Information provided by Health Train Express and Digital Health Space is informational only. We do not endorse specific solutions. Inclusions are provided as reference only. Readers should consult with their own consultants for further details.

Monday, January 31, 2011

Monday Digest for Health Train Express


And here is the top of the blogosphere news for Monday, January 31, 2011

Dr Val   5 million dollar fine for Doctors asking questions about Guns in the home

The Health Care Blog  A Medical Student’s Dilemma

Dr Wes   Carding Doctors?

Dr A  Social Media to Traditional Media, or why you should participate

Health Policy and Communications Blog Rise of the Tea Party Machine

Life as a Healthcare CIO   Cool Technology of the Week

Medinnovation   Health Reform and Pay-for Performance,Not So Fast, Macduff !

Wall Street Journal Health Blog   Six Health-Care IPOs Planned For This Week

Disruptive Women in Health Care   Who’s a Medical Doctor?

Kevin MD   Marcus Welby and the relentless growth of specialization

Edwin Leap   The Physician Exodus

iHealthbeat  Report Says Health IT Has Potential To Advance Personalized Medicine (report from the Brookings Institute


Saturday, January 29, 2011

Health Reform—The Nail on the Head


Richard Reeces, author of Medinnovation reveals that two Democrats his the health reform nail on the head.

In his blog Reece elaborates:  “Patrick Caddell, former pollster for Jimmy Carter, and Douglas Schoen, Democrat pollster, strategist, and author of The Political Fix: Changing the Game of American Democracy, say bluntly and succinctly give three cogent reasons why the health reform law has failed to impress the American people.”

Number One, the law is “anti-democratic.” It received no Republican votes, and three sneaky deals – the Louisiana Purchase, the Cornhusker Kickback, and the Connecticut U Con – made it possible. Its passage did not pass the smell test. If you believe in democratic bipartisanship and consensus, the law emits an unpleasant odor.

Number Two, the law fails flat on two false promises,
a. That everybody can keep their current policies, while in reality , employers are quickly dropping employees like flies from employer plans because it is now cheaper to do so.
b. That the individual mandate was a regulation of commercial activity and was not a tax, yet Democrats are defending it as a tax in the courts now that 28 states are challenging its constitutionality.

Number Three, the law does not deliver what the reform package the public wants,
a. Purchase insurance across state lines
b. Coverage pre-existing conditions (this being the one exception)
c. Portability from job to job
d. Support of malpractice reform
e. Incremental introduction of reform
f. Believable initiatives to hold down costs

The health reform law, in short, is a pig in a poke, an idiom referring to someone buying a low-quality pig in a bag because he or she did not carefully check what was in the bag. Now that the public is learning what’s in the law, they dislike it more than ever.

Friday, January 28, 2011

Health Train is changing Tracks


The Big Switch

I spent the past several days reviewing the content of my blog over the past six years.  It amazed me that I don’t remember writing a lot of what I read.  It seemed unfamiliar and I wondered who wrote that stuff. Perhaps some other writers experience this phenomenon whereby one does not want to own what one wrote some time ago. My blogs have changed considerably and I estimate most of it is not really original, much is cut and pasted, some is repeated with attribution.

The most I have to offer to my readers is my time. I am not seeing patients anymore and have a volume of time to read many things, sit back ponder, pontificate.  Those who can do, and those who can’t either teach or write. Both of those avocations take inordinately large amounts of time, to do well. And so does keeping a medical record, hand written or via an EMR.

For those of you in practice your time is very limited and one of the things you don’t have time to do much of is read and/or surf news articles about anything.

In the next week or so my blog design will change as well as it’s content.  Stay on this ‘channel’

Also follow me @anophthalmus for interesting news, some medical, some political, some humorous, some sad. (all in a day).

World Economic Forum



  The World Economic Forum is live today via video streaming from Davos,Switzerland.  Many health care related interviews with Bill Gates, Tony Blair and others.    Other issues regarding Information Technology, and World Health, Global Social Media Networking.





The Medicare web site, offers a “Physician Compare” section.  The stated goal is to be ‘patient centric’ to meet consumer needs.  This section supposedly  offers a means to search for physicians to compare their demographics and expertise as well as certifications.



I researched the site extensively for multiple providers who I know personally. 

The amount of information was minimalistic, demographics, specialty and degrees, ( no mention of subspecialty) medical group name (if any) with no mention of hospital affiliations. There was no mention of re-certification status, when licensed. The main features most notably displayed was if the provider accepted assignment. (apparently an indicator of ‘quality”)

It is highly inaccurate. I did a search for a physician within 15 miles of my location and came up with one that had over 100 locations listed (not in a group).

I would label this web site as dangerous !!!

Hard to believe whoever was in charge of this let it slip through. Well intentioned  but poorly implemented.

The Health Care Blog also has a post today by Micihael Millenson. Thanks to him.  I will write Czar Berwick about this one.  Suggest all of us do the same. Tags: ,,

Thursday, January 27, 2011

Pharma Crisis ??



Today’s WSJ reports that Pharma is being squeezed from all sides.

