Health Care Reform, Where to Focus

Start the video for some 'listening music' whilst you read today' offerings.

Quote of the day:
One of the first duties of the physician is to educate the masses not to take medicine. - Sir William Osler

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Steven Beller, PhD  has been blogging for over five years. His recent blog contribution at Curing Health reveals some important clues to where our resources should go in reforming our health care system. He and I became involved in what was probably one of the first blogs, Trusted.MD, started by Dimitriy Krygylak.  That was a time when I was really interested in RHIOs and the implementation of EMRs.

We need a quality Health Train, one that can efficiently carry as many passengers as possible,

and not leave patients at the train station, waiting and hoping for the next express.  When they get on the train we want them to have a safe and relatively good experience in a time when they are ill.  Additional stresses beyond getting well should not be in their path on that goal.

The buzz word for the last two or three  years has been Health 2.0. Heralded as the next "Apple" of the internet it has found some acceptance, but the business model remains weak, except for some focused applications such as .asp solutions for medical management and electronic medical records and personal health records.  In reality .asp has been around for decades since the days of mainframes.  Today's applications are being directed at patients, and consumers.  Steve Case and Revolution Health have been disappointed in their venture for our 'vision' for the future. Well intentioned, Steve Case invested a good portion of his well deserved treasury from American Online.  Revolution Health is now for sale, having been unable to establish a business model with sustainable income.  This should be a loud example that pouring large amounts of money into an idea does not always bear fruit.  Steve should not be faulted...he is not the first, nor the last to go down that path.  Sound familiar? A lot like RHIOs.

And that's the rest of the story.

PRO(TECH)T Act of 2008

Quote of the day:

 
Boys will be boys, and so will a lot of middle-aged men. - Kin Hubbard

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The role of the Federal Government rears it's head  once again

with the reactivation of H.R. 6357, as it winds it's way through the Ways and Means Committee chaired by our venerable and staunch representative, and defender of the coiffers of HCFA, Pete Stark of California.

Elements of the draft bill call for:

• Maintaining the grant and loan programs included in HR 6357;
• Directing federal officials to coordinate the development of an open source electronic health record;
• Establishing Medicare incentive payments for health care providers who adopt and use IT systems;
• Requiring federal officials to study the definition of "health care operations" to determine which activities can be performed with de-identified data and which need patient consent;
• Preserving most of HR 6357's security and privacy provisions but specifying that the accounting requirement only would apply to disclosure of information stored in EHR systems;
• Increasing penalties for HIPAA privacy rule violations and requiring a Government Accountability Office study on the "minimum necessary" standard for disclosing data; and
• Authorizing state attorneys general to file lawsuits to enforce the privacy rule.

A quick observation on my part in reviewing the list of  CCHIT certified software reveals the certified solutions are quickly gaining ground in the market place. Primary care is on the leading edge of  EMR in software applications and will be as the concept of a  "Medical Home"  gains it's foothold.

THE  MEDICAL  HOME...KEY TO THE PUZZLE??

Sometimes I just want to 'Scream'

Metrolink Express

Quote of the day:
He's turned his life around. He used to be depressed and miserable. Now he's miserable and depressed. - David Frost

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On a Sunday morning, instead of picking up the newspaper (as my father once did) I read through my feeds and blogs

Tragedy abounded this weekend.  First in the Gulf area another act of nature, the third major event transformed lives in an instant into chaos and life altering change.  In California a commuter train rounded the bend and ran smack into a freight train. 

I think there are strong parallels in these two events. The Health Train Express is rounding the bend and it will miss the switch and run head on into failure, and certain death for many of the passengers.  The failure of the train pales in the face of the deaths of the passengers, for certainly that would follow in health care.

Nature's fury and the law's of physics overruled the hardiness and downright stupidity of those who remained behind on the gulf coast. 

Denial is a powerful psychological mechanism which can lead to  poor health, or death just as it did during Ike. 

In my next  posting I will return to commentary and late news about events in health IT, the original focus of Health Train Express.

Gloom and Doom

Health reform is not an easy task. If it was it already  would have been accomplished, or at least begun.

The recent financial disasters,including bank failures in the wake of the subprime mortgage market fiasco and secondary consequences in it's wake now have impacted investor firms, and banks.  Even the backup organizations are being threatened and choices must now be made as to which institutions can or will be saved.  In any case you and I will pay for these events, regardless of who is at fault.

Our medical care system has not been immune from this instabilty, nor will it be now and in the future. There is a strong parallel in medical care.  Financial institutions have felt some level of protection by governmental safety-nets.  (Sound familar?)

