One of the problems with medical care is the lack of internal controls in

a practice.

Example:

About two weeks ago I noted a growing lump on my scalp. I went t

o see a dermatologist (a former

colleague of mine). He did a biopsy and said he would call me in t

wo or three days with the diagnosis.

He also said that if the biopsy was

positive

he would refer me to a plastic surgeon that used a surgery

center. (he did not have hospital privileges). There was some concern since I am

on blood thinners for a

stroke and several AMIs with several stents following multiple angioplasties

placing me at a higher risk. I

was concerned about the possibility of another stroke or AMI if Clopid

ogrel was stopped.

I waited four days with no telephone call. Finally, I called to find o

ut what the diagnosis was, and I was

told it was a squamous cell skin cancer. I then spoke to a receptionist who said

she would speak to the

medical assistant

...

.still no call back. I asked if they were going to make a referral to the

plastic surgeon

or should I call ? Answer

“

we will call you later this afternoon and let you know.

Good morning, it is now tomorrow and six days have gone by since the

biopsy.

My gut feeling is to find another plastic surgeon (not the one he referred m

e to) (birds of a feather, flock

together.)

Moral of the story

...

..do not be passive about lab results. Call, call, call until you

get an answer. Not

hearing anything creates great anxiety for anyone. You paid for the lab work

, you paid for the doctor

visit. This type of thing borders on negligence. Do not be passiv

e

...

it

s your life.

I have

fired

my dermatologist, especially in light of the fact I chose him sinc

e he was a former

colleague. (30 years ago). If your MD is over the age of 60 ask if they

have hospital privileges. An

unknown secret is that many senior MDs give up their hospital privileges due

to age or an unwillingness

to take call. Being an MD is a

marathon

, not a sprint. That is not to say that MDs who do not use

hospitals are bad doctors

......

..just prudent and self-aware.

Of course this is an anecdotal story. Perhaps he does call and respond to ot

her patients he has operated

upon.

P.S. He advertises himself as a

cosmetic surgeon

using lasers, creams and anti-aging compounds. In

today

s world almost any MD can call themselves

“

cosmetic surgeons

. I have seen Family Doctors

offering skin laser surgery for age spots. Always check with a hospital about th

eir privelges and what

department in the hospital they are assigned to. They should be a surgeon wi

th a designated specialty.

If this can happen to a physician, God help the rest of you. One of the problems with medical care is the lack of internal controls in

a practice.

Example:

About two weeks ago I noted a growing lump on my scalp. I went t

o see a dermatologist (a former

colleague of mine). He did a biopsy and said he would call me in t

wo or three days with the diagnosis.

He also said that if the biopsy was

positive

he would refer me to a plastic surgeon that used a surgery

center. (he did not have hospital privileges). There was some concern since I am

on blood thinners for a

stroke and several AMIs with several stents following multiple angioplasties

placing me at a higher risk. I

was concerned about the possibility of another stroke or AMI if Clopid

ogrel was stopped.

I waited four days with no telephone call. Finally, I called to find o

ut what the diagnosis was, and I was

told it was a squamous cell skin cancer. I then spoke to a receptionist who said

she would speak to the

medical assistant

...

.still no call back. I asked if they were going to make a referral to the

plastic surgeon

or should I call ? Answer

“

we will call you later this afternoon and let you know.

Good morning, it is now tomorrow and six days have gone by since the

biopsy.

My gut feeling is to find another plastic surgeon (not the one he referred m

e to) (birds of a feather, flock

together.)

Moral of the story

...

..do not be passive about lab results. Call, call, call until you

get an answer. Not

hearing anything creates great anxiety for anyone. You paid for the lab work

, you paid for the doctor

visit. This type of thing borders on negligence. Do not be passiv

e

...

it

s your life.

I have

fired

my dermatologist, especially in light of the fact I chose him sinc

e he was a former

colleague. (30 years ago). If your MD is over the age of 60 ask if they

have hospital privileges. An

unknown secret is that many senior MDs give up their hospital privileges due

to age or an unwillingness

to take call. Being an MD is a

marathon

, not a sprint. That is not to say that MDs who do not use

hospitals are bad doctors

......

..just prudent and self-aware.

Of course this is an anecdotal story. Perhaps he does call and respond to ot

her patients he has operated

upon.