2011 Looks Tough For Drug Companies  (clickable)


Despite past news of huge billion dollar profits for Pharma, the ecosystem for pharmaceuticals has gradually eroded leaving   pharma in a less tenable position.  Pressure is mounting with health reform measures, while pharma has been hit hard by restrictive formulas, and the emergence of ‘generics’.  Generics, once looked upon with suspicion and doubt have take over a large part of doctor prescribing habits.  Doctors have been forced to prescribe generics by limitations of their patient’s plans and their formularies.  Most generics are tier 1 (a classification of drugs in each formulary). It does not take long if you gaze at a typical plans formulary to see how much less the copay is for a generic drug. Specific drug formularies are easily found on plan websites. 

Pharmaceutical R &  D is expensive, as well as the FDA approval process,   The previous model of marketing a new  generation  or modification of an older drug with attendant new  patents (at a much higher price) will not work today. We have and will see a marked increase in new drug cycle times.

So bad is the situation that this documentary was written by the Bureau of Investigative Journalism (clickable link) 


NYSE Floor


The NIH National Center for Drug Research (clickable)

“The National Institutes of Health has approved Obama’s decision to assist with funding for drug research and development through a Federal Research Center.


image                   image

Federal officials concerned about the slowing pace of new drugs coming out of the pharmaceutical industry have decided to start a billion-dollar government drug development center to help create medicines.”

The New York Times reported on its website Saturday about the new effort that comes as many large drug makers, unable to find enough new drugs, are trimming back research

NIH chief Francis Collins is pushing ahead with ambitious plans to create a new center for translational medicine that will do some of the early-stage work for the drug development industry.

Collins' plan, endorsed by HHS Secretary Kathleen Sebelius and outlined over the weekend by the New York Times, is to bring together $700 million in R&D work under one roof at the National Center for Advancing Translational Sciences, where government scientists will pursue a billion dollars in funding to push the projects through the Valley of Death. Collins' blueprint calls for scientists to get enough proof-of-concept data in hand to whet pharma's appetite, spurring them to step in and finish the discovery work needed to obtain an approval.”

If I read this correctly, the FDA will have one arm to assess the safety of new drugs, and     it’s sister  NIH will be dueling.

There is some opinion  the NIH has no business  in pharma other than to provide basic science and early translational work.  It may be a different story for Orphan disease and Orphan Drugs  (clickable)


Wednesday, January 26, 2011

Algo Men to the Rescue


When all else fails, do a study. President Obama reigns supreme in this area. 

Algorithms sound impressive, not like Algo Gores. This is what higher math is for…to prove the discontinuities of existence, the universe or whatever you are plagued with in modern times. Algos are supposed to make decision making easier with a formula or diagrams directing a ‘machine’ (computer) to make stem choices. (Best stem I have had was on an apple (not the computer)

  1. President Obama will soon be appointing a new Czar. The algorithm Czar who will be the final arbiter of algoland.  The AlgoCzar will reign over health care, politics, economics, defense, security, foreign policy and the Rest rooms.
  2. You can read the entire article at the New York Times but in essence the President ran out of folks who could help him out with the technological war far that is occurring and thus has reached out and grabbed William M. Daley whoimageworks in the financial industry. They work worth with algorithms day in and out and while Mr. Daley may not be a hands on person, believe me he knows his “Algo Men” as all the banks have quite a few of them.

Before I get any further I need to give attribution to Medical Quack whose recent posts have been in reference to Algo-Medicine and our great hope for the good side of “The Force”. Barbara, or as I like to call her “Ducky”, not to be confused with Ducky from NCIS’ whose forensic abilities defy most pathologists. (why don’t more pathologists blog?) (where was I now?)

Oh yes,  Medical Quack always has an aggregation of topics that fuel my limbic system.   This is not Ducky’s fault…’s a bit like shooting the messenger.  Ducky, you bring a lot of bad Karma to the table. I like you very much. It keeps me grounded and diminishes my euphoria. Thank you very much. 

Now what was the point of this post ??

Tuesday, January 25, 2011

More on Jack


My colleague and blog friend,   The Hospitalist   expanded better than I ever could about Jack Lalanne in his blog on Monday.  It’s worth reading.

He was the original ‘health nut’. But he was ‘bolted’ down. He exemplifies the fact that we all die, but the journey to it can be a gradual slope of declining health, unhappiness, disability or a good quality of life until one goes over the cliff  suddenly.

Jack,   the original ‘Juicer"’ did not need MLM,Facebook, Twitter, Tumblr,MySpace, or coupons from Groupon to spread his ideas

So really, disciplined eating habits, exercise, avoidance of unhealthy stress counts more than blockbuster drugs and high tech enhanced hospitals. Accountable care organizations will do little for your longevity, politicians, not withstanding.

If Jack Lalanne could do all that in the 1950s and 60s, imagine what he would have done now…..that is if he did not spend his time surfing and blogging, twittering and face booking all day.

How about an internet enable set of barbells, or workout machine?I know someone out there has an iPad accessory to attach the iPad to my treadmill.

Jack had this saying,



Long before  HSAs !


