Mr. President: 'Shut up!'

The above title is my own..GML

The $50,000 Gangrenous Foot

By Buckeye Surgeon

"This one just takes the cake. We're definitely going to need another Beer Summit after President Obama's latest gaffe:

"If a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they're taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that's 30,000, 40, $50,000 immediately the surgeon is reimbursed. But why not make sure that we're also reimbursing the care that prevents the amputation? Right? That will save us money."

The ignorant arrogance, it just oozes. Vascular surgeons are getting 50 grand to lop off legs? Interesting. I surely would have done a vascular fellowship if that were the case. Sounds like a gravy train. Sit around, wait for poorly remunerated, overworked primary care docs to neglect the diabetic care of their patients, and boom, one day six of them show up in the office with gangrenous feet. Jackpot!
Listen, amputation is the procedure of last resort. And generally patients don't get referred to vascular surgeons needing amputations. They get referred with rest pain or with ischemic/diabetic ulcers. And then it's a progression of intervention. Conservative care. Stenting. Fem-pop bypass. Revision bypass. Fem-distal bypass. And then, finally, when all else has failed, the patient may need an amputation. And this process is generally managed entirely by the vascular surgeon!
There are those who would say (my least favorite Obama phrase) that our President "simply misspoke". But in the context of his recent remarks on ENT docs whacking out tonsils for financial gain, I tend to think that we're starting to see a pattern. The American College of Surgeons does as well. Once again, we see the President attacking the fragmented physician faction, demonizing us as the primary source of our health care woes. And the way he opted to use leg amputation as an example; chosen randomly out of thin air or a deliberate ploy? There is no more gruesome procedure in surgery than an elective amputation. The imagery and connotation it evokes is powerfully negative--- rich proceduralists hacking off your leg for a cash bonanza. Again, this man does not speak flippantly or off the cuff. Everything is purposeful.
I eagerly await the Great One's clarification of any "misrepresentations".

Mr. Obama's speech writers and advisors on health care are more than misinformed.  They ignore (?purposefully?) the real facts, substitute platitudes and offer politically correct lies to bolster their reform proposals.   GML

The Great Medicare Debate Part I JFK-Annis 1962

1962 and 2009, what do they have in common?  Let's watch and listen to this presentation by John F Kennedy at the 'birth of medicare'.

I was there as a pre-medical student....it seems we have not come very far since then.  $12.00/month for medicare premium... Originally presented as a program that required proof of need. JFK used the argument that the government had the duty to promote the 'general welfare"....sounds good to me.

WAR GAMES

War Games?

An interesting article appeared in iHealthbeat during the past month. iHealthbeat is a part of the California Health Foundation www.chcf.org and also publishes on the internet at www.ihealthbeat.org

The article points out what ‘we’ are up against with the coming health care reform, and the massive infusion of capital into health IT.

Several clips from the article:

War Game Forecasts Future of Electronic Records

by Leonard M. Fuld and Kim Slocum

Dateline: April 3, New York, N.Y.: Microsoft makes a play for Allscripts, then failing that attempt, pursues Kaiser Permanente to create an exclusive EHR-PHR agreement with the pre-eminent managed care behemoth. Allscripts independently cuts a deal with a large health care company to expand its sales force to aggressively penetrate the 80%-plus physicians who currently do not use EHRs."

Almost none of this has happened yet -- except within the confines of a war game used to stress test company strategies in the rapidly changing electronic health records industry. This war game, "The Battle for Healthcare Information," took place this spring, employing savvy health care-experienced business school students from Columbia, Kellogg, MIT and Wharton business schools. They formed teams, representing a variety of EHR players: Allscripts, Kaiser Permanente, McKesson and Microsoft.

War Game Defined

What is a war game? It's a disciplined series of exercises designed to stress test company strategy.  It does so by introducing today's economic reality and constraints rolled together with fact-based background on all the players, mostly competitors

A key point when considering staging a war game or strategy game: Do your homework. You need to do research on each of the companies whose roles you will play or test during the exercise

Another important echo comes in the comments on blogs reporting on the game. Doctors, hospital administrators, software designers and a large mass of patients have reacted strongly. Many patients are nervous about privacy issues. Doctors both fear the administrative burden and the potential distancing from patients that this technology will bring. The technology community admits that existing systems will not stand yet cannot see who can break down these tech walls, preventing true universal adoption of EHRs and PHRs.

 

The article diverges into areas not germane to this post.

Much of what this article discusses in regard to Health IT also applies to health reform.

