Friday, January 23, 2009

Highway Robbery on the Health Train

image

Willie Sutton, a notorious bank robber was asked, “Willy, why do you rob banks?” Willy replied, “’Cause that’s where the money is”

The WSJ blog recently ran a survey about how primary care funding can be increased.  The survey can be seen here.

The comments I made,

The poll results are most interesting, revealing a fairly even split across the board. This reflects the confusion, and disparate remedies proposed to ’save primary care and health care in general. It also tells the tale that there is no easy solution, at all. Money does not tell the entire story about primary cares negative features. I lay the entire blame on government and insurers. When CLIA came along 20 years ago many physician labs were put out of business, an important revenue source, within their own practice. Imagine a business that was ‘forced’ to use outside vendors for services easily provided in house, providing ‘convenience’ to their ‘customers’….That would be step one. Step two would be to provide additonal necessary services to patients, ie, pharmacy (which may or may not be economically feasible given today’s regulatory environment. Radiology, alternative medicine, accupuncture, chiropractic, et. also throw in  fortune tellers and palm readers (not the IT kind). As Obama once said. “It’s not a matter of too much or too little government, it’s getting it straight and doing it right.” What we need to do is signal the insurers and government that we will no longer serve their clients. Patient uproar would be so great within one month we would see a huge change. How about a 30 day withdrawal from practice. a 30 day vacation….it takes most payers 30 days to pay their bills….we can do the same thing.  If the patients take their medicine they will get better in the long run, no matter how bitter the medicine tastes. 

Comment by G. Levin M.D. - January 23, 2009 at 6:35 am

Monday, January 19, 2009

The Life of Health Train Express

For almost five years now I have been blogging at this site. It has been very enjoyable. And no, this is not a farewell post, nor an explanation that I am too busy, or bored with it all.

Writing is a passion for some people, and computers and the internet give us all a new tool for creativity, networking and publication without all the hoo-ha of a formal writer’s or author’s support group, agents, publicists, book tours,  etc etc.

I have mined more from this experience, as most blogger’s have, than what I have contributed with my little blog espousing my small opinions from my perspective as a grass roots doctor.

I have written the blog with few comments made by readers, however for me it is not all about how many ‘hits’ nor comments I get.  I have refrained from ‘monetizing’ the blog as some have done.  My primary source of income has always remained clinical patient care, my  flirtation with blogging coming in  a very close second calling.  Recently I have been getting more comments and personal comments of how the blog is seen by other bloggers, Twit contacts, Facebook and the other social networking media of the ‘new generation’ of afficionados of tech. 

Sunday, January 18, 2009

Inaugural Train Express

 

 

The Health Train Express joins the Obama entrance into Washington, D.C. for the beginning of a new era for the United States of America.

I must confess, I was not a big Obama supporter, with many doubts about the man.  I may have been wrong.  His campaign rhetoric seems distant from his early administrative proclamations. 

What does the new administration bode for us in medicine?  We have seen countless new administrations telling  us now is the time to adopt universal health care.  Congress has never agreed on how to attain that goal, either due to the fact that the devil is in the details, or a lack of conviction that it is correct to do for the United States.

I leave it at this.  “God Speed” President Barak Obama, and good luck to the rest of us.

 

Sunday, January 11, 2009

Health Train Express Dining Car..."Caramel Macchiato Anyone?"

QUOTES TO MUSIC  (click to listen)

My ego has been inflated (more than usual) by inclusion of Health Train Express in Richard Reece's  700th blog.   This for me is akin to making "Oprahs"  list of books to be read before "End times".

Matt Holt's recent "WONK" summarizes Dr Reeces' consistent eloquence in each of his blogs.  Medinnovation is always a 'must read' and deserves a spot in your "feeds list".  Richard"s  blog and Matt's "The Health Care Blog"  are right up there with my

"Carmel Macchiato at Starbucks !!!

While the holiday season was ongoing this "west coast ophthalmologist" has relocated to a secret undisclosed location on the "Mid-Atlantic" coast. I decided to change risk factors from earthquakes to tropical storms, tornadoes, and an occasional hurricane.

image

 

The Warrior Refractive Eye Surgery Program, or in militarese  WRSEP

I am safely ensconsed behind firewalls, encrypted smart cards, and two levels of separate  passwords requiring 12 characters, 2 upper case, and five lower case as well as several  of those special characters, !@#$%&* (which I have to change every 90 days).  The EMR is called AHLTA.  Armed Forces Health Longitudinal Technology Application (formerly CHCS II ; US DoD military health system 

(I could go on and on about this HIT solution, but that is a topic unto itself. So stay tuned.