Monday, January 24, 2011

An Icon Passes


Jack LaLanne


For some of you the name of Jack Lalanne brings forth images of a ‘jumping jack’ on your TV screen, or memories of “Bally” gyms, the chain that Jack started.Bally Total Fitness ™

He was among the first to popularize weightlifting and his physical fitness techniques – including the fingertip press-up – formed the centerpiece of The Jack LaLanne Show, which ran on American television from the 1950s to the 1980s. Long before the age of celebrity exercise videos, LaLanne was telling people how to get fit.

Jack left us yesterday at the age of 96 years.  The original 20th century beacon of fitness and preventive living he was a disciplined man, At the time a  version of Arnold Schwarzenegger. 

Just a moment of science from us all to thank and remember him for starting it all. We will miss the juices as well.


Sunday, January 23, 2011

Health Care and Reform Film Festival


“We” are going to introduce a new forum for ‘film” or digital productions regarding our health system.  Here is our “World Class” presentation.


Study Looks For, Can’t Find Much Evidence of E-Health’s Benefits


Surprised smile

There is a bit of a new link on the right hand sidebar. Levin’s Shout Out. Expands the audience a bit.

With the U.S. and the U.K. heading full steam towards electronic medical records and other health IT applications, how much evidence is there that they improve care?

The Wall Street Journal speaks to this issue.

Let’s keep it all realistic.  !!



Saturday, January 22, 2011

Locomotives can only Pull So Many Cars


Bird's eye view of more than a mile long rake as seen from Lowell's Observatory.(Arizona)



Clive Peedell in The Health Care Blog picks up today where I left off regarding the NHS in U.K.  He correctly identified that the NHS white paper is a plan to dismantle the NHS by allowing market forces to operate to disengage the NHS from health care bit by bit.  He call this task “creative destruction.”  This NHS will not fall overnight because the market’s invisible hand will destroy it in a piecemeal fashion, leaving the unprofitable areas of healthcare firmly in public sector hands.

“The key policy levers enabling this to happen are:

1. The purchaser provider split, with GP commissioning consortia taking the leading role on the purchaser side of the divide.

2. Patient Choice.

3. Competition between a plurality of ‘any willing providers’.

4. Payment by Results with price competition.

5. Patient held budgets.

6. Foundation trusts becoming social enterprises and the abolition of the cap on their private income.”

This demonstrates the absolute power of economics. Sooner or later most if not all nationalized systems lose influence.  They cost more than predicted,  and collapse inwardly. 

Mr. Obama, with his “community organizer” banner has had a steep learning curve in this regard.  He either disregarded his lessons in Economics at Harvard, or failed to attend all the classes.  Mr. Obama never ran a business. Observers, participants and voters see this as the reforms measures are put in place in the U.S.

Anyway, I digress, back to Mr. Peedell’s predictions.

Either way, moving to a more nationalized system,  or leaving one is a messy process for doctors and hospitals.   The players will remain the same, their checks will come from different payers,  and the taxpayer will pay for it all.

The white paper is therefore designed to fulfill a longstanding Tory dream - to dismantle the NHS and replace it with the private sector, which will receive its profits from the UK taxpayer.

Health reform, either way is always a hot political potato, It is also political suicide to dismantle the NHS, so it is being performed using the political rhetoric of patient empowerment through the patient choice agenda, and clinician empowerment by giving GPs a budget of £80bn.


Amazingly, Andrew Lansley is getting away with it because there is far too little understanding and resistance from the medical profession, which is realistically the only group of people that can prevent this assault on the NHS.

Either way politicians lose votes. This most recent election in the U.S. demonstrates this phenomenon as the democrats lost control of the US Congress.

Clive Peedell is a consulting oncologist and is co-chair of Britain's NHSCA. He contributes regularly to:

…..(to be continued)

Friday, January 21, 2011

Which Planet am I on?



A tweet arrived this morning from a twit friend. The NHS is rapidly unraveling in the U.K. according to this tweet. 

Thank you to Mike Broad and The Health Care Blog

Picture this scenario:

Health Secretary Andrew Lansley said: “In order to meet rising need in the future, we need to make changes. We need to take steps to improve health outcomes, bringing them up to the standards of the best international healthcare systems, and to bring down the NHS money spent on bureaucracy. (Hmmmm?) Andrew Lansley's health and social care bill will abolish England’s 152 primary care trusts

This sounds familiar.

The controversial Health and Social Care Bill has been published, paving the way for GPs to control 80% of the NHS budget from 2013.

Unions warn the plans are the first step towards privatizing the health service, while the health select committee said the way they have been rushed in has taken the NHS by “surprise”.

But the government argues the changes will improve care and accountability.

Accountability, isn’t that what Medicare and ACOs are planned for the U.S?

This sounds a lot like reverse engineering of the UK System that has grown to become so moribund that it must be carefully dissected to de-commission it. 

It looks to me as if they are running in the opposite direction from the U.S. Health Reform.

I wonder what Dr Berwick is thinking now?

Tuesday, January 18, 2011

TED MED 2010


TED MED today released a series of videos from the October 2010 Conference.

The conference kicked off with Steve Colbert’s enthusiastic opening speech to the conference.


