Monday, December 14, 2009

Et Tu, Mayo? Medicare Expansion Won’t Get Us There - Mayo Health Policy Center Blog

Medicare Expansion Won’t Get Us There « Health Policy Blog:

A very disappointing post from the Mayo Health Policy Center:

Proposal Would Not Increase Access to Health Care Services or Control Costs
The current Medicare payment system is financially unsustainable. Any plan to expand Medicare, which is the government’s largest public plan, beyond its current scope does not solve the nation’s health care crisis, but compounds it. We need to fix Medicare by moving it to a system that pays for value – quality health outcomes that are affordable over time – and ensure its success, before bringing more people into a broken system.
Expanding this system to persons 55 to 64 years old would ultimately hurt patients by accelerating the financial ruin of hospitals and doctors across the country. A majority of Medicare providers currently suffer great financial loss under the program. Mayo Clinic alone lost $840 million last year under Medicare. As a result of these types of losses, a growing number of providers have begun to limit the number of Medicare patients in their practices. Despite these provider losses, Medicare has not curbed overall spending, especially after adjusting for benefits covered and the cost shift from Medicare to private insurance. This is clearly an unsustainable model, and one that would be disastrous for our nation’s hospitals, doctors and eventually our patients if expanded to even more beneficiaries."

I simply have to call BS on the figure of how much money Mayo loses to Medicare. We know Mayo is one of the high performing providers and so should be doing far better.

From Ezra Klein:

On March 17th, Glenn Hackbarth, the chairman of MedPAC, testified before the House Ways and Means Committee on this very issue. Hospitals, Hackbarth argued, are inefficient. Their costs are too high. And this was backed up in the data. "MedPAC analysis has identified a set of low-cost hospitals that consistently out-perform other hospitals on a series of quality measures, including mortality and readmissions," Hackbarth explained. "Among this set of hospitals, we found that Medicare payments on average roughly equaled the hospitals’ costs." In less "efficient" hospitals, Medicare's payments were below costs.


Among the major differences between "efficient" and "non-efficient" hospitals was that the less-efficient hospitals were not under financial pressure: They made a lot more money from other sources. As such, they spent a lot more money on things like capital expansion. As example, compare the amount a young journalist spends to the amount a young investment banker spends. The banker requires more income to break even on that lifestyle. His "cost" is higher. But he doesn't need that lifestyle. He doesn't need that "cost." And if that banker is being paid on taxpayer dollars, I don't want him to have that lifestyle. I want him to have what he needs, rather than what he wants. Because I'm paying for it.
And so too with Medicare payments. Indeed, what MedPAC found was that hospitals under "financial pressure" -- hospitals that made less money, in other words -- managed to control their "cost" better. Medicare's payments sufficed for them. And their quality outcomes weren't any worse.

This is a remarkably "retro" viewpoint from Mayo, which has taken progressive stands on cost containment, reducing over utilization of procedures and testing, chronic care management and the like. To hear them call Medicare unsustainable is surprising. While I agree that Medicare payment has to be radically changed in some areas, the only thing unsustainable is our current course!

And, regardless of what Mayo "believes" about government run entities (which they disparage in their piece), government run or strictly regulated systems consistently outperform the US system in France, Germany in many other places. The ACP Policy Committee has recognized this for years and has advocated for a single payer system like France or a hybrid system like Germany's for many years.

And one more thing, wouldn't you rather get paid by those expensive 55-65 year olds who don't have insurance instead of eating it (or eating part of it, and bankrupting families)? I realize the Mayo's catchment area has few uninsured, but consider the rest of the country in making pronouncements!

And the Mayo release has been picked up by Fox News for goodness sake! In a fair and balanced piece on Medicare expansion, of course.

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Physicians on Health Reform, UPDATE!

Update 1/23/12 : the ASA, No. 7 below did not support the HCR Bill, just a Public Option. See the full correction here. My apologies. 

Below are the largest physicians organization, in order, with estimated membership numbers based on their own websites (or other sources when the Web Site didn't have them).

All are YES on reform with Public Option except 11 and 12 as noted below.

1. AMA 240,000
2. ACP 126,ooo (Internists and many medical subspecialists)
3. AAFP 94,000 (Family Practice)
4. ACS 76,000 (surgeons)
5. AOA 67,000 (osteopaths)
6. AAP 60,000 (pediatricians)
7. ACOG 52,000 (ob-gyn)
8. ASA 43,000 (Anesthesiology!)
9. APA 38,000 (psychiatry)
10. ACC 37,000 (cardiology)*

NO: 11. ACR 32,000 (Radiology - Not on Board)*
NO: 12. ACEP 27,000 (Emergency Medicine - Has policy statements, no stand on bills)

13. AGA 17,000 (gastroenterology)

14. It gets a little fuzzy from here on. I think Dermatolgy with 14K is next (they are against a public option), but there are probably organizations that I'm not thinking of that belong in here. Please fill me in and I will update accordingly.

SO, actually, the BIG NEWS is that 10 of the 10 largest physician organizations support health reform with a public option.

[*I had mistakenly put Radiology above Cardiology. But I checked the numbers again today, and these, I think are accurate as they are from the society's websites. PLEASE correct me if you think I've erred.]

State Medical Societies (these are rough estimates):

1. Texas 43,000 Against Senate Bill, member survey: more worried about govt than private insurer interference in medicine.
2. California 35,000. Sent letter of support to AMA
3. NY 30,000. Sent letter of support to AMA
4. PA 20,000. Sent letter of support to AMA on principals, not specifics
5. Florida 19,000. Has set of principles, no specifics
6. Illinois xx,000. For reform, worried about Medicaid expansion (low reimbursement) and no fix for SGR in Senate)

If you'd like to add your state to the list or correct what I have, please do and I will put it up on my blog.

And, of course, don't forget the recent NEJM published surveys of physicians' opinions on reform.

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Wednesday, December 9, 2009

Gawande on what agricultural reform can teach us...

Testing, Testing by Atul Gawande

"America’s agricultural crisis gave rise to deep national frustration. The inefficiency of farms meant low crop yields, high prices, limited choice, and uneven quality. The agricultural system was fragmented and disorganized, and ignored evidence showing how things could be done better. Shallow plowing, no crop rotation, inadequate seedbeds, and other habits sustained by lore and tradition resulted in poor production and soil exhaustion. And lack of co√∂rdination led to local shortages of many crops and overproduction of others.