 

Thursday, January 8, 2009

Health Train Express--The New Engineer

Tom Daschle appears headed toward an easy confirmation as the head honcho at Health and Human Services, where he would oversee the FDA, Medicare and the NIH. Today, he had a friendly hearing before the Senate’s Health, Education, Labor and Pensions Committee

 imageHe is no stranger to the hall of congress, and most legislators will be very comfortable with him as the  point man, bully pulpit for health reform.

His early pronouncements offer no new panacea, however he does espouse the new politically correct  illusion of "transparency"

Daschle cataloged a bunch of problems with the health system, from the “unacceptable” figure of nearly 46 million uninsured to a “loss of confidence” in the FDA. He of course pledged to work on these problems. Here are some highlights:

Health Reform: In his prepared statement, Daschle said reform “cannot be dictated from the White House and Washington,” but instead must come from the grassroots and must be an open and transparent process. He pledged close collaboration with Congress.

His next pronouncement is focused on the Food and Drug Administration:" 

image

Unfortunately, there is growing concern that the FDA may have lost the confidence of the public and Congress — much to our detriment. When Americans are nervous about eating spinach or tomatoes or cantaloupes, that’s not good for our health and it is terrible for our farmers. When nearly two-thirds of Americans do not trust the FDA’s ability to ensure the safety and effectiveness of pharmaceuticals, the result is Americans may hesitate to take important medications that protect their health. This is unacceptable."

National Institutes of Health:

image

The NIH’s funding has been flat in recent years, reducing the NIH’s “buying power,” Daschle said. There’s been a sharp drop in success rates for research grant applicants, with the figure at 10% for many of the institutes, he added. The NIH has also “suffered from some instances of people putting politics before science.” He said he’ll work to “strengthen NIH.”

None  of us can do anything but wish him the 'Best of Luck" and determination.

GML

Thursday, January 1, 2009

Critical

2009 brings nothing new in health care.  Tom Daschle invited me to hold a group meeting t several weeks ago to discuss what is on the minds of the country ( a kind of town meeting forum) and present a group consensus of what should be done to reform health care and health care financing.

Today I received an email from him requesting my report, in a survey form. 

 

Obama-Biden Transition Team

Dear Gary,
Over the past two weeks, thousands of people representing all 50 states and every corner of the country have hosted health care discussions in their homes and communities. Just this week, I attended a discussion hosted by the Fire Department in Dublin, Indiana, and one hosted by a Senior Wellness Center in Southeast Washington, D.C.
Leading your discussion was the first step. Equally important, we want to hear back from you. I learned so much from attending discussions this week, and we want to know about your discussions, too.
The President-elect has asked me to share your feedback from these discussions -- that's why your submission is so essential.
Please tell us how your discussion went by visiting http://change.gov/reportback. We need to hear from you as soon as possible -- by Sunday, January 4th, 2009 at the latest -- so we can prepare our report for the President-elect.
Both President-elect Obama and I are committed to reforming the health care system from the grassroots up -- and leaders like you are crucial to that effort.
I'm looking forward to reading your submissions about your Health Care Community Discussions.
Thank you,
Tom
Tom Daschle
Secretary-designate
Department of Health and Human Services

Matthew Holt on The Health Blog accurately assesses this effort and mirrors my personal opinion on the liklihood of a political solution for what ails health care in America.

Matt's  takeaway points are:

Like legions of other wonks when I discovered that Tom Daschle was going to be Obama’s point guy on health care, I sent off for a copy of his book Critical. It’s a fast and easy read, but in its examination of the problem it doesn’t add much to superior books on what’s wrong with health care (much of the first section reads like an undergrad’s attempt to summarize Jonathan Cohn’s Sick) and there are some pretty weak logic flows and basic editing throughout (he refers to the book Uninsured in America on p155 as though it’s already been introduced before it actually gets introduced on p161). But ignoring all that, what does Daschle suggest we actually do?

The ill-fated & exclusive White House study groups of Feburary to May 1993 are therefore only to be repeated in set of window dressing home study groups & Internet bulletin boards—who’s participants will have as little actual positive impact on health reform as Ira Magaziner did in 1993–4. Still the process now is notably open.

Daschle likes and wants to see more of. Mental health parity is one, dental insurance is another, and long-term care a third. To be fair these are three areas crying out for a better solution, but Daschle doesn’t make it clear how we’re going to expand the current definition of insurance to include them. In addition these are areas for which Medicaid is the current de facto half-assed solution. Medicaid is a program Daschle likes, while many health policy wonks (well me anyway) think it should be abolished and rolled into a genuine universal social insurance system, or at least (as Paul Krugman suggests) be Federalized and thus removed from the vagaries of state budgets.