Our health care financing system and insurers have had the ability to maintain profitabilty and sustainability by their ability to carve out profit each year by forcibly reducing their reimbursement to those providing the actual care, without concern for rising cost, nor deterioration of   care.  The safety nets of medicare and medi-cal are now stressed to the maximum.

Further statements of insurance coverage now belie the fact that even those with "insurance" are not covered. Many providers now are not accepting medicare and many more do not accept medi-caid.  Patients who "have" medicaid are in fact unable to find providers who will see them.  The recent budgetary crisis in California has now totally placed all medi-cal payments on hold.

Tens of thousands of patients in skilled nursing facilities are about to be 'evicted' since their  'homes" will be closed and shuttered.

Costs are being shifted by the surge of non covered patients on medi-cal to private payors because the hospitals have to offset these losses.

There is no doubt that patients are suffering and even dying. More will die if further cuts occur.

Health Train Express Weather Report

Quote of the day:
In the land of the blind, the one-eyed man is stoned to death. - Joan D. Vinge

 

Our health train travels along on it's rails but may be battered or damaged by inclement weather, earthquakes, tsunamis or other uncontrollable factors.

Such an event may be occuring in the U.S. economy. More bad news today about Lehman Brothers, which follows on the heels of Bear Stearns takeover by JP Morgan, and the failure of Fannie Mae, and Freddie Mac which has all been attributed to the subprime mortgage fiasco. And there are rumblings about WAMU as well.

Nevertheless the present U.S. administration insists that our economy is basically sound....FOR WHO? Certainly not for the majority of Americans, nor their physicians.

My previous post regarding a "Health Train" bailout was a fictitious accounting of what would happen to the healthcare market, were the same rules applied to it as the financial markets and general economy. 

I only wish we could be "taken over". (not really)  Nevertheless we seem to be driven close to that feeling of wanting to get "it" off our backs as physicians, and that does not pertain only to the financial responsibilities for operating our practices, both large or small.

What does the catastrophic financial failure mean?

1. In the first instance it threatens many retirement investment accounts, and if your firm is not involved it at leasts makes  you very nervous about your holdings.  (where does all this money go?  Does market value really reflect the value of products produced by companies as they appear on the stock exchanges?  If the experts cannot predict what is going on,and I think they can, but withold information so as not to depress the market further and cause panic.

2. The depression of the markets  carries over to the holdings of insurance companies, and capital markets upon which major hospital construction and operating expenses depend.

3. Short term and long term credit has constricted to the point where capital is not available to most borrowers, especially to  younger physicians who are heavily in debt just from medical school loans.  Most physicians are in a negative net worth situation for the initial five to ten years of practice.

This very much effects the ability for new providers to migrate to underserved, or rural areas, without some form of support by a hospital or community.

The consolidation of the banking industry also effects the ability to obtain local credit, unless the health care borrower seeks credit from a local community source, deeply involved in a local community that shares the need to see healthcare services continue.

..............In my next blog I will review the history of present events and what corporatization has done to your medical care.

Health Train Express Bailout

Washington, D.C. September 10,2008.

Today in an unprecedented action the Department of Justice, Homeland Security, and the Department of Defense    filed an action with the first District Court of the District of Columbia to seize the Department of  Health and Human Services' all hospitals, providers and related interests in regard to the workings of the healthcare system in the United States.

This action came on the heels of the past several months of instability in the health care financing market. All health care providers and hospitals sighed a collective gasp of relief at this move.

Federal officials, HHS, the Department of Justice were unavailable for comment. Telephone calls and inquiries from media sources have not been returned.

Hospitalized patients were 'frozen' in their beds,, in surgery or wherever they  were at the time. All admissions and appointments for physician visits have been cancelled.

One of the terms of the bailout was that all insurance premiums would be made, as usual.  Payments from Medicare, and private payors were suspended.

Today's events follow a several week long crisis in the banking industry, with the seizure of Fannie Mae and Freddie Mac, who by coincidence are inpatients at Walter Reed Medical Center.

Their prognosis is extremely guarded, but the information is protected by HIPAA.

The President in his secure underground bunker beneath the West Wing of the White House held a secure video conference with the heads

of all the aforementioned departments.  He also asked that the White House be declared a "medical home".  A secure encrypted email was intercepted by Homeland Security to

(warning, some may object to part of the contact on this link)

 Dr Jay Parkinsnon for an electronic house call.   This information from an unknown source who insisted on anonymity (because he/she is not authorized to disclose this information)

Both the democratic and republican candidate weighed in with their campaign platform to sovle the challenges of financing health care in America.

Senator MacDonald

stated that it was below his paygrade and rank. (this from a close associate) because Senator McDonald was having a biopsy of his face and  was also seized during the HHS takeover.