You might think that the invisible hand of market competition would have solved these problems, that the prospect of higher income from improved practices would have encouraged change. But laissez-faire had not worked. Farmers relied so much on human muscle because it was cheap and didn’t require the long-term investment that animal power and machinery did. The fact that land, too, was cheap encouraged extensive, almost careless cultivation. When the soil became exhausted, farmers simply moved; most tracts of farmland were occupied for five years or less. Those who didn’t move tended to be tenant farmers, who paid rent to their landlords in either cash or crops, which also discouraged long-term investment. And there was a deep-seated fear of risk and the uncertainties of change; many farmers dismissed new ideas as “book farming.”

Another inciteful piece showing how far agriculture came in a few short decades by experimenting and scientifically evaluating methods for improvement and the parallels for us in this centuries health reform debate. How does he come up with these?

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An Interview With Thomas Russell for Health Affairs

Health Affairs Blog link to full interview.

John Iglehart, one of the Founders of Health Affairs posts an interview with surgeon and retiring Executive Director of the American College of Surgeons. There are quite a few pleasantly surprising moments in the interview, which I'll bullet here, but you can go read on your own.

  • Q. I would assume that more than a few surgeons regard such activity as an intrusion into the independent practice of medicine. Is there a generational difference among surgeons in their willingness to cooperate or at least participate in these kinds of initiatives?
    Russell: Absolutely. The younger surgeons have trained in an environment in which they to expect that the quality of care they deliver will be measured and evaluated, so they don’t really have any difficulty participating in these activities. It’s some of the older physicians who entered practice in a more autonomous era who struggle with these new forms of oversight.
  • First, let me say that the surgical community is not homogeneous, and they’re all over the map on reform. The College has a split membership. Some surgeons think that the status quo is just fine and that greater oversight and accountability are unnecessary. They view them as intrusions into the autonomy of a sovereign profession, while others are all in favor of reform.
    There is at least one matter on which I think we mostly agree, and that is the fact that we have to do something to fix our broken payment system. So, the number-one change that I would like to see emerge from the health care reform debate is fundamental, long-term improvement in how physicians are paid, so that they really are being paid for providing cost-effective, high-quality services.
  • Iglehart: Would that mean, according to your vision, an abandonment of the fee-for-service payment model and going to an alternative model, or some kind of a hybrid?
    Russell: I recently addressed a large group of surgeons and asked them whether they are paid a salary, and most of them raised their hands. Throughout the nation, more surgeons are becoming salaried professionals. Most academic surgeons as well as those in integrated delivery systems—such as the Mayo Clinic, Geisinger, Kaiser, and many others, including Veterans Affairs—are on salary. So are doctors who are employed by the VA. I think it’s safe to say that more than 50 percent of the nation’s physicians are paid a salary. And, some of the happiest doctors whom I’ve met are the salaried ones because they don’t have to deal with the hassles of malpractice insurance, including the high premiums they pay, or coding, or any of the other administrative burdens that confront physicians who are in private practice and reimbursed through the complicated fee-for-service system.
  • We also need to look in a very thoughtful, ethical way at rational – I’m not using the word rationing, I’m using the word “rational”–ways to improve end-of-life care.
    In addition, the medical and surgical professions need to develop protocols for the best ways to approach diseases. We need policies about when scans, such as a CTs and MRIs, are indicated, and to make sure they are not unnecessarily repeated by another physician. And we must develop standardized ways of treating diseases so that every health care professional involved in coordinating a patient’s care is addressing the condition in the most cost-effective way that follows the scientific evidence.
  • For instance, I think that the Number One way to help patients avoid frivolous trips to the ER is to educate them about where they should turn to receive appropriate care for nonemergency conditions and to make certain they have access to primary care physicians. [We do a poor job of getting people into PCPs- cmhmd]
  • Here’s how this maldistribution of surgeons has arisen. About 80-90% of medical school graduates who pursue surgery as a specialty begin their residency training in general surgery. After five or six years of residency, and at ages 32 to 34, many pursue additional training in a fellowship that will allow then to focus on just one type of disease or organ that general surgeons treat and operate on. That is to say, they become super-specialized in breast surgery, minimally invasive surgery, bariatric surgery, cardiac surgery, or cancer surgery. So they’re taking themselves out of the pool of professionals who can perform the broad range of general surgery procedures. And, most of this highly specialized surgery is performed in large cities, so these surgeons are not typically accessible to rural patients.
  • Organized medicine and many Republican legislators have long argued in favor of capping awards for noneconomic damages, but I don’t believe the nation will ever reach a consensus on that proposal, although a few states have implemented the limits. I think instead more efforts should be made to educate, in this case surgeons, about how to avoid or better manage risk by staying within their scope of practice. Communication with the patient and his or her family throughout the surgical experience is also key to helping these individuals understand why there was a negative outcome. When a mistake is made, apologize, if you practice in a state that has passed legislation providing legal protections for saying, “I’m sorry.”
    Very important, too, is for the profession to develop evidence-based best practice protocols and for physicians to follow them closely. In my era, we objected to this form of standardization and called it “cookbook medicine.” But, as calls for accountability have increased, lawmakers should consider setting policies that protect physicians who adhere to professionally developed protocols. In these cases, if a patient sues because of a bad outcome, the physician can respond with a legitimate defense: ”Look, I followed the protocol that we all agreed was best practice. I’m sorry for the bad outcome, but a bad outcome does not equal malpractice. [Except for this and people like Bernadine Healy, who should know better -cmhmd]

Thanks to Mr. Iglehart and Dr. Russell for the informative interview.

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Monday, November 30, 2009

A Senate Minority Hijacks Health Care - Pittsburgh Post-Gazette

A Senate Minority Hijacks Health Care - Pittsburgh Post-Gazette

According to the U.S. Constitution, each state is represented by two senators, regardless of population. This arrangement is the legacy of a deal struck in 1787 at the nation's founding, partly to keep the slave-owning states from exiting the then-fledgling nation. As a result, California, with more than 36 million people, has the same number of senators as Wyoming, with a half-million people.

That disproportional allocation has only gotten worse over time. When the Senate was created, the most populous state had 12 times more people than the least populous state; now it has 70 times more people. In the 1960s, the Supreme Court established the groundbreaking principle of majority rule based on 'one person, one vote,' meaning that all legislative jurisdictions must be equal in population. This applied to the U.S. House of Representatives, yet the U.S. Senate completely violates this fundamental principle.

As a result, the 40 Republican senators represent a mere third of the nation, meaning Republican voters have more representation than everyone else. That overrepresentation is bad enough, but it gets even worse. For the United States has added an arcane layer of parliamentary procedure known as the 'filibuster' that takes us out of the frying pan and into the fryer.