But the actual coverage solution Daschle proposes, which is pretty similar to the ones emanating from Clinton & Baucus are basically to expand FEHBP and give it both a Massachusetts Connector-type role and include in it a buy-in to Medicare, and to impose a pay or play option onto employers. Somehow he’d also expand Medicaid and S-CHIP, and then add to all this an individual mandate with subsidies to those who can’t afford to buy-in to FEBHP. The whole thing is tied together, sort-of, by a Federal Health Board

Daschle is damn lucky that he didn’t call his board Fannie Med, but he’s also unlucky in that he links it to the success of the Federal Reserve at a time when that “success” is looking, shall we say, shaky. However, the main role of the Federal Health Board would be as a cost-effectiveness review organization with teeth—in that Medicare, Medicaid & FEHBP would all be bound to follow its guidelines.

So the problem with this always comes back to two things.

One; most of the uninsured are working poor and their employers are the NFIB small employer crowd who are all for health reform until they figure out that it means they have to pay for it. Even despite the incredibly confused rhetoric coming out of NFIB lately, my guess is that only a puny Massachusetts type “pay” fine ($213 or so) will be little enough to get them to willingly back a public and compulsory plan for their employees. And of course at that point all but the richest of the remaining 55% or so of small employers who offer coverage will ditch it too, meaning that the public subsidy for the working poor to get insurance will have to be much greater than Daschle thinks. Not to mention the continuing administrative nightmare of figuring out whether someone should be in Medicaid, the new plan, or covered by their family member.

Second, while it may be getting harder and harder for the Sally Pipes of the world to get people worried about rationing when it’s clear that we already have it here but that they don’t really have it in Switzerland, Germany or France, the Federal Health Board will be fought tooth and nail by the industry. Sally Pipes is the author of "Miracle Cure"

As I’ve been saying for a long time, to rationally rationalize the health care system, we need to make cardiologists in Miami behave like cardiologists in Minnesota with a consequent impact on the incomes of doctors, hospitals and stent & speedboat salesman in high cost areas (Yes, Jeff, I do mean Louisiana, New York, Los Angeles and Boston too). If the Federal Health Board has teeth, that’s what it’ll do, and the AMA, AHA, AdvaMed, PhRMA et al know it.

So my guess is that the Federal Health Board, if it gets established, will get defanged by lobbyists immediately. The consequence of that is that the mish-mash of an “expand what we got now” system will cover a few more people at a lot more cost (as has been the Massachusetts experience). That’s OK because suddenly we’re rich (or at least suddenly the government is pretending it is!).

 

There is much more to be read on Matt Holt's Health Care Blog.
----


Thursday, December 25, 2008

Health Train Analytics

No degree of dullness can safeguard a work against the determination of critics to find it fascinating.
  - Harold Rosenberg

***************************************************

This is my preface for today's stories

It's the end of 2008, and between nodding off and consuming egg nog there are some interesting blog writings, analyses, and reports emanating from various congressional reports, foundations, and health care think tanks.

If you are a pessimist the tanks are half empty or even empty, if you are an optimist the tank is half full.  If you are like most people, the 'tank' is meaningless and does not apply to the real world.

There is a certain amount of common sense that is lacking in many things we now have to deal with in our daily lives.

******************************************************

Robert Laszewski in THCB writes about two reports from the CBO detailing the options for reform of health care policy.

Caution, this is over a 600 page report, all written by Peter Orszag, Director of the CBO.

Mr Orszag is President-elect Obama's nominee for Director of the Office of Management and Budget.

Key Issues in Analyzing Major Health Insurance Proposals

Budget Options for Health Care (Volume 1)

Federal Perspective on Health Care Policy and Costs

Abbreviated summaries of the articles are here.

Key Issues

Budget Options, Volume 1

  • Robert Laszewski opines, "After reading these two reports, totaling more than 400 pages of some of the most valuable health policy analysis I have ever seen, I now know that I had no reason to worry that the CBO would just tell the politicians what they wanted to hear."
  • "It is also clear that, whoever the Congressional Democratic leadership appoints to succeed Orszag, a marker is down. The CBO is on the record about what the likely reform options will cost before anyone had a chance to bring political pressure to bear. And, that just might have been intentional."
  • "The work contains an inventory of about all of the health care reform options being discussed complete with a thorough cost/benefit analysis detailing their impact on federal spending."