P.S. He advertises himself as a

cosmetic surgeon

using lasers, creams and anti-aging compounds. In

today

s world almost any MD can call themselves

“

cosmetic surgeons

. I have seen Family Doctors

offering skin laser surgery for age spots. Always check with a hospital about th

eir privelges and what

department in the hospital they are assigned to. They should be a surgeon wi

th a designated specialty.

If this can happen to a physician, God help the rest of you.

The Illicit Perks of the M.D. Club and why Physicians are burning out The New York Times

The Illicit Perks of the M.D. Club

By VATSAL G. THAKKARJUNE 30, 2016

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Now and then I share the experiences physicians witness, even in their own nor family's care. For them it is also a challenge. Pity the ordinary patient citizen.

I received an email from Doximity, a closed professional social media site restricted to physicians. On Doximity we all share elevator talk...the few seconds of intercourse discussing patient experiences among peers. (probably illegal under the shield of HIPAA regulations.  These regulations have become more than burdensome, because they do effect patient care.

Continue reading the main storyShare This P

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• SThe article illuminates what insurance companies have done to the physician-patient relationship. This further requires the physician to impose his lessened authority on those who are supposed to serve both patient and physician. Yes there are those who abuse the system.  Physicians learn the workaround to obtain what the patient need

This story spells out one or more such situations a  physician experiences in his own care or that of a friend or family.   This process consumes an inordinate amount of time during an appeal process. One case in particular concerning a serious lumbar disc illuminates the tension of reading a guideline of prior treatment pursuant to approving a request for an MRI. MRIs by the way are considered standard practice for serious back injuries. Prolonged herniated disc problems often lead to permanent nerve injury and disability.The insurance company insisted on a six week waiting period before an MRI was approved. Their decision is based upon the fact and MRI costs $ 1,000, not the welfare of a patient.

From a Medical-legal standpoint this places the physician in jeopardy, despite his order for an MRI. Had the patient presented at an emergency department an MRI most likely would have been ordered. And since it was in an acute emergent condition it would have been pefrormed immediately and without a prior authorization.  The risk of a legal incident in the emergency setting would pre-empt any decision by the insurer. The hospital or MRI center would be the loser if an insurer retroactively did not authorize a payment. (they do not like losing money with smaller margins.).  The insurance company is under control, unless the physician insists using his authority to protect the patient.

This scenario occurs multiple times a day for most MDs.   It is a major cause for burnout, which most patients are aware occurs often early in a physician's career.

Many articles now discuss the rising tide of physician burnout, and suicide. How can it be prevented?

The loss of physician authority and the complex tension between advocating for the patient and the bottom line for health insurers creates a conundrum for the doctor. She (he) has been placed in a repeating cycle of conflict, a chronic emotional enui leading to a similar state as PTSD.(post traumatic stress disorder). Only in this case it is not post-traumatic, it is ongoing on a daily basis.

This may be the primary cause for physician burnout and suicide Doctors have been trained to work long  hours and to deal with emergencies, even in the middle of the night.

Read the entire article here...

The Illicit Perks of the M.D. Club - The New York Times

Next time you are denied a test or procedure, call your insurance company and protest vehemently. You probably won't get very far.

Insurers must share liability for thier medical malfeasance...It must not sit on the shoulders of  your physician.

Gates Annual Letter Health Initiatives

Gates Annual Letter 2013_AL_English.pdf

Affordable Care Act causing more mega=-mergers

Two mega-mergers in the health insurance industry are sparking intense debate over cost and competition.

California has two health insurane regulatory agencies:  1. Commissioner Dave Jones, and 2.Shelley Roullaard and the Dept of Managed Health Care.  The Department of Manged Health Care came into existence about 20 years ago when the boom in  HMOs occured.  

California Insurance Commissioner Dave Jones has criticized both deals — Anthem-Cigna andAetna-Humana — as being anti-competitive, and he has asked the U.S. Department of Justice to block the mergers on antitrust grounds. Jones has questioned whether policyholders will see much of the savings these companies tout in their proposed acquisitions.

But California’s other insurance regulator, Shelley Rouillard at the Department of Managed Health Care, approved the Aetna deal with a condition that the company try to keep future rate increases to a minimum. She hasn’t weighed in on Anthem’s merger.

Meanwhile, another key regulator reviewing the deals — Connecticut Insurance Commissioner Katharine Wade — has come under scrutiny because of her extensive ties to Cigna.

Chad Terhune of California Healthline discussed these developments, and the potential impact of industry mergers on consumers and market competition, last Friday on WNPR’s “Where We Live” in Connecticut.

