Ramblings on the Health Train

 

My day here at the government run undisclosed location started off with my morning read of health related blogs, pundits, and rumor mongers.

Buckeye Surgeon from Ohio presents a personal interview with two of his medical school chums, one in private practice and the other who is employed by the Cleveland Clinic. Rather than trusting media sources and medical management statistics, Buckeye decided to do his highly statistically significant study with a cohort of two…..My take on the interview is that some doctors like to work in a group practice, while others are individualists, and like to work alone or in a smaller controllable environment, where you have a choice of wallpaper color, who you hire and fire, and are accountable for just about all you need to practice medicine, and all that you perform. That is what is so unique and vibrant about our health care system….choices for physicians and patients.

Over at MedPolitics , and RealClear Politics The discussion turns to the uninsured.

Here is the “scoop” from t he CATO Institute regarding the uninsured, and who they really are.

 

del.icio.us Tags: uninsured,medpolitics,health train express,buckeye surgeon

Lieberman--A Voice in the Wildness

Joseph Lieberman, (IDem) Senator from the nutmeg state, CT boldly goes where no man goes before...a voice of reason, perspective and quiet reasoning. (typical of Lieberman).

One of the Senate's most powerful Democrats, Joseph Lieberman  said  Sunday that President Obama should take an "incremental" approach to fixing health care and argued that the country should postpone adding nearly 50 million new patients to the government system until after the recession is over.

"We morally, every one of us, would like to cover every American with health insurance," Sen. Joseph Lieberman of Connecticut, told CNN's John King on the "State of the Union" program.

One of the Senate's most powerful Democrats said Sunday that President Obama should take an "incremental" approach to fixing health care and argued that the country should postpone adding nearly 50 million new patients to the government system until after the recession is over.

"We morally, every one of us, would like to cover every American with health insurance," Sen. Joseph Lieberman of Connecticut, told CNN's John King on the "State of the Union" program.

"I'm afraid we've got to think about putting a lot of that off until the economy's out of recession," he added.

"There's no reason we have to do it all now, but we do have to get started. And I think the place to start is health delivery reform and insurance market reforms."

 

 

Although we physicians recognize perhaps more than most that out health system is flawed, most know that this must be accomplished in small steps, focusing first on defects in our insurance system, which lead to the increasing numbers of insured, and increasing overhead to physicians and our society in general.

In the back of each our minds are the millions of uninsured who present in our offices, on an hourly basis,  in the emergency department and public health clinics. 

The term "The Public Option" thus far remains clouded in hyperbole, sounds good or bad, depending  if your leaning is to the left, or to the right.

For many "The Public Option" remains a poorly disguised euphemism for Socialized Medicine.

del.icio.us Tags: lieberman,public option,recession

Value, Security, Beauty and Elegance

Mark Smith, CEO California Health Care Foundation, (video link)  spoke at the Microsoft Connected Health Conference meeting in June.

Comparisons between Richard Nixon’s Health Reform Proposals and Obama’s proposals..as described by Mark Smith, illuminate the similarities and differences. Read what a staunch conservative Republican proposed for a national health universal payor program.

Mark Smith and the things to get ‘right’

1. Standards
2. How will we wire doctors …nagging fear
3. Attributes for providers:
   1. Simplicity, Adaptability, Functionality
4. Attributes for “patients”
   1. Value (for the patient) solve the patients perceived needs.
   2. Security and privacy issues
   3. Beauty, elegance (something ‘they want’)

Dr Smith presented what doctors and patients would like from health IT developers.

K.I.S.S.

Health care financing in itself is a morass of complicated systems. Those who wish to make it as simple as possible, are mistakenly driven toward a universal payor model. What lurks behind the scene with that model is unknown and unintended levels of bureaucracy and the considerable expense of reorganization of the entire system.

It seems public opinion is focusing on these elements:

1. Eliminate cherry picking by private payers, elimination of exclusionary policies and waivers as well as predatory premiums.