Drive through pediatric office

Do providers and hospitals need to play more ‘War Games”? Without this strategizing no one can tell or even prophecy about unintended consequences of health reform. Because each segment of the health care industry plays to it’s own unique players, health reform may not have it’s intended consequences.

Will the changes increase the number of primary care providers? Will the changes reduce over-utilization.

Will it equalize reimbursements between primary care providers and specialists? Will bureaucracy be reduced? How will insurance companies react to legislated and mandatory rules forbidding cherry picking, waivers and exclusions, and discriminatory premiums?

Health reform is a big ticket item, complicated and will have many repercussions.

It's important to get the political issues, assumptions and ghosts regarding the "fearsome" competitor on the table in advance.

The health care industry is a highly regulated segment of the economy and has demonstrated in the past it’s unique reaction to market pressures.

Porter’s five force analysis (see above) can well be applied to the forthcoming changes being proposed for health care. Porter referred to these forces as the micro environment. They consist of those forces close to a company that affect its ability to serve its customers and make a profit. A change in any of the forces normally requires a company to re-assess the marketplace. The overall industry attractiveness does not imply that every firm in the industry will return the same profitability. Firms are able to apply their core competencies, business model or network to achieve a profit above the industry average. A clear example of this is the airline industry. As an industry, profitability is low and yet individual companies, by applying unique business models have been able to make a return in excess of the industry average. In other words one cannot generalize about issues. Those who plan strategically with the forthcoming changes will profit immeasurably.

Undoubtedly this will also apply to healthcare, pharma, hospitals and payors. Universal payor at first glance would seem to eliminate the vagaries of the ‘marketplace”, however it is also problematic adjusting to short and long term changes.

Which Health Plan is Better??

Those of you who have read my two previous posts realize how fortunate we are to have Dr.Tom Coburn as a U.S. Senator. He uniquely represents  physicians (as advocates of the patient). and is highly articulate, and well informed.  His comments on the previous posts were from the Health, Education, Labor, and Pensions Committe during their discussions on SR 325.

WHICH HEALTH CARE PLAN IS BETTER??

The Patients Choice Act   S 1099  or:

The Democratic House Bill  HR 3200

Health Train Express--Personal Observations

 

I was just responding to a thread between several of my former classmates from GWU Med School.  After composing it and reading it I realized my thoughts probably reflect those of you who read my blog. 

 

Dear Gary,
    I thank you for your letter to Al.  Your continued leadership is a blessing.  Jim  Rowsey  On Aug 8, 2009, at 7:52 AM, Gary Levin wrote:

> Dear Al,
>
> Sorry my response was so abbreviated.  I was thinking a great deal
> about what you said about opposition vs. leadership.
>
> As you and I know this is a very complex  "industry'. Each segment
> responds to market pressures in it's own way.
>
> I agree that physicians must be leaders, as we have always attempted
> to do so as patient advocates...
>
> Frankly my feeling (and many others) is that our advocacy for patients
> and our desire to 'comply' and not rock the boat has led many segments
> to take advantage and use their own advantages to obtain what they
> desired.
>
> Now we are being asked to agree with an overall sweeping change to
> further accommodate and endorse what we already know does not work.
> Some of these changes started as far back as 1971 when the HMO act
> began a series of events that had many unintended consequences such as
> the failures of many practices, unethical marketing practices, the
> construction of many evanescent organizations which controlled
> physician referrals, closed out markets to new entrants (ie, new
> physicians). And some of these have led to the shortage of primary
> care physicians.
>
> Our present system gives more credentialing clout to insurance
> companies than state medical boards, The only group of people that
> have consistently been asked to do more for less while our overhead
> has soared is physicians and hospitals.  It is close to a miracle we
> have survived.  Many of us went bankrupt in the late 1980s here in
> California.  Medicaid is an unfunded mandate, and actually Medicare is
> as well.
>
> The devil is in the details.  I doubt if any legislator is capable of
> analyzing the impact of this gargantuan bill.  Our leadership should
> consist of careful advice in regard to the known impact and the
> unintended consequences of each portion of this 'global HR 3200.
>
> I am not opposed to change, however slick slogans and the 'crisis
> mentality'
> of our present administration is disingenuous.  Doctors have been
> talking crisis for the past 20 or more years.
>
> Change can be made.  The first is that the insurance industry must
> stop cherry picking and have a level playing risk pool. Health
> insurance should not be an employer responsibility.  That is obvious
> by the many who lose their coverage for no good reason other than they
> lost their job and COBRA rates are punitive.  If someone in their mid
> 40-50s becomes ill and loses their coverage, it is neigh well
> impossible for them to regain coverage due to exclusions wavers and
> predatory premiums. These changes are do- able.
>
> Reimbursing primary care doctors equitably would swell the ranks of
> primary care. Even though I have been an ophthalmologist the majority
> of my career, I miss many aspects of general medicine.  Primary care
> physician spend a lot of time triaging to specialists. They are not
> reimbursed for this cognitive skill.
>
> I know that most physicians have tried to be calm, reasonable, and
> also have compromised a great deal (under the economic threat of
> worse)....
>
> Perhaps the younger physicians will not know better.
>
> Americans will lose their freedoms if medicine goes the way Obama
> wants it to. We are a deeply divided nation.  I don't think we need to
> look at other countries for a 'better solution'...we have it in our
> power to develop a beter system right here, and now.
>
> The argument that if we don't do it now, it will not be done, and our
> economy, the country and the world  will go away. Balderdash!!! The
> taxpayers were forced to bail out the financial world, why should they
> be asked to continue throwing money down the toilet. (there is no end
> to medical expenses, Who wants to let their parents, brothers, etc
> die?
> Especially if mandated by a huge unfeeling government or insurance
> entity.
>
> For many years children, brothers and sisters made those decisions
> based upon their family's needs and desires.
>
> We now have to get authorizations, certifications, approvals to have a
> bowel movement. How much money does all of that cost?  A doctor can no
> longer express his anger or discontent at the hospital without being
> sent to 'anger management'  I doubt if there is a group of
> professionals who have been taught more about imperturbability and
> equanimitiy than physicians.