Key regulators disagree in  approving these consolidations. Some who are smaller insurers or those forming new entities say there is adequate competition in the market place.

California’s Bifurcated Regulatory View of Health Insurance Mergers | California Healthline

Affordable Care Act causing more mega=-mergers

Two mega-mergers in the health insurance industry are sparking intense debate over cost and competition.

California has two health insurane regulatory agencies:  1. Commissioner Dave Jones, and 2.Shelley Roullaard and the Dept of Managed Health Care.  The Department of Manged Health Care came into existence about 20 years ago when the boom in  HMOs occured.  

California Insurance Commissioner Dave Jones has criticized both deals — Anthem-Cigna andAetna-Humana — as being anti-competitive, and he has asked the U.S. Department of Justice to block the mergers on antitrust grounds. Jones has questioned whether policyholders will see much of the savings these companies tout in their proposed acquisitions.

But California’s other insurance regulator, Shelley Rouillard at the Department of Managed Health Care, approved the Aetna deal with a condition that the company try to keep future rate increases to a minimum. She hasn’t weighed in on Anthem’s merger.

Meanwhile, another key regulator reviewing the deals — Connecticut Insurance Commissioner Katharine Wade — has come under scrutiny because of her extensive ties to Cigna.

Chad Terhune of California Healthline discussed these developments, and the potential impact of industry mergers on consumers and market competition, last Friday on WNPR’s “Where We Live” in Connecticut.

Key regulators disagree in  approving these consolidations. Some who are smaller insurers or those forming new entities say there is adequate competition in the market place.

California’s Bifurcated Regulatory View of Health Insurance Mergers | California Healthline

Affordable Care Act causing more mega=-mergers

Two mega-mergers in the health insurance industry are sparking intense debate over cost and competition.

California has two health insurane regulatory agencies:  1. Commissioner Dave Jones, and 2.Shelley Roullaard and the Dept of Managed Health Care.  The Department of Manged Health Care came into existence about 20 years ago when the boom in  HMOs occured.  

California Insurance Commissioner Dave Jones has criticized both deals — Anthem-Cigna andAetna-Humana — as being anti-competitive, and he has asked the U.S. Department of Justice to block the mergers on antitrust grounds. Jones has questioned whether policyholders will see much of the savings these companies tout in their proposed acquisitions.

But California’s other insurance regulator, Shelley Rouillard at the Department of Managed Health Care, approved the Aetna deal with a condition that the company try to keep future rate increases to a minimum. She hasn’t weighed in on Anthem’s merger.

Meanwhile, another key regulator reviewing the deals — Connecticut Insurance Commissioner Katharine Wade — has come under scrutiny because of her extensive ties to Cigna.

Chad Terhune of California Healthline discussed these developments, and the potential impact of industry mergers on consumers and market competition, last Friday on WNPR’s “Where We Live” in Connecticut.

Key regulators disagree in  approving these consolidations. Some who are smaller insurers or those forming new entities say there is adequate competition in the market place.

California’s Bifurcated Regulatory View of Health Insurance Mergers | California Healthline

Fantastically Wrong: The Strange History of Using Organ-Shaped Plants to Treat Disease

Eat a Walnut and treat your brain







According to the doctrine of signatures, plants and nuts and vegetables that resemble a human body part or organ must be divined by God to treat said limb or organ. Thus should a walnut fix your brain if it gets too wrinkled ... or something. Original Images: Getty

IT’S HARD TO imagine being the first human being to look at a plant like, say, a stinging nettle and think, “I probably shouldn’t eat this, on account of the general agony it would cause me. But what if I cooked it first?” So you prepare it and nervously drop it down your gullet—and luckily enough, it turns out to be edible. But what if it hadn’t been? And what if there wasn’t a decent gastroenterologist nearby?

Fantastically Wrong

It's OK to be wrong, even fantastically so. Because when it comes to understanding our world, mistakes mean progress. From folklore to pure science, these are history’s most bizarre theories.

Browse the full archive here.

For tens of thousands of years before modern medicine, choosing plants that not only wouldn’t kill you, but could cure you of ills was an exercise in trial and error. So wouldn’t it be nice if nature (or God, who I guess would also be nature in a way) dropped hints as to which ones were good for the human body? Such thinking, known as the doctrine of signatures, actually developed with remarkable frequency all around the world from culture to culture. Plants meant to heal certain organs and body parts, like the liver or the eye, must show a certain “signature” by resembling the thing they treat.