The Senate's use of the 'filibuster' means you need not a majority of 51 votes, but 60 votes to stop unlimited debate on a bill and move to a vote. So a mere 41 senators can kill any legislation. The 40 Republican senators representing only a third of the nation need to peel away only a single conservative Democratic or independent representing a low-population state like Montana, Nebraska or Connecticut to torpedo what the senators representing two-thirds of the nation want.

Given such a vastly mal-apportioned and unrepresentative Senate wielding its anti-majoritarian filibuster, it is hardly surprising that minority rule in the Senate consistently undermines majoritarian policy. Besides health care, senators representing a small segment of the nation have thwarted renewable-energy policy, sensible automobile mileage standards, cuts in subsidies for oil companies, tougher campaign-finance reform, congressional oversight of national security and war, and more.

Minority rule in the Senate has been with the nation for a long time; in fact, it is widely blamed for perpetuating slavery for decades (between 1800 and 1860, eight antislavery measures passed the House, only to be killed in the Senate). For all these reasons, two of America's most revered founders, James Madison and Alexander Hamilton, opposed the creation of the Senate, with Hamilton warning in Federalist Paper no. 22 that representation in the Senate "contradicts the fundamental maxim of republican government, which requires that the sense of the majority should prevail.

This was written by Steven Hill, "director of the Political Reform Program for the New America Foundation and author of "Europe's Promise: Why the European Way is the Best Hope in an Insecure Age," which will be published in January."

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Thursday, November 19, 2009

Evidence Based Medicine and Reform

This week has been very disappointing, with the USPSTF breast cancer screening guidelines coming out and recieving such an intemperate analysis by virtually everyone with access to a microphone or a camera.

Here is a very thoughtful analysis for those who are interested, but I'm really writing this because of what it says about us as Americans and our love-hate relationship with science.

So, researchers at USPSTF have made an evaluation and recommendations that fly in the face of "common sense." Common sense in America being that more is always better, whether it be testing or surgery or whatever. You can't be overtested, there are no downsides to excessive intervention. Except when there are. I will not go into the downsides of overtesting and overdiagnosing, but it really bothers me that we look to science to advance medicine, to make breakthroughs, to guide treatment and yet, we get a recommendation that falls outside of what we "know" to be true, we flip our collective gaskets.

Apparently, sensing opportunity, Glen Beck had on Bernadine Healy, whom I remember becasue she was in a position of responsibilityin Medicine (she was the Director of NIH from 1991-93), and she apparently doesn't care much for scientific thinking. She trotted out the old saw about prostate cancer survival being better here in America than in the UK because, obviously, the British hate their citizenry.

I have this debunking on the blog here, and it is basically that screening finds things that don't need treatment, but treating all of these cases as if they are life threatening makes our numbers look good. For a better estimate of how the US really does in saving people for dying from preventable causes, go here to see we have the distinction of being 19th out of 19.

But hearing about Ms. Healy being on glen beck reminded me that I had a letter published in US News (that's what the editor told me, though I never actually could find the link - ah, well), after she wrote an article praising anecdote above evidence based medicine. HCRenewal has an analysis here, and here is my letter:

To the Editor:

Healy castigates the practice of evidence based medicine in her polemic as if it were anathema to medical science, and, more particularly, to the individual physician's practice of medicine. Hippocrates knew that "Experience is delusory." "Experience," or anecdote, is sometimes helpful in medicine, but often harmful, because we physicians often internalize our experience into hard rules about treating patients. This often leads us down dangerous paths.

Evidence based medicine is long overdue counterweight to this kind of medical practice. EBM, when evidence is available, makes us think hard about our practices: Are we doing this because that's the way we've always done it, or because we have scientific research to back up our decisions? Sadly, it is too often the former, because the evidence is just not there or has not yet been synthesized into a useful form, or, most commonly, not yet reached the physicians "in the trenches." EBM is not discarding or devaluing physician judgment," as Healy argues, it is rather an attempt to make our judgment more rational.

I find it astonishing that Healy trumpets the jury awarding damages against a physician who did not order a PSA test based upon the best evidence available to him. Every physician should howl in protest at this outcome. Using this standard, we should all have monthly full body high speed CT scans and massive blood testing to search for every possible disorder that comes to the mind of the physician or the patient. But we do not practice this way because it is, yes, I'll say it, stupid!

Evidence based medicine is not a "straightjacket", but a means to an end: providing the best care based on the best scientific evidence we have.

So are we a scientifically based medical community and society, or are we thinking irrationally and letting fear mongers lead us over a cliff?

Don't answer that.

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Wednesday, November 18, 2009

Intellectual conservatism, RIP -

Neoconservatism -

I was once a young neoconservative. The word meant something different then, before it was hijacked by extremists by Michael Lind
A nice article on the history of neoconservatism - not what I thought - but I brought it here for this great quote:

Ultimately Milton Friedman and other free-market ideologues did far more damage to America than the carnival freaks of the counterculture.

Love it!

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Wednesday, November 11, 2009

AMA - AMA votes to continue commitment to health system reform

AMA - AMA votes to continue commitment to health system reform:

AMA votes to continue commitment to health system reform
Outlines details to guide efforts toward making the health system better for patients and physicians
For immediate release:
Nov. 9, 2009
HOUSTON – The American Medical Association (AMA) House of Delegates today voted on health system reform policies, reaffirming the AMA’s commitment to health system reform. The AMA's House of Delegates is the nation's broadest, most inclusive assembly of physicians and medical students. Delegates representing every state and medical specialty debate and vote on behalf of their physician peers.
“Now is a defining moment in the history of the AMA,” said AMA President J. James Rohack, M.D. “In a democratic process, the AMA House of Delegates today voted to continue AMA’s commitment to health system reform for patients and physicians. The time to make health system reform a reality is now.”
The AMA reaffirmed its support for health system reform alternatives that are consistent with AMA policies concerning pluralism, freedom of choice, freedom of physician practice and universal access for patients. It also outlined specific elements it will actively and publicly support and oppose as the health system debate continues.
The AMA’s support for H.R. 3962 and H.R. 3961 remains in place.
“H.R. 3962 is not the perfect bill, and we will continue to advocate for changes that help make the system better for patients and physicians as the legislative process continues,” Dr. Rohack said."

Now that the American Society of Anesthesiology has voted to support the House Bill, we now have an AMAZING NINE OF of the TEN largest physicians organizations supporting reform.

Even if you take out the AMA and AOA as a friend suggested because they are multispecialty groups, we have 8 of the ten largest physician specialty organizations supporting reform. The American College of Radiology is still against it, the American College of Emergency Physicians (# 9) has still not committed and the American College of Cardiology ( which I'm pretty sure is # 10) is on board.