More details are forthcoming for the reader at The Health Care Blog, 

NAIVE POLICY MAKERS NEED NOT APPLY

 

I agree with Docanon that this is the best article on the subject I have read thus far.  Kudos to Mr. Laszewski......and to Peter Orszag.

Wednesday, December 24, 2008

Content for 2008 Health Train Express

The end of 2008 certainly has been remarkable. What unexpected cataclysmic events await us in 2009? Will what we have experienced in 2008 give us a better understanding of other impending chaos, without our taking serious proactive measures, rather than retroactive reflexes.??? Read more at Health Train Express

Monthly Content for Health Train Express—December 2008

Primary Care

Interruption

Express 2008

Denoument

Brain Train and Fitness

Transitions

Transparency

Bailout

Cooling Down

Throwing Money

Consensus

Transition Team

Arogant Physicians (Surgeons)

Hypoprimarenia

And have a safe and blessed Christmas.

Tuesday, December 23, 2008

Primary Care needs to get on the Health Train Express

Richard Reece MD of Medinnovation Blog is the rare breed of specialist (in his case, pathology) who waves the flag and cheers on the family physician, and general practitioner in their battle to survive.  Even I as an ophthalmologist will join his efforts and realize if primary care can be picked off then all of us are very vulnerable.  No specialist should be excited about the impending doom of PCPs and the secondary loss of patient access to healthcare in America. 

The American College of Physicians has sent a letter to President-elect Obama via HHS Secretary designate Tom Daschle requesting a ten percent bonus for primary care physicians alloted from the economic stimulus package.

Tom Daschle has been handed to our physician group without our input and/or comments. He has still yet to be confirmed, and all readers should make comments regarding his appointment. Daschle knows bupkas about caring for patients, and may be a great negotiator 'across the aisle' and deal maker to get healthcare legislation passed.  Perhaps the message has not been presented to our group.

Mr Daschle correctly analyzes our problems in the article he published in the Huffington Post.  Re Progressive Solutions to Health Care.

However, his ideas about a 'Federal Health Board,  for Healthcare' comes at a very inopportune time given the failure of our Federal Reserve Bank  for the Financial Markets.  It is doubtful that an agency of that size could truly keep track of anything.....

Monday, December 22, 2008

Health Train Interruption

Sorry I have been away the past week, moving from California to Georgia.  I've been looking for a 'retirement phase out" and appear to have found one.  Once I settle in I will be able to alot scheduled time to my newly acquired fondness of blogging.

image

Known for it's peanuts and peaches and pecans

image

image

image

Tuesday, December 16, 2008

Health Train Express--2008

The end of 2008 seems a good time to review the state of health information technology and the progress of Electronic Medical Record implementation.

Much has not occured since 2003 when GWB appointed David Brailer MD as the National Coordinator for Health Information Technology (ONCHIT). Initially, like all new things, ONCHIT attracted a great deal of publicity.  It stimulated the organization of CCHIT, a national certifying authority for producing interoperable information systems, assuring the compatibilty of different vendor offerings to move toward a goal of the National Health Information Network.

During the ensuing years, the most successful vendors became CCHIT certified, but now without annual costs paid for by the vendorss themselves to become certified each year.  These applications also are the largest companies and the most expensive software.  While bolstering interoperability, at the same time many vendors have disappeared because of  the CCHIT requirement.  The industry consolidated leaving fewer vendors.

All of the media excitement and cheerleading is now led by promises (mostly empty) of bailout funding.  Admittedly some states have ponied up to the bar with funding for EMRs. However, these 'integrated systems and EMR are limited to mostly public sector agencies. Little money has trickled over to private practice.  And this group needs it  most.

MRI (The Medical Records Institute) released it's Status Report, 2008, by it's  CEO C. Peter Waegmann.

iHealthbeat regularly charts the progress and adoption of EMRs several times each year.  It is my estimation that these figures are biased.   Many users report the use of EMRs which do not offer many functionalities which should be inherent in an EMR.

It is true that some practices have adopted electronic prescribing. and one or two other functionality.

The Chart below is taken from National Health Care Surveys done by the CDC.

infosheet_nhcs_fig1 (1)

The fact that EMR adoption has lagged does not take into  account the adoption of health information technology available via the internet and other sources.  The parallel development of Health 2.0 online services and mobile devices, such as smartphones, Personal digital assistants, and others hand held devices reflect the interest and willingness of physicians to utilize IT when cost effective. Adding to this strong trend is the deployment of high speed 3G cellular technology which empowers internet use almost anywhere.

A new survey found that 58% of U.S. physicians surveyed go online for clinical information at least two times per day. More than three out of four respondents said they go online for clinical information more often now than they did a year ago, according to the survey.