The 16th Century  physician, Paracelsius wrote extensively on the doctrine of signatures in a tiny notebook.

This may be the first example of  "Precision Medicine." 

A Shot in the Arm for Obama’s Precision Medicine Initiative

.Precision medicine is a big idea. Tailoring drugs and therapies to a patient’s individual disease, lifestyle, environment, and genes could touch off a health-care revolution, or so the thinking goes. But first there is much we need to learn about what that all means to a person’s health. That’s why the Obama administration announced Wednesday evening that it is devoting $55 million this year to the creation of a public database containing detailed health information about a million or more volunteers. It’s also why it’s trying to figure out how to better regulate the fast-growing genetic testing market.

Precision medicine is not wihout high risk, as the molecules have powerful effects, and side effects that are potentially lethal.  Hence the need for clinical trials.

Called the Precision Medicine Cohort, the database will be the “largest, most ambitious research project of this sort ever undertaken,” said Francis Collins, director of the National Institutes of Health, during a call with reporters. It will contain medical records, sequenced genomes, blood and urine tests, and even data from mobile health tracking devices and applications. Collins stressed that the database will represent people from all races, ethnicities, and socioeconomic classes, and said it will track participants over many years.

In a separate but related project, also announced Wednesday, the U.S. Food and Drug Administration published draft guidance documentson how it might police the exploding field of genetic testing. The agency is concerned that a new generation of genetic tests could risk patient safety. The technology underlying these tests can quickly and inexpensively sequence an entire genome and identify millions of genetic abnormalities at a time. But interpreting the results is still a work in progress.

Many of the tests purport to tell patients whether they have or are at risk for certain diseases and even direct them toward targeted therapies. The whole area has been largely unregulated, but the FDA aims to use its regulatory power to assess how accurate and clinically useful the tests really are.

Advanced tests like these are “pivotal to the future promise of the Precision Medicine Initiative,” said Robert Califf, the FDA’s commissioner, but that promise is only “as good as the tests that guide diagnosis and treatment.” Califf wouldn’t say when the new regulations would be finalized, but the new information should clarify some of the regulatory uncertainty facing companies that develop such tests.

                                                                     (figure 1) retina of a patient with retinitis pigmentosa:

Patients with currently untreatable neurologic diseases may benefit from novel therapies such as Retinitis Pigmentosa, Schizophrenia and Parkinson's disease.

 (figure 2) Normal retina

VC companies are investing in companies such as  Retro-sense to develop novel methods using injectables directly into the eye.

The current clinical trial is now recruiting it's initial patient cohort. To learn more about the study, it is published at Clinicaltrials.gov  

RST-001 is a gene therapy given as an injection into the eye and delivers a gene encoding a photo switch, channelrhodopsin-2, (optogenetics) to cells in the retina of the eye. When expressed, the channelrhodopsin-2 protein can depolarize in response to light thus generating a signal that is transmitted to the brain.

The study is composed of two parts. An initial dose-ranging study (part 1) is proposed whereby three dose levels of RST-001 will be studied in three separate groups of adult patients with advanced disease. This first part of the study is aimed at determining a single dose of the experimental agent which is safe and well tolerated, to further evaluate in a fourth group of patients. The second part of the study is aimed at obtaining additional safety data at the highest tolerated dose and providing important additional clinical data to guide the design of future efficacy studies.)

A Shot in the Arm for Obama’s Precision Medicine Initiative

The Personalized Doctor Experience | Arlen Meyers, MD, MBA | Pulse | LinkedIn

The Personalized Doctor Experience | Arlen Meyers, MD, MBA | Pulse | LinkedIn

ANIHFMA lauds 150 healthcare providers for leading in patient financial communications

HFMA lauds 150 healthcare providers for leading in patient financial communications

A major complaint of patients is they are unable to obtain accurate costs for their health care and visits to the hospital.

Hospitals also have good reason to join patients and complain about predictive pricing. A typical explanation of benefits (EOB) is laden with misleading information. Furthermore it makes no sense, except to perhaps an accountant or health administrator on the inside. A Medicare EOB is quite different than one from a private insurer or  a managed care program. Furthermore there are no public documents that relate true costs for each service to the amounts on explanation of benefits.