One of the topics near and dear to me personally is the session on Lung Transplantation in Cystic Fibrosis.  One of the participants was a young woman who had received a pulmonary transplant and gave a wonderful inspiring opera recital.  Any trained vocalist can attest to just how much strength and stamina an opera singer must have to peform.  Truly an inspiring presentation:

The first presentation is  Charity Tillemann-Dick whose personal story and the results of her pulmonary transplant are even more amazing!

Dr. Shaf Keshavjee from Toronto, who is pioneering new technology to help organ recipients, demonstrated how in vivo extracorporeal circulation allows ‘targetted therapy’ to make potential organs for transplantation more like ‘self’ to minimize organ transplant rejection.

Dr. Sanjay Gupta reports from Haiti about motivation in the setting of a tragic disaster. Sanjay related how he was so inspired about the reactions of the devastated people and their warm responses to visitors and aid workers.

Please note:  Registration for TEDMED 2011 is open.  The dates are October 25-28, 2011, once again at the magnificent Hotel del Coronado in San Diego. 

The 2010 event sold out with a wait list hundreds long... so we encourage anyone interested in attending TEDMED 2011 to secure their seat now:

It is well worth the time and money to go.

Are you a QR user?


The 3 Rs ,  long the basis of educational dogma in the United States has been supplemented, and at times replaced by word processors, spelling and grammar checks and calculators capable of calculating algebraic, trigonometric, and calculus ..

Add to this the spice of mobile apps, smart phones with cameras and the  QR code   

image  Hold this up to your iPhone equipped with one of the  QR reader apps,   readily available at iTune for  FREE !  If it’s free, it must be free. There is also a web cam app available.

Any digital camera and web cam is capable of reading these ideograms and with the proper software spit out the message in old fashioned plain English, French, German, or whatever.

A QR (Quick Response or Quick Read) Code is a two-dimensional matrix/bar code.  Users hold their phone up to the code displayed on a sign, in a book, on a computer screen, TV, or almost anywhere.  The phone camera snaps the code and takes the user to a website or video with more information – no typing needed – just point and click.

QR Code                QR App

The hieroglyphic figures encapsulate a new wave of capturing ,storing and transmitting information.  They have been around for awhile in the shipping industry, the IRS, legal forms and provide a means of sorting documents and packages by machines.  Bar codes may be on the way out.  Their readers are more complex expensive,and require lasers. The beauty of these little beasts is that they are easily read by a camera.

If you hadn’t noticed health related applications abound:

For example, QR codes can be used to help patients use health information in specific contexts, such as when needing to:

  • take a pill
  • interact with a device (for example, a glucose meter, a smart band-aid, etc.)
  • engage in a behavior (e.g., finding a hospital, exercising, buying food, selecting a meal, etc.).
    • QR codes on food/drink packages to link to nutrition information, interactive calorie counters, and personal information about a patient’s diet plan (which would require the learner/patient to interact with a Web site linked to the QR code)
    • QR codes attached to medication labels, linking the codes to patient-friendly information, as well as physician and pharmacy contact information
    • QR codes to identify drug interactions (useful for patients and physicians) via an interactive or static Web interface
    • QR codes on devices patients use, to link to how-to information (e.g., text, video, or audio information, that could be presented in different languages)
    • QR codes to link medications, patient devices, physical locations, etc., to live assistance (e.g., nurses, other health care providers) via phone numbers associated with the code or links to sites with live chat capabilities
    • QR codes on a card the patient carries or on a key-chain attachment that’s linked to the patient’s personal health care record (PHR) and/or emergency contact information
    • QR codes to help patients identify health care providers or emergency medical services in their area
    • QR codes on the equipment on a jogging path or in a gym to encourage appropriate exercises, connect to heart rate monitors, etc.

    IF you’re smart, here are 22 ways you will use QR codes in health care.

          • Billboards advertising hospitals and medical groups will have QR codes so travelers can get more information about facilities or  get directions to the closest Emergency Department, Urgent Care or family practice.
  • Television advertising for pharmaceuticals will have QR codes so viewers can get more information on the spot.
  • Healthcare facilities will have QR codes for all types of information and videos that providers and nurses will instruct patients to scan based on their health problems.
  • Magazines and newspapers will have QR codes that readers can scan to get health information and health product coupons.
  • Scanning QR codes when exercising or purchasing healthy foods will get you reward points with your health plan, your doctor or your employer.
  • Comparison of foods that you should or should not buy in grocery stores based on your individual health problems will be easy when you scan the food’s QR codes.
  • Caregivers will scan QR codes to receive information and videos for caring for their loved one at home.
  • When purchasing over the counter medications, vitamins and supplements, you will scan the QR to make sure the medication isn’t contraindicated for any prescription medication you are taking.
  • Scanning the QR code on food or cleaning products will let you know if they contain anything that you are allergic to.
    1. At health fairs, attendees will scan QR codes for more information on health topics and your facility and services.
    2. Disposable diapers will each come with a unique QR code that Moms (and babies) can scan to get childcare tips, games, songs and medical advice.
    3. Urgent Care facilities and Emergency Rooms will have QR codes for instant access to wait times.
    4. QR codes in healthcare facilities will let users download helpful mobile healthcare applications like those that help you control your chronic illness or lose weight.
  • In print advertising for physicians, potential patients will scan the QR code to view the physicians talking about their background, their specialties and their desire to have you as a new patient!
  • Referring patients to facilities or specialty practices will be much easier when patients scan the QR code for the referral and receive information, instructions and directions to the appointment.
  • Healthcare facilities will give out t-shirts and carrying bags promoting their services and the QR codes on them will spread the word to others. (Yes, people will scan each others’ t-shirt codes!)
    1. Patients taking home halter monitors and CPAPs will be able to scan the QR code on the machine to get a “how-to” video on using it.
    2. Patients taking home sample medications from physician offices will have QR codes on the bag to scan to remember how they are to take the samples.
  • Temporary tattoo QR codes will identify those patients who won’t wear identifying bracelets, have dementia, or tend to wander away.   
  • Hospital patients will scan the menu broadcast on their TV to order their daily meals.
    1. If you are going to be late to your doctor’s appointment, you will scan a QR code to email an alert to the office that you are on the way. (Wait, maybe that’s too easy!)
    2. Pharmacies will have QRs loaded with prescription prices by insurance company plan on their website so providers can compare different drugs and chose the best drug for the patient at the best price.