That's about as close as you can get to running the table with physicians groups.

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Tuesday, November 10, 2009

How to reform the broken medical malpractice system. - By Darshak Sanghavi - Slate Magazine

How to reform the broken medical malpractice system. - By Darshak Sanghavi - Slate Magazine

For many doctors, the malpractice case against a family physician named Daniel Merenstein epitomized how the broken medical liability system drives up costs. In 1999, Merenstein, then a resident, saw a 53-year-old man for a routine checkup and discussed with him the dubious value of a blood test to screen for prostate cancer. Since the test leads to many false positives and pointless treatments that can cause impotence and other harm, neither the American Cancer Society nor U.S. Public Health Service support its routine use. Presented with the data, the patient chose not to get the test.

When the man later developed prostate cancer, he sued Merenstein and the residency training program and ultimately won $1 million. According to the plaintiff's attorney, the doctor should have ignored the evidence-based national guidelines and not even have given the patient the choice to refuse the test.

This is the same story told on This American Life last month, and it is quite disturbing. In my "to-do list" for health care reform, medical liability reform is relatively low on my list*, but this story gives me pause.

I hope we can address this and make following guide lines in good faith a reason to dismiss a lawsuit. For more information on guidelines and Comparative Effectiveness Research in action, go here.

*Caps are not even on my list, but there are many other things we can do that benefit patients AND physicians, as outlined in this Slate article, and by the AMA.

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Monday, November 9, 2009

A Christmas Carol's Social Justice Lessons...

Social Justice - Loyola Press:

Since Jim Carey's new "Christmas Carol" is number one at the box office, and we need to talk more about the moral case for health care reform in particular and with governing ourselves in general, I'm reposting this, from the Jesuits...

"In Charles Dickens's classic A Christmas Carol, Ebenezer Scrooge is visited by the spirit of his former business partner, Jacob Marley, who has come to alert Scrooge to the three spirits who will visit him in an attempt to save his soul. When Scrooge asks Marley why he is laden down with chains and irons, Marley explains that he is wearing the chains he “forged in life” as a punishment for not making better use of his time on earth. Scrooge protests, “But you were always a good man of business, Jacob.” To which Marley laments, “Business! . . . Mankind was my business! The common welfare was my business; charity, mercy, forbearance, and benevolence, were, all, my business. The dealings of my trade were but a drop of water in the comprehensive ocean of my business!”

There's more, and I thought it is still a nice Christmas message...

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Sunday, November 8, 2009

House Bill Effects on Physician Income

I had a piece in the Pittsburgh Post-Gazette today on physician support of health reform.

A sadistic friend posted it on Sermo. Weee!

The subject of the effect on physician income came up on our Doctors for America and I said:

I often ask my colleagues who 1.) complain about Medicare rates and 2) say all care for the uninsured should be via charity by physicians , "Wouldn't you rather get paid a bit less and have everyone covered so you have more paying patients?"

I doubt anyone has done an analysis of what the net effect of this would be, but perhaps the net effect would be neutral or positive, I don't know. BUT as the NEJM survey said, most of us find it acceptable to take lower reimbursements if everyone is covered.

Our terrific Media Mogul, Mandy Krauthammer-Cohen, MD, of course, had a great bit of information:

Some additional food for thought. If you look at the Lewin group analysis....which does have a conservative bias given it is owned by United Health...physicians will actually make more money under health reform with a public option.

Testimony by Lewin states: "In the first year of the program (when public option is only opened to small businesses with less than 10 employees), physician income would increase by $10.9 billion. This reflects the reduction in uncompensated care for uninsured people as well as increased health services utilization for newly insured people. It also reflects the House bill provisions that would increase Medicaid reimbursement for primary care services to Medicare payment levels. Thus, the reductions in payment for people who shift to the public plan are outweighed by increases in reimbursement for Medicaid, reductions in uncompensated care and revenues from increased service use for newly insured people. Average net-income per physician wouldincrease by $15,237 in 2010 under this scenario."

Read the whole testimony here.

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Monday, November 2, 2009

T.R. Reid: Can We Really Fix U.S. Health Care?

From the Commonwealth Club of California Podcast is here.

Friday, September 18, 2009, 12:34:52 PM

T.R. Reid, Correspondent, The Washington Post; Commentator, National Public Radio; Author, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

For 100 years, U.S. presidents have unsuccessfully strived to provide universal health coverage. When LBJ created Medicare in 1965, he thought the program would gradually be extended – to people over 60, then 55, then 45, etc., so that everybody would have government health insurance by 2000. Decades later, the Clinton plan failed. George W. Bush created Medicare Part D. Barack Obama says we have the best chance ever this year to fix our health-care system. Is he right? Reid weighs in and reveals what we can learn from health-care models across the globe.

This program was recorded in front of a live audience at The Commonwealth Club in San Francisco on September 14, 2009.

A very good listen. Excellent tid bits about health promotion in Britain, insights into the minds of Canadians and more!

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Friday, October 30, 2009

Welcome WMNY Listeners

If you found your way here after listening to Will Clower on WMNY, thanks for checking this out.
My interview ( MP3 link ) with Will Clower is here.

This is my ICU week, so I don't get a lot of time to post usually, so feel free to go over to the right side of the blog and explore the topics.

If you want the information I gave about organized medicine's support for reform, click on "organized medicine," if you want more on surveys of physicians, click on "physicians surveys," and so on.

I highly recommend "Anecdote-off" for all of your friends and relatives who tell you how swell we have it here and how horrible it is in other countries!


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Thursday, October 22, 2009

Paying for Reform - Updated

I was asked recently, how will we pay for reform. Tom Coburn, on, asked physicains to support him not supporting us physicians in asking for repeal of SGR with its $250 billion dollar price tag. I don't know when he had this sudden change of heart, feeling physicians should not get paid more for Medicare patients, but hey...

The other question was about the overall price tag of HR 3200, somewhere in the neighborhood of $100 billion a year, or $1 trillion over ten years.

[Cross posted at DailyKos.]
No problem. First and best answer: REPEAL THE BUSH TAX CUTS!

They were bad economics, bad public policy, and bad morally.

UPDATE: Susie Madrak at Crooks and Liars summarizes a Citizens for Tax Justice report on the disaster that the Bush Tax cuts were and are:

I'd advise listening to the two EXCELLENT "This American Life" episodes on HC reform:

Follow the links, download the MP3's and you can make audio CDs for the car.

There are lots of answers in there, but I'll give you a few easy ones:

1.) McAllen, TX and EOL Care:

That's actually two, practice variation and EOL care.