By now, most providers are familiar with software offered by third  parties as downloadable applications.

In 2008, 84% of physicians surveyed reported using the Internet and other technology to find information about pharmaceuticals, biotechnology and medical devices, up from 64% in 2004, according to a survey

 

Utilization of Health IT by Patients

A new survey found that 31% of non-elderly Americans with private health insurance and Internet access have used an online physician or facility finder. Meanwhile, 16% reported using an online health plan selection tool and 10% have used an online health care cost information tool.

Privacy Issues

In 2008, 62% of U.S. adults age 21 and older said they were not too or not at all confident that electronic health records would remain confidential, while 12% of survey respondents said they were extremely or very confident that EHRs would remain confidential

The area of explosive growth of health IT is in electronic prescribing. 

Fueling this growth is CMS's indication that users will receive a 2% bonus for using ePrescribing.

What does 2009 have in store?

iHealthbeat reports:

Nearly half of health IT professionals surveyed said that Democratic control of the White House and Congress will strengthen efforts to promote patient safety and the use of health IT, according to a new survey from the Healthcare Information and Management Systems Society.

Fourteen percent of respondents said that Democratic control of the White House and Congress will weaken efforts to promote patient safety and the use of health IT, while 29% said that it would have no impact and 9% said that they did not know what kind of effect it would have, according to the survey.

Meanwhile, 20% of respondents said that President-elect Barack Obama's proposal to spend $50 billion over five years on health IT is sufficient to advance health IT adoption, while 46% said that the funding would advance health IT adoption but that additional funding would be required to truly accelerate adoption. Fifteen percent of respondents said that Obama's proposed health IT funding is insufficient.

Results are based on a November survey of 622 health care IT professionals.

Source: HIMSS, "2008 Presidential Election"

 

This appraisal is based upon uncertain funding, intense competition for federal dollars, an exploding federal deficit, and many other unknowns. 

 

Saturday, December 13, 2008

Health Train Express--Denoument

Today we are changing from the train to an airliner. I do my best 'creative thinking', or perhaps I become a bit delusional at 40,000 feet. Perhaps it is the reduced atmospheric pressure or  decrease in oxygen.  No matter...it is the end result here that is important rather than the science.

An economic survey, or just reading the news tells us that financial institutions have failed.  Our industrial production base has changed, and what was once the bastion of middle class attainment, the automobile companies in the United States have tanked.

As I fly over the United States I see Wall Street in ruin, empty houses, unfinished home construction, and

a hole in the ground where the world trade center used to stand, the midwest where steel factories and other heavy manufacturing plants lay rusting in the cold damp winters, and in the warm humid summers.

We in health care bemoan our sad state of affairs as health  care costs have risen seemingly without end and naysayers who say most of our money is 'wasted' with little evidence for better outcomes and better health. 

Actual facts dispute this. Evidence and statistics show that mortality has changed. Fewer heart disease deaths, a drop in mortality from infectious diseases, and relatively more deaths from cancer. The increase in death and morbidity from cancers may more be a reflection of  increasing survival .

Despite these facts healthcare has now become a major backbone of  financial flow....health care provides employment for millions of Americans. 

image

The economicengines of the United States are service industry,  healthcare, education,  government (at all levels), regulatory agencies,public safety,the judicial system, technology, and communications. ( I leave entertainment as another driving force)

My previous post relates to the merger of health, prevention and entertainment.

Stepping back from all of this I think, what better use of our resources is there than keeping one another healthy.  What finer product is there than the human body?  What product grows and maintains itself automatically for up to 75 to 85 years?

 

Friday, December 12, 2008

Brain Train Express

FB_Brain_Mind_Map_350x255px

For those of you who have not noticed videogaming is a 3 billion dollar industry, and is fluorishing during hard times.  For one thing it has a lot of 'bang for the buck',  compared to theme parks, movies, and does not use any fuel.

It also turns out that 16% of the gaming market has to do with health and fitness.  Yes,that's correct, you couch potatoes can use brain power as well as fitness training with interactive Wii (Nintendo) games.

Here are some examples:

Flaghouse  

PE & RECREATION

SPECIAL POPULATIONS

ACTIVITIES FOR LIFE

SENSORY SOLUTIONS

FITBRAINS

PHYSICAL FITNESS VIDEO TRAINING

POSIT SCIENCE BRAIN FITNESS PROGRAM CLASSIC

TRY AN INTERACTIVE DEMO HERE

EXERCISE IN A BOX

DANCE  DANCE REVOLUTION

 

BEFORE

 

AFTER

EVIDENCE BASED MEDICINE