Senator Osama Obama

stated that it was beyond his paygrade, but if elected he would be able to answer these issues, since his paygrade would increase.

Governor Palin was unavailble due to a prior appointment hunting, snow mobile racing, and caribou watching.

She would be available for comments as soon as the moose stew was done.

Senator Biden was unavailable because he was 'frozen' while in Bethesda Naval Hospital during his annual physical.

All other calls from patients were told to leave a message, or call 911 if it is really a  life and death situation....However due to the emergency you would need a credit card to reach 911.   They were also told that if their credit score was less than 799 they would be unable to reach 911.

In other late breaking news........................

WAIVER AND DISCLAIMER

The author of this information is solely responsible for this posting, which he patently admits if false. Any assumptions or actions resulting from this posting are not his responsibility and will fall upon the reader.

Health Train Carousel

Does anyone remember those 'merry go round' devices at the end of the railroad line that  revolved so the engines could be turned around. There was a circular table that rotated and one could select one of about 8 garages for the engines as well as turn them around. I haven't seen one lately do they still exist?

 

Why do I bring this up?  Well it is because our health train  engine is on that carousel....spinning and spinning, unable to get off or decide which house to get into, or turn around and go back.

Which way do we go?  Left? Obama.

Right McCain?

Stay where we are? Has anyone factored in what the cost will be to make that change? Will our economy withstand this upheaval in the midst of a real crisis, failing banks, failed Fannie Mae, Freddie Mac and probably a whole lot more we don't know about. Hospitals failing, providers leaving medical practice and one observation is the fact that insurers are "fat" in the midst of all the upheaval with "blue chip" companies such as General Motors, Ford. I wonder why?  Anyone care to comment on that?

There I was in 1964 so pleased to be going into  medicine and not have to deal with obscene corporations, business shenanigans, enjoy caring for patients, and being able to retire.

 

BOY,  WAS I SURPRISED!!

Passengers on the Health Train Express

Quote of the day:

Confusion is always the most honest response. - Marty Indik

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Our express train has many cars, pulled by a locomotive. If the train gets too long, another locomotive is added to pull or push the train along with its passengers, and freight.

The train is not as important as the riders, they are the ones on a mission, going to work, going home, going somewhere to be productive, vacation, and enjoy their freedoms in our great country. 

What is critical is that the locomotives are synchronized and pulling together and not in opposite directions.

     I will post some observations about the state of affairs in California, after this diversion. But then again, read this

It does not take a rocket scientist to observe that the political and legislative process is unable to resolve political party differences in transforming health care financing and policy.

Stuck in their universal payor vs open market competition, politicians fail to think out of the box.

Studies abound, with only temporary fixes, based upon budgetary crises, and the fact that most of medical administration is stuck in the early 1960s.

Medicare was ill conceived to begin with, yet now sets a standard for all insurers and payors,  Ironically, when medicare was first legislated it was designed to duplicate standard indemnity health coverage and cover 80% of the usual and standard fee.  (a concept long gone).   As governmental health spending increased, it became  a dominant driving force in the market.  It rapidly fueled inflation in the late 60s through the mid 80s.  The availablilty of 'easy money' for providers and hospitals was a temptation. Not because hospitals and providers were intentionally greedy, nor commiting fraud.  Prior to 1964 there were fewer elderly, and those without coverage fell into the charity safety-net of hospitals, or were given free care....hospitals almost never sent anyone to collections, there was an unwritten word that 'doctors' would figure something out to make sure their patient could receive the necessary attention and care.  It was far from an ideal system, but the diagnostic and treatment options were far less expensive.

So where do we go from here?  I am not against standards set by states, or perhaps the federal government ie  "universal standards v. universal payor.  Let's face it in the United States Universal Payor sound like socialism....not a good word in a republic.  

What is Universal Payor going to cover?

 

Adding to our dilemna is there is no real uniform policy regarding actual health care costs for each patient as related to billing and reimbursement by hospitals.  Different standards apply to different methods of payment....prepaid, capitated, DRGs, and individual contracting (largely influenced by market share)

It is difficult enough to analyze and plan health systems within the context of politics.  Politics should not reign over health care.  As long as there are resources to insure health care availablity politics seems to keep out of the patient's and providers private business.  As soon as there is not enough resources, then the government comes into play.

New Orleans

New Orleans, and the surrounding areas of Louisiana,Missippi, Alabama and Texas are faced with yet another challenge.  However this time they were prepared by being proactive. There was intense cooperation between many disparate organizations for the better good.

What a terrific example and inspiration for success...These folks did not have much of a choice, and what happened was not totally dependent upon financing, under very adverse conditions.

It was a life or death decision to survive.