2.) Prescription co-pays: $10 for a $20 prescription, $30 for a $600 prescription. (Unless you have a coupon from the manufacturer to make the $30 copay $0.00 - the second TAL episode explains this.)

3.) George Lundberg has a few ideas:

4.) Uwe Reinhardt has a modest proposal:

5.) Wendell Potter, too:,8599,1920893,00.html

6.) Administrative costs:

Bottom line is, as has been suggested before, passing the bill is going to be half the battle, implementing reform in a way that is most beneficial to patients at the least cost to us as a society is next up.

But let's get everyone taken care of first, and avoid the 18K to 45K people dying EVERY YEAR due to lack of access to health care and THEN we'll deal with reducing costs. Turns out, if you read the Gawande article, they may be by doing the exact same things.

And finally, $1 trillion over ten years is $100 billion a year, and we spend $2.5 trillion a year on HC already, so that is very little money in the grand scheme of national economics. So, as Uwe would say, "Go explain to God why you cannot do this. He will laugh at you."


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Wednesday, October 21, 2009

New Nationalism - Roosevelt Speeches - 1912

New Nationalism - Roosevelt Speeches - 1912
I'm listening to a biography of TR, "A Lion in the White House," and there is a lot about this speech given by Roosevelt at Osawatomie, Kansas on August 31, 1910.

He makes me sound like Rush Limbaugh. Here are a few quotes:

"Labor is prior to, and independent of, capital. Capital is only the fruit of labor, and could never have existed if labor had not first existed. Labor is the superior of capital, and deserves much the higher consideration."
If that remark was original with me, I should be even more strongly denounced as a Communist agitator than I shall be anyhow. It is Lincoln's. I am only quoting it; and that is one side; that is the side the capitalist should hear.
Now, let the working man hear his side. "Capital has its rights, which are as worthy of protection as any other rights.... Nor should this lead to a war upon the owners of property. Property is the fruit of labor; . . . property is desirable; is a positive good in the world."
And then comes a thoroughly Lincolnlike sentence: "Let not him who is houseless pull down the house of another, but let him work diligently and build one for himself, thus by example assuring that his own shall be safe from violence when built."
It seems to me that, in these words, Lincoln took substantially the attitude that we ought to take; he showed the proper sense of proportion in his relative estimates of capital and labor, of human rights and property rights. Above all, in this speech, as in many others, he taught a lesson in wise kindliness and charity; an indispensable lesson to us of today. But this wise kindliness and charity never weakened his arm or numbed his heart. We cannot afford weakly to blind ourselves to the actual conflict which faces us to-day. The issue is joined, and we must fight or fail.


Now, this means that our government, national and State, must be freed from the sinister influence or control of special interests. Exactly as the special interests of cotton and slavery threatened our political integrity before the Civil War, so now the great special business interests too often control and corrupt the men and methods of government for their own profit. We must drive the special interests out of politics. That is one of our tasks to-day. Every special interest is entitled to justice - full, fair, and complete - and, now, mind you, if there were any attempt by mob-violence to plunder and work harm to the special interest, whatever it may be, and I most dislike and the wealthy man, whomsoever he may be, for whom I have the greatest contempt, I would fight for him, and you would if you were worth your salt. He should have justice. For every special interest is entitled to justice, but not one is entitled to a vote in Congress, to a voice on the bench, or to representation in any public office. The Constitution guarantees protections to property, and we must make that promise good But it does not give the right of suffrage to any corporation. The true friend of property, the true conservative, is he who insists that property shall be the servant and not the master of the commonwealth; who insists that the creature of man's making shall be the servant and not the master of the man who made it. The citizens of the United States must effectively control the mighty commercial forces which they have themselves called into being. There can be no effective control of corporations while their political activity remains. To put an end to it will be neither a short nor an easy task, but it can be done. We must have complete and effective publicity of corporate affairs, so that people may know beyond peradventure whether the corporations obey the law and whether their management entitles them to the confidence of the public. It is necessary that laws should be passed to prohibit the use of corporate funds directly or indirectly for political purposes; it is still more necessary that such laws should be thoroughly enforced. Corporate expenditures for political purposes, and especially such expenditures by public-service corporations, have supplied one of the principal sources of corruption in our political affairs.
Moreover, I believe that the natural resources must be used for the benefit of all our people, and not monopolized for the benefit of the few, and here again is another case in which I am accused of taking a revolutionary attitude. People forget now that one hundred years ago there were public men of good character who advocated the nation selling its public lands in great quantities, so that the nation could get the most money out of it, and giving it to the men who could cultivate it for their own uses. We took the proper democratic ground that the land should be granted in small sections to the men who were actually to till it and live on it. Now, with the water-power with the forests, with the mines, we are brought face to face with the fact that there are many people who will go with us in conserving the resources only if they are to be allowed to exploit them for their benefit. That is one of the fundamental reasons why the special interest should be driven out of politics.
Of all the questions which can come before this nation, short of the actual preservation of its existence in a great war, there is none which compares in importance with the great central task of leaving this land even a better land for our descendants than it is for us, and training them into a better race to inhabit the land and pass it on. Conservation is a great moral issue for it involves the patriotic duty of insuring the safety and continuance of the nation. Let me add that the health and vitality of our people are at least as well worth conserving as their forests, waters, lands, and minerals, and in this great work the national government must bear a most important part.
In every wise struggle for human betterment one of the main objects, and often the only object, has been to achieve in large measure equality of opportunity. In the struggle for this great end, nations rise from barbarism to civilization, and through it people press forward from one stage of enlightenment to the next. One of the chief factors in progress is the destruction of special privilege. The essence of any struggle for healthy liberty has always been, and must always be, to take from some one man or class of men the right to enjoy power, or wealth, or position, or immunity, which has not been earned by service to his or their fellows. That is what you fought for in the Civil War, and that is what we strive for now.
We grudge no man a fortune which represents his own power and sagacity, when exercised with entire regard to the welfare of his fellows. Again, comrades over there, take the lesson from your own experience. Not only did you not grudge, but you gloried in the promotion of the great generals who gained their promotion by leading the army to victory. So it is with us. We grudge no man a fortune in civil life if it is honorably obtained and well used. It is not even enough that it should have gained without doing damage to the community. We should permit it to be gained only so long as the gaining represents benefit to the community. This, I know, implies a policy of a far more active governmental interference with social and economic conditions in this country than we have yet had, but I think we have got to face the fact that such an increase in governmental control is now necessary.