Those of  you wishing to check this can get one of these apps for  your camera smart phone.  You can also obtain a web camera app if you don’t have a camera smart phone.

NeoReader,   OptiscanQR AppQuickMark

All of these QR apps can be downloaded from the web site.

Sunday, January 16, 2011

Pills and other Things on Health Train Express






Pill cap 2.0 ? It’s time for your medicine cabinet to become IT literate. Yes, plans have been developed, the hardware and software ready to go.  The carriers are dreaming big about subscriptions to a service that reads your medicine bottles over your bathroom sink. Gigaom   reports that at C.E.S. 2011  the activity about tablets was intense,   however there were other more profitable things going on behind those doors on the sides of the exhibit hall.

For example? Your medicine cabinet. AT&T said last week it would provide the service behind an innovative pill cap that will connect to its network and text users when it’s time to take their medicine, or it could text a caregiver.

The nifty little pill bottle top costs $10 per cap and requires a $15 per month service plan. That’s likely worth it for people who need reminders about the drugs they or a loved one are taking, but on a per-megabyte basis that $15 per month nets out to about $25 per MB, although it’s not clear if AT&T gets the full $15. The folks at Vitality, the maker of the cap, said the connected cap transmits less than 20 kilobytes of data per day over the network — a mere crumb when compared to bandwidth hogs watching streaming video on their iPhones.

Vitality relies on pharmacies to dispense drugs in GlowCaps. Chains bid on how many of the caps they can distribute and get paid each time they dispense a bottle with one. Vitality recently launched its program with Express Scripts, one of the largest pharmacy benefit managers, to distribute certain medications in bottles outfitted with its caps. When does a non-event become an event?

The device has been shown to lift adherence. Data from a Partners Healthcare study released last month shows adherence increased 27%. Patients adhered to medications 98-99% of the time when the pill cap's reminder services, along with financial incentives, were used, according to data collected by the Center for Connected Health, a division of Partners Healthcare.

“Across all bottles in the field, we see compliance above 85%,” added Reim. Compared to what he said is the going compliance rate of roughly 65%, plus or minus depending on the drug, “That kind of 20% improvement in compliance has ramifications for outcomes, sales and new sources of data.”

So your spouse or significant other, mother, father will no longer have to berate you ‘not to forget your cough syrup"'’.

In 2011 expect there to be an explosion of ‘intelligent home devices"’ broadcasting your compliance, vital signs, and also most likely biopsying your wallet.  What’s in Your Wallet?

Friday, January 14, 2011

Health Train Express and the Sleeper Car


When I began this blog six years ago I had no idea how useful the title would be for my forum.  If you look at my several hundred posts I have been able to use train analogies for many of my issues with medicine and health care.

The title today says it all for today’s blog posting.

One of the largest, and ignored medical problems (sleep apnea) creates an enormous fall out of heart disease, hypertension, sleep disorder, depression, and not the least, marital dysfunction.


At home monitoring technology offers much  to physicians and patients alike.  I am not referring to  EMR,HIT, Health Information Exchange or other in office  technology assist devices.

Home monitoring devices are now entrenched firmly in the DME space, and many  are covered by Medicare and private insurers.

How about having a FEDEX box delivered to your home with a self contained Sleep laboratory, and all the computer monitoring modules and attachments,  along with a video instruction course found on the internet or in the package? It is shipped pre paid with the material enclosed, and a return label (pre paid).

The instructions included detail the step by step process from beginning to end.  The module records all the parameters from the night’s sleep or non-sleep, as the case may be.

The test is the same given at a certified sleep laboratory. Who sleeps normally in a strange bed or environment?

Have I mentioned the sleep test is at no charge ! 

Sleep apnea represents a “sleeper” public health problem.  It is probably just as significant as diabetes, hypertension, obesity, and elevated blood lipids .  As physicians should all ask.  “Why it has never stimulated public prevention and/or diagnosis?”

It is recognized by most PCPs but the referral process for evaluation, diagnosis and treatment is circuitous and often not easily available for now avoidable reasons.