A word from Senator Coburn D Oklahoma, physician.
>
>

 

 

My next post will contain Part II>
> It's great that our class is still so active in these matters.
>
> My best to you , old friend...I hope your health maintains..
>
> Gary Levin
>

The failure of cost comparitive Medical Care

THANK YOU TOM COBURN

Part I is on my previous blog post.

How many rules does it take to make a Ruler?

Matt Holt, last week proposed these two basic rules to guide us in health care reform:

Rule 1 A health care reform bill needs to guarantee that no one should find themselves unable to get care simply because they cannot afford it. Neither should anyone find themselves financially compromised (or worse) because they have received care.

Rule 2 A health care reform bill needs to limit the amount of GDP that is going to health care to its current level, with an overall aim of reducing the share of health care going to GDP.

This week Uwe Reinhardt expands a bit:

Writing in his blog in the NY Times, Uwe Reinhardt sets out three overarching goals of health reform

1. Financial barriers should not stand between Americans and preventive or acute health care that they sincerely believe will address concerns over a troubling medical condition, in a timely manner, before that condition grows into a critically serious illness.

2. Having received needed health care, no American family should be so financially devastated by medical bills that it cannot meet routine daily living expenses — for example, make utility or mortgage payments on time or finance the education of the family’s children.

3. The future growth in national health spending should be constrained to fall significantly below currently projected spending growth, which has the United States devoting about 40 percent of its G.D.P. to health care by mid-century.

All other goals are subordinate to these three overarching goals, as are the means to reach them.

How do we get from here to there?

SERMO AND MSNBC.COM

Another word for SERMO. Dan Palestrant (founder of Sermo) was on MSNBC.com for another ‘debate’ with “established’ organized medicine. This time it was with the head (/Dr. William Struck ) of the Bassett Hospital in Cooperstown, New York. The argument again was about ‘salarizing’ physicians as a means of cost containment.

Viewers of this ‘sound byte’ need to know about Bassett Hospital.. Bassett Hospital operates in a rural area of Northern New York. It is a pristine small community with a fairly large drawing area of a lightly populated region. Solo private practice in that communitiy would be untenable economically. Bassett Hospital also is affiliated with Columbia University School of Medicine, and has multiple training programs for residents from Albany Medical Center (over 100 miles distant) and also from Columbia University in New York City, over 200 miles distant.

This is a unique population of physicians and their practice setting. The presence of residents in training (who are salaried at a much lower level than attendings) shifts a great deal of work load, night call and physician administration, such as record keeping to junior physicians who are not yet qualified to practice independently..

Attending physician work load in this setting is diminished when compared to other settings. The lowered physician income does not decrease overall costs, and any benefit is shifted to the administrative staff, capital expenditures, and operating budgets. Physician income is a very small component of their budget. (so is income for physicians not in integrated health care systems.)

When asked, the CEO of Bassett hospital dodged the question from about how much savings there were by salarizing their physicians. I suspect this was because he either did not know, or would not admit there are “NO SAVINGS” overall.

Dr Struck contends that salarizing physicians removes the added administrative tasks from physicians and allow them to focus on their patient care. This begs the question and denies the culpability of the insurance industry and regulatory affairs that has imposed these tasks upon the physician. It puts the horse before the cart and attempts to make physicians responsible to reduce the cost of this burden imposed by insurance and government payors.