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Tuesday, October 20, 2009

This American Life HC Reform Part 2

This American Life:

This week, we bring you a deeper look inside the health insurance industry. The dark side of prescription drug coupons. A story about Pet Health Insurance, which is in its infancy, and how it is changing human behaviors—for example, if you have the pet health insurance, you bring your pet to the vet more often, and the vet makes more money and...well, you can see the parallels. And insurance company jargon, frighteningly decoded.

Prologue. Host Ira Glass describes the crazy world of medical billing, where armies of coders use several contradictory different systems of codes...and none of it makes us healthier. (5 minutes)

Act One. One Pill Two Pill, Red Pill Blue Pill.
Planet Money's Chana Joffe-Walt explains why prescription drug coupons could actually be increasing how much we pay, and prevent us from even telling how much drugs cost. (13 1/2 minutes)

Act Two. Let's Take Your Medical History.
Alex Blumberg and Adam Davidson recount how four accidental steps led to enacting the very questionable system of employers paying for health care. (11 1/2 minutes)

Act Three. Insurance? Ruh Roh!
Planet Money correspondent David Kestenbaum investigates the growing popularity of pet
insurance, and what it reveals about insurance for people. (14 minutes )

Act Four. Sorry Johnny... It's Only Business.
This American Life producer Sarah Koenig reports on a very surprising reason why insurance companies dump members, and how this reasoning contradicts President Obama's argument for what will lower health care costs. (11 1/2 minutes)

Again, a very interesting program to follow up on last week's episode.

In Act IV, the interview with Uwe Reinhardt is very thought provoking. Specifically, he talks about the power of suppliers (i.e., hospitals) in the insurer-provider tug of war, and about Maryland's "All Payer System," which I will try to learn more about and pass along when I do...

MP3 of Part 2

MP3 of Part 1 is not offered directly at the website. You can subscribe to the podcast and then download yourself here:

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Saturday, October 17, 2009

Hawaii's Lessons - NY times

In Hawaii’s Health System, Lessons for Lawmakers

Since 1974, Hawaii has required all employers to provide relatively generous health care benefits to any employee who works 20 hours a week or more. If health care legislation passes in Congress, the rest of the country may barely catch up.

Lawmakers working on a national health care fix have much to learn from the past 35 years in Hawaii, President Obama’s native state.

Among the most important lessons is that even small steps to change the system can have lasting effects on health. Another is that, once benefits are entrenched, taking them away becomes almost impossible. There have not been any serious efforts in Hawaii to repeal the law, although cheating by employers may be on the rise.

But perhaps the most intriguing lesson from Hawaii has to do with costs. This is a state where regular milk sells for $8 a gallon, gasoline costs $3.60 a gallon and the median price of a home in 2008 was $624,000 — the second-highest in the nation.

Despite this, Hawaii’s health insurance premiums are nearly tied with North Dakota for the lowest in the country, and Medicare costs per beneficiary are the nation’s lowest. Hawaii residents live longer than people in the rest of the country, recent surveys have shown, and the state’s health care system may be one reason. In one example, Hawaii has the nation’s highest incidence of breast cancer but the lowest death rate from the disease.

Bottom line? Employer mandate ensures near universal health care. Duh.

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TIME - A Healthier Way to Pay Doctors

From Time Magazine

With the effort to rein in health-care costs increasingly framed as an unhappy trade-off in which insurers either slash benefits or raise premiums, some in Washington are beginning to ask a question long considered off-limits: Do we simply pay doctors too much?

The truth is, we pay them all wrong.

Doctors themselves could tell you that — particularly primary-care providers (PCPs), the foot soldiers of the U.S. medical system. New doctors graduate from medical school lugging up to $200,000 in student loans. Paying that off takes a big bite out of even a low-six-figure salary. Add to that the high costs, long days and billing headaches involved in running a practice, and it's no wonder so many family docs are trading up to specialties like orthopedics or neurology, where the pay can be three times as great and the hours a whole lot shorter. Only 3 out of 10 doctors in the U.S. now are PCPs, compared with 5 out of 10 elsewhere in the world. Those family physicians who remain find themselves in a constant money chase, meeting their monthly nut with the help of the revenue they make by prescribing tests — X-rays, CT scans, EKGs — that may or may not be strictly necessary but generate a lot of separate billing.


In his Sept. 9 speech to Congress, President Obama singled out Geisinger and Utah's Intermountain Healthcare as examples of organizations that are learning to do things right. He could have cited others too: the Cleveland Clinic, the Mayo Clinic, Kaiser Permanente. What these providers have in common are the creative ways they're doing away with fee-for-service and replacing it with an imaginative mix of systems that cost less, keep patients healthier and make doctors happier. "We need a transition to rewarding the actual value of care," says Dr. Elliott Fisher, director of population health and policy at the Dartmouth Institute. "For now, our payment system is getting in the way.

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Thursday, October 15, 2009

NY Times: Medical Malpractice System Breeds More Waste

From the NY Times "Ecnomic Scene," with thanks to New America Health Blog for the link.

The title belies the very even-handed way this topic is addresses. Worth reading.

The debate over medical malpractice can often seem theological. On one side are those conservatives and doctors who have no doubt that frivolous lawsuits and Democratic politicians beholden to trial lawyers are the reasons American health care is so expensive. On the other side are those liberals who see malpractice reform as another Republican conspiracy to shift attention from the real problem.

Yet most people, I suspect, still aren’t sure exactly what to think. For them, the good news is that the issue has inspired a lot of research by economists and others with no vested interest. And after sifting through years of data, these researchers have come to some basic factual conclusions.

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Tuesday, October 13, 2009

Physician's Perspective on Health Reform Slides

I updated my slides on physicians' opinions on health reform for a talk tonight for the Pittsburgh Chapter of Drinking Liberally.

The new slides are here. ( I hope I fixed the link!)

I had to strip out the slides of me (and Doctors for America) at the White House, and on our way TO the White House, already in our white coats in order to get under the 5 MB Google docs limit.


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Excess Deaths Due to Lack of Access to Health Care

From coverage of the recent study of Woolhandler, et. al.

As medical care has improved for people with health insurance, the consequences of being uninsured have worsened, according to a new study that says the lack of coverage translates into nearly 45,000 deaths each year among working-age Americans.
Researchers from Cambridge Health Alliance report in the American Journal of Public Health on a study that followed 9,005 adults under 65 years old who took part in a national survey conducted by the Centers for Disease Control and Prevention from 1986 through 1994. After 12 years, 351 people had died. Sixty of them were uninsured and 291 were insured.
After accounting for age, education, income, and other factors, the researchers found that people without private insurance had a 40 percent higher risk of dying than people with private insurance. An earlier study by the Institute of Medicine based on 16 years of data through 1993 found that uninsured people had a 25 percent higher risk of dying than insured people, which translated into 18,000 additional deaths.