If you want or need to know more about  it don’t hesitate to ask me for further details. (no obligation whatsoever)

I can be reached at Include your email address or how you would like to be contacted.



Your travel companion,

---The Conductor, Locomotive Engineer, and Caboose Manager of the Health Train Express.. (all aboard please, next stop Dreamland.)


Thursday, January 13, 2011

ACOs, HMOs in Drag?



December 1st, 2010

by Dr. Jesse Cole

altACO models offer nothing that other ASOs--alphabet soup organizations--have not offered in the past. HMOs, PPOs, MPOs and more have all been tried and if not failed, at least have never lived up to the hype.

There is no reason to believe ACOs will fare any better. But it's possible the ACO experiment will be more dangerous than its proponents care to admit.


Let's start with the assumption that healthcare is so fragmented and inefficient that putting people in a hospital-based ACO will reduce costs. Where's the evidence for that? Do most people actually need a complex, multiprovider team to deliver their healthcare?

The answer is no.

Throughout their lives, most people have fairly self limited acute problems, or chronic, medically managed problems which required limited interventions that can be performed in a physician's office. Private physician's offices are generally run in a cost effective manner because the physician is paying the bills.

The critic will say the physician is over-ordering examinations to pay the bills. How? Most primary care physicians have fairly limited in-office ancillary income, generally basic lab, EKG, pulmonary function tests, and perhaps X-ray. These procedures generate an income, generally enough to pay for themselves but not enough for the physician to retire on.

"Ah ha," cries the critic. "You, Dr. Primary Care, don't really have enough in office resources to provide high quality coordinated care. I see no educators, pharmacists, social workers, physical therapists, specialists, subspecialists, billing coordinators or dieticians. That's costing the health care system money."

Or, according to the experts...a primary care practice is too small to provide high quality, cost efficient coordinated care because it lacks all of these elements.

Therein lies the problem. The ACO model depends upon the assumption that all health care delivered by primary care physicians in their office is cost inefficient and of lower quality than what an ACO will provide, without the necessary evidence.

Could the care provided by private physician practices be improved? Certainly. But where is the evidence that the fee for service, private physician model of health care is not efficient and does not provide good care? The ACO model is still fee-for-service. It's just that the fee will go to a larger organization, composed of many more people, all fighting for a piece of that dollar and creating costly overhead.

Do people with the vast majority of medical problems, such as acute upper respiratory infections, urinary tract infections, hypertension, and diabetes. Do they really need a multidisciplinary task force to take care of them? Such is the nature of an ACO.

Hospitals have certainly jumped on the bandwagon for ACOs, with good reason from their point of view. Hospitals are an anachronism when it comes to providing cost effective care. That's not a bug. That's a feature. Hospitals are supposed to be for people who cannot be managed as outpatients.

In fact, the irony is that outpatient medical care, largely delivered by outpatient physicians in private practice, has advanced to the point where hospitals have seen their occupancy rates plummet. Few remember the days in the 1950s and 1960s when those who survived heart attacks might spend several weeks recuperating in the hospital.

Hospitals now employ more than 50 percent of physicians, and that number is expected to grow. Among reasons cited, the new generation of doctor is more interested in lifestyle and security rather than the stress of private practice. But in accepting employment offers from hospitals, are doctors trading one set of stresses for another? I believe so, especially if the ACO model is widely adopted.

Dr. Jesse Cole is a radiologist in private practice in Butte, Montana. He is also subspecialty certified in neuroradiology, and vascular and interventional radiology and practices at Big Sky Diagnostic Imaging in Butte with a limited practice at Community Hospital in Anaconda. Tags: ,,

Wednesday, January 12, 2011

From iHealthBeat


A brief visit to an excellent source of Health News


Health Care Providers Identify Roadblocks to Meaningful Use

On Monday and Tuesday, more than a dozen physicians and representatives of hospitals discussed challenges associated with meeting requirements under the meaningful use program, AHA News reports.

Under the 2009 federal economic stimulus package, health care providers who demonstrate meaningful use of electronic health records can qualify for incentive payments through Medicare and Medicaid (AHA News, 1/11).

Attendees spoke during a two-day meeting of the Implementation work group of the Health IT Standards Committee. The speakers were advanced users of EHRs, according to Modern Healthcare (Conn, Modern Healthcare, 1/12).

Attendees' Concerns

Attendees said that many hospitals will face challenges complying with the incentive program's meaningful use requirements.

Joanne Sunquist -- CIO of Minneapolis-based Hennepin County Medical Center -- said developing reports to demonstrate meaningful use "has become an onerous, difficult and time-consuming process" ADD EXPENSIVE (mine)(Page, Becker's Hospital Review, 1/12). Sunquist added that health care organizations might encounter difficulty implementing quality reporting systems using vendor-provided workflow information (Goedert, Health Data Management, 1/12).

According to Charles Christian -- CIO of Good Samaritan Hospital in Indiana -- smaller facilities could experience difficulty implementing health IT because they might not have appropriate in-house staff and would have to rely on outside help.

Linda Reed -- vice president and CIO of Atlantic Health in New Jersey -- said that physicians need more guidance on implementing technology to support health information exchange (Monegain, Healthcare IT News, 1/12).