Patients must insist on receiving a full explanation of benefits and questioning the numbers as well as how they are derived.  The present system is corrupted and every patient should become a "whistleblower"

Managed care programs have different contractual reimbursement models, 

MANAGED CARE PAYMENT METHODS 

Many methods exist to pay for provider services, including discounted fee-for-service charges, and capitation. Listed below are some common terms used in insurance plans to define payment obligations on the part of a patient, provider of services, or the insurance company. 

Capitation A payment system in which health care providers (physicians, hospitals, pharmacists, etc.) receive a fixed payment per member per month (or year), regardless of how many or few services the patient uses. 

Coinsurance An insurance policy provision under which both the insured person and the insurer share the covered charges in a specified ratio (e.g., 80% by the insurer and 20% by the enrollee). 

Co-payment A cost-sharing arrangement in which the managed care enrollee pays a specified flat amount for a specific service (such as $15.00 for an office visit or $10.00 for each prescription drug). It does not vary with the cost of the service, unlike coinsurance which is based on some percentage of charges. 

Deductibles Amounts required to be paid by the insured under a health insurance contract before benefits become payable. 

Discounted Fee-For-Service An agreed-upon rate for service between the provider and payer that is usually less than the provider’s full fee. This may be a fixed amount per service or a percentage discount. Providers generally accept such contracts because they represent a means of increasing their volume or reducing their chances of losing volume. 

Fee-for-Service (FFS) Reimbursement Payment in specific amounts for specific services rendered. Payment may be made by an insurance company, the patient, or a government program such as Medicare or Medicaid. The form of payment is in contrast to payment retainer, salary, or other contract arrangements (to Physicians or other suppliers of service); and premium payment or membership fee for insurance coverage (by the patient). 

Out-of-Pocket Expense The amount not reimbursed by insurance coverage and paid by the patient such as co-payments, deductibles and premiums. 

Pharmacy Benefit Coverage of prescription drugs by an insurance company. Often, beneficiaries will have an identification card designating their eligibility and will have to pay partially for the drug in the form of co-payments, deductibles, or coinsurance. Also referred to as a “Prescription Drug Benefit.” This benefit may be offered through a company other than your health insurer. 

Premium The amount paid to an insurer for providing coverage, typically paid on a periodic basis (monthly, quarterly, etc.). 

Prevailing Charge This is a fee based on the customary charges for covered medical insurance services. In Medicare payments for services or items, it is the maximum approved charge allowed. 

Reasonable Charge A methodology used by Medicare to determine reimbursement for items or services not yet covered under any fee schedule. Reasonable charges are usually determined by the lowest of the actual charge, the prevailing charge in the locality, the physician’s customary charge, or the carrier’s usual payment for comparable services. 5 

Reasonable Cost A methodology used by Medicare to determine reimbursement for items and services that takes into account both direct and indirect costs of providers such as hospitals, as well as certain Medicare HMOs and competitive Medical Plans. 

Reimbursement Reimbursement Refers to the actual payments received by providers or patients for benefits covered under an insurance plan. 

Third-Party Payment (a) Payment by a financial agent such as an HMO, insurance company, or government rather than direct payment by the patient for medical-care services. (b) The payment for health care when the beneficiary is not making payment, in whole or in part, on his/her own behalf. 

Usual, Customary, and Reasonable (UCR) Charges Private health insurance offers the basis for reasonable-charge reimbursement of physicians. This approach was developed before the introduction of Medicare and was adopted by Medicare. “Usual” refers to the individual physician’s fee profile, equivalent to Medicare’s “Customary” charge screen. “Customary,” in this context, refers to a percentile of the pattern of charges made by physicians in a given locality. “Reasonable” is the lesser of the usual or customary screens.

Contrary to opinions of most pundits, the American health system is strong and robust. The strength can be measured by the survival of any system, at all given the proclivity for congress to make law that has little to do with enhancing patient care.

Because our health system(s) are so diverse is it's main strength. When one segment gets out of balance another one rises to the occassion. Just recently the head of the Veterans Administration forecast that many of their beneficiaries would be sent out to civilian providers in order to meet the demand of primary and specialty care.  (they must not be aware of the dire situation of civilian primary care givers.)

At its 2016 ANI event, the Healthcare Financial Management Association on Sunday named 150 healthcare providers as leaders for adopting best practices when it comes to patient financial communications, an important benchmark as patient financial responsibility rises.

The award program was developed in 2013 to call attention to providers who excel at communications around billing, costs and payment options.