I usally quote the 18,000 number as it is from th IOM, a very respected body, but the new figures point to an increase that likely reflects what's going on "on the ground."

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Monday, October 12, 2009

Doctors for America on way TO the White House

White coats already on, thank you very much!

October 5, 2009
And a link to the article with quotes from me that were, happily, pretty accurate.

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NEJM -- Doctors on Coverage -- Physicians' Views on a New Public Insurance Option and Medicare Expansion

NEJM -- Doctors on Coverage -- Physicians' Views on a New Public Insurance Option and Medicare Expansion:

"Overall, a majority of physicians (62.9%) supported public and private options. Only 27.3% supported offering private options only."

I realized I didn't have this posted yet! The 3/4 of physicians ties in nicely with my estimate that physicians groups representing 3/4 of physicians also support health care reform in general and HR 3200 in particular.

The companion article is instructive, too.

a large majority of respondents (78%) agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%). By contrast, physicians were divided almost equally about cost-effectiveness analysis; just over half (54%) reported having a moral objection to using such data "to determine which treatments will be offered to patients.

...the 28% of physicians who consider themselves conservative were consistently less enthusiastic about professional responsibilities pertaining to health care reform.

This last bit is a bit interesting, as at our Pennsylvania Medical Society Board retreat we discussed this last bit and the overwhelming consensus, as best I could tell, was that this was not controversial, and that part of our jobs was making these determinations.

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Wednesday, October 7, 2009

Swiss Model for Health Care Is Gaining Admirers -

Swiss Model for Health Care Is Gaining Admirers -

ZURICH — Like every other country in Europe, Switzerland guarantees health care for all its citizens. But the system here does not remotely resemble the model of bureaucratic, socialized medicine often cited by opponents of universal coverage in the United States.

Swiss private insurers are required to offer coverage to all citizens, regardless of age or medical history. And those people, in turn, are obligated to buy health insurance.
That is why many academics who have studied the Swiss health care system have pointed to this Alpine nation of about 7.5 million as a model that delivers much of what Washington is aiming to accomplish — without the contentious option of a government-run health insurance plan.

In Congress, the Senate Finance Committee is dealing with legislation proposed by its chairman, Max Baucus, Democrat of Montana, which would require nearly all Americans to buy health insurance, but stops short of the government-run insurance option that is still strongly supported by liberal Democrats.

Two amendments that would have added a public option to the Baucus bill were voted down on Tuesday. But another Senate bill, like the House versions, calls for a public insurance option.

By many measures, the Swiss are healthier than Americans, and surveys indicate that Swiss people are generally happy with their system. Switzerland, moreover, provides high-quality care at costs well below what the United States spends per person. Swiss insurance companies offer the mandatory basic plan on a not-for-profit basis, although they are permitted to earn a profit on supplemental plans.

And yet, as a potential model for the United States, the Swiss health care system involves some important trade-offs that American consumers, insurers and health care providers might find hard to swallow.

The Swiss government does not “ration care” — that populist bogeyman in the American debate — but it does keep down overall spending by regulating drug prices and fees for lab tests and medical devices. It also requires patients to share some costs — at a higher level than in the United States — so they have an incentive to avoid unnecessary treatments. And some doctors grumble that cost controls are making it harder these days for a physician to make a franc.

The Swiss government also provides direct cash subsidies to people if health insurance equals more than 8 percent of personal income, and about 35 to 40 percent of households get some form of subsidy. In some cases, employers contribute part of the insurance premium, but, unlike in the United States, they do not receive a tax break for it. (All the health care proposals in Congress would provide a subsidy to moderate-income Americans.)

The German system also does fine without a "public option," and is my favorite model, but this type of advance will take us a few years, but I think we will get there eventually. Having a successful public plan pulling the private insurers, including the not-for-profit-in-name-only ones, into some sanity will help tremendously. The bold, italicized part above is really the key to real reform and universal access: "Swiss insurance companies offer the mandatory basic plan on a not-for-profit basis, although they are permitted to earn a profit on supplemental plans."

Another interesting tid-bit:

As in the United States, practitioners typically are paid on a fee-for-service basis, rather than on salary. But they make less than their American counterparts. According to the O.E.C.D., specialists in Switzerland earn three times more than the nation’s average wage, compared with 5.6 times for American specialists. General practitioners in Switzerland make 2.7 times more than the average wage, versus 3.7 in the United States.

So specialists:PCP income here in the US is $1.51: $1
Switzerland is $1.11:$1.00

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Doctors for America at the White House

I blogged my day at the White House over at DailyKos:!


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Tuesday, October 6, 2009

Eight of Ten Largest Physician Groups Back HR 3200

(Original Title) "American Psychiatric Association voted unanimously to support H.R. 3200"

Medical News Today News Article - Printer Friendly:

The Board of Trustees of the American Psychiatric Association voted unanimously to support H.R. 3200, America's Affordable Health Choices Act, as the basis for health reform.

'In doing so, the APA is pleased to stand with the American Medical Association,' said a letter presenting the board's decision to the American Medical Association. 'The APA Board of Trustees also voted to support the concept of a public plan option based upon the voluntary participation of physicians and other healthcare professionals in the ongoing dialogue of health care reform.'

'While H.R. 3200 - like any bill - is not perfect, we recognize that it offers many positive benefits for psychiatrists and other physicians, and most importantly for our patients,' the letter said.
This now adds the 9th largest physician organization to be on board for HB 3200, including the AMA, ACP, AAFP, AAP, AOA, ACS, and ACOG.

For completeness, #8, the American Society of Anesthesiology and #10, the Amercian College of Radiology are still against reform until they get reimbursement "fixes."

#11, the American College of Emergency Physicians is still waiting for final form bills to commit.

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Wednesday, September 30, 2009

Southern Baptist Convention: Politics trump morality

Unbelievably (or not), considering Richard Land's history, this position on health reform:

In his August 18, 209 press release, Dr. Land states that he opposes the current House bill, H.R. 3200, but does believe that health care reform is needed.
According to Land, he "recognize[s] the need to rework certain elements of the health care equation in America. While the health care industry in the U.S. is relatively robust, it is not without flaws. And there is a segment of the American population, either because of their income level or their medical condition, that needs responsible and well-regulated government assistance."
Dr. Land doesn't believe that greater government involvement is the answer. Dr. Land believes that tort reform is one of the biggest avenues of savings in the health care industry. He states, "If we had tort reform, just tort reform, getting the stinking, rotten lawyers out of the business of ambulance chasing, we would eliminate about $50 billion of medical costs every year that doctors have to pay for malpractice insurance which is then passed on to you in the form of bills."
Dr. Land does believe that in a country as prosperous as the United States, every one should have guaranteed access to some level of health care, though he rejects government involvement. According to Land, the "answer is to provide alternatives and incentives for most people to be in health care that they provide for themselves, and then the government can focus like a laser on those who aren't able to provide it for themselves and you give them a basic level of health care. If I could use the car analogy, everybody should have a Chevrolet. Those who can afford it can get Cadillacs or even Mercedes."
It is amazing that Mr. Land's SBC seems to have more in common philisophically with Ayn Rand than Jesus Christ. Or the Pope.