2. A public option (which could be temporary) for lapses in employment, and/or insurability, or disability

3. Developing an actuarial insurance base that includes all citizens of the United States.

4. Elimination of free care for undocumented aliens.

5. Elimination of reimbursements based upon procedural coding.

6. Transparency and private oversight of government insurance plans and development of health IT.

7. Improve physician availablity for both primary care and specialty physicians by ''federalizing' medical licensure. Present state regulations amount to restraint of free trade. State licensing largely depends upon national testing standards.

K.I.S.S.  Keep it Simple, Stupid !

The SERMO-AMA Disconnect

Kevin MD today makes some keen observations about the recent dissolution of the AMA – SERMO connection. The sad fact is the outcome weakens the credibility of both organizations. No one knows what the ‘pre-nuptial agreement’, nor what investment in hard cash we as physicians made in SERMO. It would be nice if there were some transparency, other t han the posturing of either side.

My view is that we as physicians were hurt by these events. Neither side seems to want to own accountability for the rupture in the partnership. My guess is that The American Medical Association reacted like a ‘hurt parent’ when confronted by SERMO with the ‘truth’. The AMA and it’s board obviously did not see the relationship as mutually beneficial. The American Medical Association seems to have treated SERMO as a mere ‘marketing opportunity” for the AMA. They never really saw this relationship as a true “partnership.” Partnerships require trust, and trust requires time and actions to prove it’s worth. The AMA lost the opportunity to hear from the disenchanted physicians who no longer belong to the AMA. Perhaps the AMA thinks that by withdrawing its support for SERMO, it will wither and die. SERMO will find a number of other suitors. Mere numbers do not make any organization strong. Many ordinary decision makers and the general public no longer see the AMA as representative of doctors, and the AMA now shares the stereotyping as just one more special interest lobbying group.

Even as an early supporter of SERMO, and Dr. Palestrant’s meteoric rise in medical social networking, as well as major media, I feel somewhat chagrined, and can feel the angst of Dr. Palestrant….

I do not know the inner workings or the need for capital that SERMO required when the partnership was formed. The AMA is a much more mature and well structured organization, not dependent on the actions of one man. Dr. Palestrant seems to act alone, however I do know that I once served on an advisory council. I haven’t heard anything about that council for several years.

The fact that so few replied to the survey about the AMA is not surprising, given that most surveys have a very low yield . Also, given the fact that most doctors only occasionally sign into SERMO occasionally most missed the actual survey itself.

The fact is that doctors need the AMA, and also need organizations such as SERMO.

Other organizations have made the same observations

Daniel Palestrant, MD

Dan Palestrant, CEO and founder of Sermo.com has made the rounds of three media giants CNN,  MSNBC,  & CNBC.

In a friendly face-off with the AMA and other organized medical groups, Dr. Palestrant ably demonstrates that the AMA does not accurately represent many physicians. Of the 800,000 physicians less than 250,00 are AMA members.

What is fascinating to me is that SERMO began only three years ago as a meeting place for grand rounds, and physician to physician interaction regarding interesting clinical cases and treatments.  Members must be authenticated as duly licensed and credentialled MDs or DOs.  Sermo's 110,000 members represent all specialties of medicine from family practice to all specialties.

Members communicate almost in real time posting in different categories of interest, ranging from business, politics, practice management to each specialty. SERMO also surveys it's membership regarding clinical issues and treatment. The high interest in health reform and AMA positions on health reform stimulated active discussions on the SERMO boards, and it became apparent that 90% of participants did not support AMA positions.  Dr. Palestrant decided to provide a more formal poll of issues. In the limited time available for sound bytes he was unable to elaborate on all the other issues of concern to physicians.

Sermo has unexpectedly developed into a sounding board for previously  alienated physicians, not it's original intent.

SERMO has only been in existence less than three years.

Not only will SERMO continue to play an important part in health reform discussions, but it will also have a moderating effect on the AMA from a formerly silent minority (majority) of physicians.

Hat's off to Daniel Palestrant MD  another courageous physician and true visionary.

del.icio.us Tags: SERMO,Daniel Palestrant,AMA,Lou Dobbs,Wolf Blitzer,SERMO survey,CNBC,CNN,MSNBC

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?