According to Lyle Berkowitz -- medical director of clinical information systems at Chicago-based Northwestern Memorial Physicians Group -- independent physician practices are at a disadvantage because they do not have access to resources compared with hospital-affiliated groups (Modern Healthcare, 1/12).

Meeting attendees called for HHS to provide more time before implementing the incentive program's Stage 2 requirements (AHA News, 1/11).

Read more:

SCOTUS in Mayo Clinic v. IRS


Health Train is back on the track again.  In another round of health care complications where getting a medical education turns into a high priced legal venture for one of the largest most famous medical clinics in the world.  You can bet your bottom dollar this had much more to do with cash flow for Mayo than whether the relatively less well off junior MDs could escape Uncle Sam’s money sucking vacuum machine.  More about Complications here.

I found some commentary on the WSJ blog on Health



  • workaholic wrote:

As interns in the 70’s, we worked 128 hour weeks and loved it. We are graying now and find the trainees to be eager but lazy, not committed to their patients, while very committed to their CPOEs, EHRs, and mobile devices, as the patient lies in pain and poop. We were paid a fixed amount per year, period, with weekends on and two weeks of vacation when someone else told us to take it.

There is a reason why the Hopkins is so great. I do not remember if they took out social security, I will check my stubs (I am a packrat) but if they did, I will seek a refund plus interest.

  • Anonymous wrote:

Perhaps they can be employees for the purpose of IRS but not employees for the purpose of some different state laws. Part of the Supreme Court’s point is that it will defer to the reasoned and careful judgment of the agency (here, IRS) when there is not some compelling reason to reverse the position of the agency. This creates a public climate and legal climate where irrational decisions of agencies can be corrected, but, all the decisions of all government agencies are not constantly being revised over and over every time a judge somewhere entertains an alternative opinion. I agree with the IRS that the job has most of the characteristics of employment, not those of being “a student.”

  • Academic wrote:

This has other potential negative consequences. If residents are considered employees than there are overtime rules, and limits on work hours that could be applied depending on the states laws. This could mean that in the future newer physicians will have less time spent in training. Not a pretty picture, especially for surgeons where hours, repetition and numbers of procedures makes a huge difference in ability to perform a task correctly.


SCOTUS blog goes into further analysis and arguments:


How can the Web be used for Health Health Habits.?

Now for the real bread and butter.  I just attended a webinar from Health 2.0 where participants are meeting t he Health 2.0 challenge thrown down by Matt Holt of the Health Care Blog.

One of the solutions can be found at :  Healthy People .

Tuesday, January 11, 2011

Analysis for 2011

Pronouncements From on High

LOS ANGELES, CA -- (Marketwire) -- 01/11/11 -- The sluggish economy and the farthest-reaching health reform in more than 50 years will continue to ratchet up pressure on U.S. providers to reduce costs and improve quality, setting the stage for The Camden Group's annual Top 10 Trends in Healthcare in 2011. These pressures will trigger an avalanche of activity centered on accountable care organizations (ACOs), bundled payments, and patient-centered medical homes. At the same time, they will compel more physicians to seek employment with hospitals or large medical groups and spur more consolidation of hospitals and medical groups/independent practice

"2011 is the year when a growing number of providers move forward with new care delivery models and run into the very real challenges posed by overhauling traditional ways of treating patients. The fundamental question is whether providers can manage costs and improve quality while maintaining provider choice and open access," says Steven T. Valentine, president of The Camden Group. "As always, the devil is in the details."

Yes, indeed it is. (Health Train Express)

Further predictions:

The Camden Group    predicts the following Top 10 Trends will have major and continuing impact on the healthcare sector during 2011:

1. Insurance membership takes hit from slow recovery. Few unemployed will take advantage of COBRA while employees, faced with paying more of their health plan premium, will select high-deductible, low-premium PPO plans, hurting HMOs.

2. No easing on payment pressure. Although health plan payments will keep pace with inflation and operating cost increases, they will not make up for declining or stagnant Medicaid and Medicare payments.

3. Patients postpone care, hurting providers too. With high unemployment and underemployment and increased out-of-pocket costs, people will continue to put off treatment, keeping volumes at hospitals, ambulatory centers, and physician offices soft.

4. Cost is king. Soft volume, downward pressure on revenues, and deteriorating payer mix with increased bad debt will drive providers to seek more cost savings. However, unions, staffing ratios, and regulations will make cuts difficult. At the same time, health plans will begin to explore and increase the use of tiered networks and stratify payment to encourage use of lower-cost providers.

5. Capital remains elusive. As in 2010, most non-profit hospitals will find it difficult to access capital. Lenders are requiring an increase in days cash-on-hand, coverage ratio, stronger EBITDA, and smaller borrowings. Credit rating agencies want to see: 1) physician alignment strategy, 2)clinical integration and cost reduction action, 3) IT plan, and 4) plans to capture more market share.

6. Physicians make or break new care models. To improve outcomes and lower costs, hospitals and medical groups will focus on accountable care, bundled payments, patient-centered medical homes, and/or clinical integration. Reducing variation in care -- primarily by physicians -- will be central to any successful strategy. An effective bundled payment strategy, for example, requires specialists to address clinical resource consumption and supply cost and use while standardizing care protocols in conjunction with hospitalists and intensivists.

