centered Medical Homes – lack of clarity about essential features to  ensure quality outcomes, sustainability of savings unproven –  quality-funding link not built into the model, access to well-trained  care coordinators.""


I also suggest these additional issues:

In order to address the problem, one has to evaluate and anlyze what has caused the dramatic shift from general practice to specialty care, issues as great as reimbursement are only one part of the challenge..

Most analysts enumerate the disparity between specialty care and primary reimbursment, and  more administrative issues in primary care

I added these additional issues and challenges:

Several factors have been at work over the past fifty years.

1.The urbanization of America has caused a flight of young and old to the urban areas to seek out 'culture', diversity,access to health care and economic opportunity .  This has caused a well known  phenomenon of an economic shift from small towns to larger metropolitan areas.

2. Our challenges in primary care have followed this trend.

3..Some of these  problems involve the social and economic millieu in which highly educated professionals desire to work, live and recreate.

4. No one can challenge the fact that physicians are amongst the most highly educated members of society.  This is not just a technical skill, but by exposure to multicultural diversity, general fund of medical and social, political knowledge.  Physicians do want to serve, however are very reluctant to place their  families in areas that do not offer the best education or cultural opportunities.

4a.. Spouses generally drive where the physician choses to live in the long run. To do otherwise usually ends up in divorce.

5. Physician recruiting from rural and underserved areas is fraught with challenges, to attract bright inquisitve p eople who may be challenged by underachieving schools and other social and family barriers,both economic and other.  Many of these young potential physicians see education as a road out of their community, for many good reasons.It would be interesting to evaluate what percentage of physicians do return to their home to practice in their community in which they grew up.

6. Programs developed with economic incentives such as loan


forgiveness with contractual obligations provide some basis for supplying these areas, however what percentage of recipients remain when their time is up?

7..Although not as frequent in today's educational structure were those physicians who would practice general medicine for several years and then specialize.  The elimination of the  free standing internship with a possible break to work and perhaps look at a long term view of general practice has virtually destroyed this mechanism to produce general physicians

8. The well meaning elevation of family practice to a recognized specialty created the necessity to become board certified in family practice to be credentialled at hospitals and also insurance companies.Insurance companies are now 'driving this boat", Because specialty care pays so much better, one asks the question, why spend two to three years becoming eligible for a family practice credential, why not spend the same amount of time training to become 'specialty trained."