"Adopting the best practices promotes trust and helps prevent misunderstandings between patients and healthcare providers," said HFMA President and CEO Joseph J. Fifer, in a statement. "In a time when patients are paying more out of pocket for their health care, clear communication about financial matters is crucial. We encourage all provider organizations to seek Adopter recognition."

The organization said 85 hospitals and 68 clinics earned the recognition, though the bulk of the awardees were part of nine major healthcare systems. Those are Carolinas HealthCare, the Duke University Health System, Essentia Health, the Geisinger Health System, Intermountain Healthcare, Novant Health, St. Luke's Health System, The Metro Health System of Cleveland and UAB Medicine. Two critical access hospitals, Henry County Health Center in Mount Pleasant, Iowa, and Maury Regional Medical Center in Columbia, Tennessee, earned recognition.

According to Rodney Williams, senior manager of patient revenue management organization at Duke University Health System, the system makes it priority to understand how the cost of care affects its patients.

"We perform a comprehensive analysis to make sure that patients are not going to be surprised by the costs they are responsible for on the back end," he said in a statement.

Providers must attest to a range of patient communication best practices to earn the adopter status, the HFMA said.

Health Train Express.....A Venue for Health Reform and Health Information Technology

Rarely have two components of our health system advanced so swiftly.  There have always been advances in the science of medicine, however the speed of advances has increased, almost exponentially.  It has been fueled by increased computing power on the  desktop, mobile apps and the cloud. At the same time the cost of storing and processing information decreased considerably.



Individual users and enterprises can access information with little cost using only browser based access to large cloud servers providing software as a service (SAAS).

Is Obamacare Universal Health Care? - Rob Schwab

Senator Hatch sponsors bill targeting Affordable Care Act

U.S. will spend $2.6 trillion less on health care than expected before Obamacare, study projects

ObamaCare Facts: Facts on the Affordable Care Act

HolaDoctor: Helping the Hispanic Community Navigate the Changing Healthcare Landscape – Telehealth and Medicine Today ™

Reports shows catastrophic rise in uninsured rate should Affordable Care Act be repealed

Texas physician: MACRA law more dangerous than Affordable Care Act

Health Care Premiums: Up, and Rising Again | RealClearPolitics

The simultaneous changes in information technology and in  health finance administration has a double sided sword effect.

The Gary M. Levin Daily

The Coming Medical School Bust

Jun 20, 2016    |    Arlen Meyers, MD, MBA

Lower-tier law schools are in trouble. The latest saga is at Valparaiso, which faced a conundrum of whether to lower admissions standards to keep enrollment up, or maintain standards and suffer from falling revenue. Soon, we may be reading about the same thing for medical schools.

The Association of American Medical Colleges predicts that medical school enrollment will increase by 30% by 2019. But, suppose they are wrong? Suppose new business models make the physician shortage a myth?

The issues sound familiar:

1. Larger and larger student debt that may take an entire lifetime to pay off. 

2. A job market that is shrinking due to macroeconomic forces and the threat of substitutes, such as technology, robomedicine, and non-MD providers.

3. Adherence to an academic medical center model that is not suitable for most schools, given shrinking and vacillating basic science research funding, dwindling state support for higher education, and dropping reimbursement for the clinical cash cow.

4. Tenure policies that are no longer economically feasible.

5.  A business model that is broken. [ Many high tier academic centers refuse to believe this reality]
6. A PhD and post doc system that creates more and more student debt with limited academic tenure track possibilities.

7. The changing sick-care landscape demanding graduates with knowledge, skills, and attitudes that medical schools refuse to teach

8. Online teaching technologies that make non-clinical face-to-face lectures and memorization, and the basic science faculty who teach them, increasingly irrelevant. There are many online courses in basic sciences that would prepare students for the Part I National Board Examinations.[Coursera is one source that could easily be expanded.. The cost would be a fraction of today's unrealistic model]
9. The potential collapse of the employed physician market with limited opportunities or desire to participate in independent clinical practice.

10. An aging and more heterogeneous physician workforce full of people who refuse to retire.[Perhaps they could not save enough to retire]

Premeds, medical students, and trainees should plan for a worst-case scenario. Just like there are many non-practicing lawyer opportunities for those with a JD degree, there will be many non-clinical practice opportunities for those with an MD degree. You should plan and borrow accordingly.
 

- See more at: http://www.hcplive.com/physicians-money-digest/contributor/arlen-meyers-md-mba/2016/06/the-coming-medical-school-bust#sthash.vL77GLWg.dpuf