Dr. Palestrant and Sermo join other real physician advocates in their proactive and aggressive education program for the general public.

Summer Recess

As some of us prepare for the long awaited "August" vacation, remember that your elected congressman, senators are also spending time in their congressional districts.  Keep them busy at this critical time and voice your opinions on health reform. 

Things are reaching a critical mass, and this now has national attention, with everyone weighing in...Make our voices heard, fellow physicians and health care workers.

It is apparent that some beginning of health reform will take place. Most opinions revolve around increasing availability of primary care, levelling  reimbursements between primary care (family practice for you other dinosaurs) and specialty care.

 

Rather than over all revolution it seems that the insurance companies should be the focus of initial changes in regard to cherry picking,

 

increasing risk pools and universal coverage via market economics, not government intervention. Government should act to enable this to occur via present structures rather than inventing new government bureaucracy and restrictive regulations.

It seems the critical mass has boiled down to "

THE BAUCUS SIX".

 

del.icio.us Tags: health train express,max baucus,congressional hearing,vacation,red tape,health reform,cherry picking,primary care,reimbursements

Health Train Express and Calculus

Health reform created a weird calculus of outcomes, decision makers and political intrigue

by Catherine Rampell

Update | 2:11 p.m. List of states has been corrected.

My colleagues David Herszenhorn and Robert Pear had an article on Tuesday on the Baucus Six — the group of six senators tasked by their parties to hammer out a new health care package to be considered by the Senate Finance Committee (and then, presumably, the full Senate).

The senators are from Maine, Iowa, Montana, North Dakota, New Mexico and Wyoming. A colleague noted that it’s a somewhat odd group to be asked to design a new health care system, given their constituents.

Whom, exactly, do these senators represent?

They come from some of the country’s least populous states, with no true urban centers to speak of. None of their home states contains even one of the 20 biggest cities in the country. Forget that: Of the country’s 100 biggest cities, just one is in these states (#34, Albuquerque, N.M.).

These states represent less than 3 percent of the country’s population, and hold only 2 percent of the nation’s uninsured, according to Census Bureau estimates.

It makes sense to give the residents of Montana and Wyoming a strong say in the future of health care reform, which will likely affect residents of every state. But shouldn’t someone representing a state with a few big complicated cities also have an official seat at that table, which is trying to determine a compromise that works for (almost) everyone? The way health care functions varies greatly from region to region, in terms of things like patient needs, delivery systems and resources. A more metropolitan state with a few rich, research-oriented medical facilities will operate differently, with regard to everything from expenses to treatment options to patients, from a rural state with fewer resources.

There would be a similarly problematic imbalance if the senators asked to design a template for the future of American health care were all from California, New York, New Jersey and Florida, and excluded all the Iowans and North Dakotans from the table. The plan that resulted from some Bizarro-World, urban-state-only cabal would have altogether different blind spots, of course.

This problem transcends the issue of health care reform; there are surely many occasions when the actual representativeness of our “representative democracy” seems in doubt.

But in this case — where the richer, more populous states will likely disproportionately contribute the federal taxes used for any additional government involvement in health care — it seems especially curious, not to mention impolitic, to exclude a California or a New York from the current discussions.

The Baucus Conference Room:

Last week, there were chippers — chocolate-covered potato chips — described on a sign as “North Dakota Diet Food.” More often, there are Doritos, pretzels, Oreo cookies and beef jerky: fuel to get through hours of talks on topics like the actuarial values of private insurance plans or the cost-sharing provisions of Medicare.

The fate of the health care overhaul largely rests on the shoulders of six senators who since June 17 have gathered — often twice a day, and for many hours at a stretch — in a conference room with burnt sienna walls, in the office of the Senate Finance Committee chairman, Max Baucus, Democrat of Montana.

President Obama and Congressional leaders agree that if a bipartisan deal can be forged on health care, it will emerge from this conference room, with a huge map of Montana on one wall and photos of Mike Mansfield, the Montanan who was the longest-serving Senate majority leader, on the other.

The battle over health care is all but paralyzed as everyone awaits the outcome of their talks.

del.icio.us Tags: health train express,max baucus,montane,wyoming,north dakota,David Herszenhorn,Robert Pear

CAT scans for your cat

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

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

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

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

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

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

Now it's ACO

Dear Mrs Jones;

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It’ simple, really !!

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

Wisdom on the Health Train Express

from 'GOOZNEWS'

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

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

(underlining, mine)

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

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

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

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

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

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

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