7. Construction focus is on fast returns. Construction projects will be scaled down, with a focus on regulatory compliance, enhancing throughput, improving care/outcomes, and if possible, capturing additional market share. Providers also will prioritize construction that generates superior returns, such as surgical services and imaging centers. Do not be surprised to see the growth of freestanding emergency departments to reduce the need for hospitals, increase access, and provide capacity for the newly insured.

8. IT becomes more pervasive -- or else. Information technology underpins providers' ability to shift to new care models, so IT moves to center stage with efforts to implement electronic medical records, (EMRs,) computerized physician order entry (CPOE), and health information exchanges (HIEs.) Provided, of course, medical facilities already have in place ePrescribing, PACS, and online results reporting and scheduling.

9. Let's make a deal. Mergers and acquisitions will be brisk as more hospitals and physician groups acknowledge they lack the resources to invest in information technology, facilities, and equipment for new delivery models or the leverage to negotiate effectively with health plans. Given their central role in new models, the value of primary care medical groups will increase. It is possible that health plans will enter the market to acquire these medical groups.

10. Market share, market share, market share. Hospitals and medical groups have underutilized assets and must get them busy. Providers also realize that more volume will generate incremental revenue and decrease per unit cost. Hospitals will hunt for new programs to fill empty or underperforming assets.


We also need to factor in the “Social Media Impact” on ACOs

Social Media goes to the E.R.

Pretty soon it will be all F.U.B.A.R.

Monday, January 10, 2011

Stem Cell and Grievous Brain Trauma.


First let’s go over to KevinMD where my post about Public Health, and MPH’s has been re-posted by Kevin Pho MD.  I had actually forgotten about this post and did not know which one Kevin had chosen.  As a PCP my  post must have tweaked his Kool-Aid dispenser.



Personally I prefer Gatorade or G2, the drink for 21st Century Health Care.


My post today is about Stem Cell Research and it’s potential for Translational application to severe head injuries such as the one sustained by Gabrielle Gifford, Congresswoman from Arizona.

My thoughts are an imaginary scenario of injecting central neuro-stem cells into the wound tract of the bullet’s pathway. There it would  become part of the healing process, integrating, transforming and establishing new connections to replace those destroyed by the injury.  If only life and medicine were ever that simple.

The only positive aspect of this horror would be to stimulate a young (or old) clinical and basic science team to embark on the animal, pharma, and microbiology study toward succeeding in that goal.


Sunday, January 9, 2011

The Medical Blogosphere will be hosting Health Train Express tomorrow, Monday January 9th 2011 . You can look for it at

Kudos  to Dr. Pho !  All good  things start and end in New Hampshire.

Kevin Pho. MD has been at this about the same amount of time that I have been at my blog space.  Judging from the number of ‘hits’ his site has daily compared to mine reveals how ignorant I have been in regarding to the new age of information exchange.

I seem to know what to do,  but just have not invested time, money or staff into doing it.  He has been published in many big-time media spaces, such as CNN, USA Today,

Kevin’s appearances include the CBS Evening News with Katie Couric, New England Cable News, and WNYC-New York Public Radio’s The Takeaway, and he has spoken at the New England Journal of Medicine, Blog World and New Media Expo, and at academic Grand Rounds nationwide.

As social media’s leading physician voice, was voted 2008′s Best Medical a “must-read health blog,” and CNN.commanded @KevinMD one of its five recommended Twitter health feeds.

The Wall Street Journal had this to  say about KevinMD, ““punchy, prolific blog that chronicles America’s often dysfunctional health care system through the prism of a primary care provider,” while others have noted that “a lively comment stream on one of Kevin’s posts provides more insight on the day-to-day realities of health care than any piece of journalism can ever hope to impart.” hailed as a “must-read blog,” and named @KevinMD as one of its five recommended health care Twitter feeds.

Kevin Pho on the Medical Blogosphere


With over 40,000 RSS subscribers and 33,000 followers on Facebook and Twitter, is among the web’s most influential and prominent health care platforms.

Dr Pho, when do you have time to make an appointment for me?

Thursday, January 6, 2011

Health Train Leaves the Station (again)


The Health Train Express is moving once again, leaving the not so grand central terminal. 

The 112th Congress, 1st session has commenced, with another full plate regarding unraveling Obama care The first day consisted mostly of procedural matters.

Early today Speaker John Boehner had this to say early this morning regarding Obama care in preparation for the upcoming debate on new legislation to repeal all or parts of Obama care.  The discussion and vote which were to have taken place this week is to be postponed due to a procedural delay designed by Democratic opponents of repeal.

Speaker John Boehner ®


Greg Scandlen posted his “Welcome Freshman'” lecture to the  neophytes, and newbies in congress about the disastrous Obama care law.

My comments are (Yogi Berra), “It isn't over until it’s over.) We physicians must continue our opposition to this law, but not the goal of expanding health care coverage to many more of our citizens, and improving outcomes, reducing cost by increasing efficiency and reducing mindless bureaucracy.