To me, the comparison between that scenario and health care is obvious.  Can we survive if we do nothing? Can we come together to overcome our disparity?  Will we drown if we do nothing?

CAN WE BE PROACTIVE?

 

Do we have inspirational leaders who can step back, make decisions, or will we continue to have 'committee meetings" and never ending micromanagement, fixes and patches to shore up our dysfunctional health system?

The balkanization of United States health care has created a churning mixture of oil and water, immiscible...the only thing that keeps it going is the constant stirring of the cauldron.  The surge of water over topping the canals reminds me of our system being overwhelmed as well.

Let's pray for the people of the Gulf States.  Volunteer your time, raise funds, give generously to the Red Cross, and your faith based organizations whose mission is to aid the flood victims.

Schedule for the Health Train Express

The Thumbnail Timex

Next time you want to check your timepiece for the arrival of the health train express, you can literally put your finger on it (or thumb as the case may be.  This mini-timex was developed as a design concept for Timex.  This one literally takes "a licking and keeps on ticking".

Okay, a bit off topic, however the political conventions have me at a disadvantage.

Congressional Health Train Express

 

Quote of the day:

The greatest pleasure in life is doing what people say you cannot do. - Walter Bagehot

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The response to my recent email newsletter was surprising and encouraging.  I had a response that I wish to share with all of you.

Healthcare in the United States is on the crux of great change. During change we have broken the inertia and are able to more easily transform the system during the period of plasticity.

One proposal is in the U.S. Senate Bill  SB 1019 sponsored by Senator Tom Coburn.  Jim Rowsey MD an alumnus (along with me) of GW Medical School has been working with Senator Coburn. Together, they have prepared this video, which I would like to share with you, and ask you to forward it to colleagues.  Note that there are links in this presentation for you to prepare a letter for your senator.  Click the "A Message......

A Message from Senator Tom Coburn M.D. and Jim Rowsey M.D.

 

You may also notice a change to the logo of the  web site. This was the winning entry from a highly competitive list of suggestions.

I'm sorry the system is too busy to take your call

Quote of the day:

Whenever you have an efficient government you have a dictatorship. - Harry S Truman

 

Beginning Oct. 1, Comcast will put a 250 gigabyte-a-month cap on residential users. The limit will not affect most users, at least not in the short-term, but is certain to create tension as some technologies gain traction.  Whether or not this might extend to commercial usage, such as Health 2.0, or Web 2.0 is not addressed in this announcement from Comcast. Certainly as technological advances proceed it is difficult to predict when 'excessive use' becomes the average utilization. The  use of PAC systems, streaming video, mobile phone solutions, remote at home monitoring, and connectivity among health care sectors is growing exponentially.

In other news,  the FAA suffered a catastrophic breakdown of it's Atlanta operations center last week, causing delays in air traffic routing for several hours.  The FAA's system is outdated and obsolete, despite a decade old effort to upgrade it. The FAA has two centers, one in Atlanta, and another in Salt Lake City. This allows for some redundancy, however, neither center is capable of providing full support without overload. The two videos which follow indicate the seriousness of this problem.

Personnel problems

 

Technical Issues

 

Why is this important to healthcare?  It places in serious doubt whether the federal government is capable  of designing, installing, or maintaining a nationwide system, something Health IT interests, providers, payors, hospitals and safety net providers  should pay close attention.  Governmental process grinds along, inexorably slow, and incapable of keeping up with technological advances that health care depends upon. The governmental role might be to encourage adoption of national standards.

Comments are welcome, and welcome to all our new readers and subscribers. The response has been  awesome!!

The Temple of Obama

Quote of the day:

The world is governed more by appearances than realities, so that it is fully as necessary to seem to know something as to know it. - Daniel Webster

I couldn't ask for a better quote of the day after last night's Graeco-Roman festival.  Where were the gladiators?

 

I have been away from the blog for several days, longer than I realized.  My focus has been on the DNC and RNC conventions.

I did not hear much in the way of real programs, just left vs right, man vs. woman, black vs. white, free market vs socialism, more taxes vs. less taxes, more spending vs. less spending and what it used to be like in the 1950s  which gave me kind of a warm fuzzy

Obama is not just a great orator, but a mass hypnotist. His voice carries with it a kind of "fragrance" that overpowers your ear, and resonates somewhere in the limbic system.  Whatever it is about his voice and resonance we should study it carefully and bottle it, to be re-broadcast at some time in the future when all is about to be lost. I am concerned that somewhere in all that oratory he left us with a post-hypnotic suggestion, which will be unleashed at some unknown time in the future. (perhaps at the polling places in November). So wear your earplugs and eye blinders when you go to the polls.

I had to get that off my chest.  Tomorrow I will be rational again.