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Monday, September 28, 2009

Altmire on Public Option

This is from Firedoglake

List of Blue Dogs who have expressed support for a public option (with Nate Silver's estimate of district support/opposition in parenthesis):

1. Jason Altmire: (35-53)

Signed HCAN principles

July 17: Voted 'no' as a member of the Health & Labor Committee against 3200 because of wealth surtax.

September 11: 'I - I'm speaking for myself, I think that the public option may, if it's done correctly may be a part of the package and could play a role. As Congresswoman Woolsey described, it would have to airtight, completely self-sustaining, not funded through taxpayer subsidies, and have to meet all the same insurance regulations. So, I don't think that is the sticking point for the Blue Dogs and the moderate members. I think what we are most concerned about is we have to do this in a fiscally responsible way.'

September 22: 'Altmire's chief complaint about his own chamber's bill was the inclusion of a surtax on the wealthy. But he said he didn't expect that provision to make it through, and he signaled that excluding it would allow him to vote for the final bill.'

It looks like we in Western PA have some work to do in getting Altmire's district turned around. Those are abysmal numbers of support for the Public Option.

Sounds like a job for Doctors for America.

If you would like a doctor to come speak in Mr. Altmire's district, please let me know and I will do it or find someone who will!

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Wednesday, September 23, 2009

Hospitalists' Take on Baucus Bill

From The Hospitalist Web site

Addition of a hospital value-based purchasing (VBP) program to Medicare beginning in 2012. The program would tie incentive payments to performance on quality measures related to such conditions as heart failure, pneumonia, surgical care, and patient perceptions of care. So far, the program’s rough outlines have been well received. “We fundamentally support hospital value-based purchasing,” Dr. Siegal says. “We think it’s a necessary step in the evolution to higher-value health care in general.”

Expansion of the Physician’s Quality Reporting Initiative, with a 1% payment penalty by 2012 for nonparticipants. The bill also would direct the Centers for Medicare and Medicaid Services (CMS) to improve the appeals process and feedback mechanism. Although the Baucus plan’s “mark” doesn’t discuss transitioning to pay-for-performance, Dr. Siegal says the shift likely is inevitable. In the meantime, pay-for-reporting can encourage better outcomes through a public reporting mechanism and “grease the skids” for a pay-for-performance initiative.

Creation of a CMS Payment Innovation Center “authorized to test, evaluate, and expand different payment structures and methodologies,” with a goal of improving quality and reducing Medicare costs. Dr. Siegal says the proposal is consistent with SHM’s aims. “We have for a long time advocated for a robust capability to test new payment models and to figure out what works better than what we have right now,” he says.

Establishment of a three-year Medicare pilot called the Community Care Transitions Program. The program would spend $500 million over 10years on efforts to reduce preventable rehospitalizations. SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) likely would qualify. “We’re very positive about that,” Dr. Siegal says. “I think there is a huge amount of scrutiny now on avoidable rehospitalizations. We think BOOST is a step in the right direction, and we’d love to see greater funding to roll this out on a much larger basis.”

For more information on the current healthcare reform debate, visit SHM’s advocacy portal.

Bryn Nelson wrote the piece for The Hospitalist, and Eric Siegal, MD, is chair of the Society of Hospital Medicine's Public Policy Committee.

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Sunday, September 20, 2009

The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States -- Rodwin 93 (1): 31 -- American Journal of Public Health

The Health Care System Under French National Health Insurance: Lessons for Health Reform in the United States -- Rodwin 93 (1): 31 -- American Journal of Public Health:

Keepin' it real. Every system comes with trade-offs...

THE FRENCH HEALTH CARE system has achieved sudden notoriety since it was ranked No. 1 by the World Health Organization in 2000.1 Although the methodology used by this assessment has been criticized in the Journal and elsewhere,2–5 indicators of overall satisfaction and health status support the view that France’s health care system, while not the best according to these criteria, is impressive and deserves attention by anyone interested in rekindling health care reform in the United States (Table 1). French politicians have defended their health system as an ideal synthesis of solidarity and liberalism (a term understood in much of Europe to mean market-based economic systems), lying between Britain’s 'nationalized' health service, where there is too much rationing, and the United States’ 'competitive' system, where too many people have no health insurance. This view, however, is tempered by more sober analysts who argue that excessive centralization of decisionmaking and chronic deficits incurred by French national health insurance (NHI) require significant reform.

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Tuesday, September 15, 2009

Tort Reform does not necessarily equal caps

From the AMA.

Tort reform may still be coming, per President Obama's Address last week. While caps are still the AMA's favorite remedy, in this recent letter they outline some other considerations...

Alternative Reforms

While the AMA continues to advocate for proven reforms like MICRA, we are also committed to finding innovative solutions to the broken medical liability system such as offering of grants tostates to pursue alternatives to current tort litigation. These alternatives include:

• Health Courts. Health courts would provide a forum where medical liability actions could be heard by judges specially trained in medical liability matters and who hear only medical liability cases. The AMA developed and adopted health court principles in 2007 to assist state and local governments, insurers, hospitals and other entities interested in exploring this option for medical liability reform.
• Early Disclosure and Compensation Programs. Under an early disclosure and compensation model, providers would be required to notify a patient of an adverse event within a limited period of time. Notification does not constitute an admission of
liability. Providers offering to compensate for injuries in good faith would be provided immunity from liability. Payments for non-economic damages would be based on a defined payment schedule developed by the state in consultation with relevant experts and with the Secretary of Health and Human Services (HHS).
• Administrative Determination of Compensation Model. A state’s administrative entity would be charged with setting a compensation schedule for injuries, resolving claims for injuries, and establishing compensation based on the patient’s net economic loss, subject to periodic payment and offset by collateral payments from sources such as insurance.
• Expert Witness Qualifications. Several states have amended the statutory qualifications for those who may serve as medical expert witnesses at trial. Some states (e.g., Georgia, Texas, and Illinois) have created additional standards that medical expert witnesses must meet in order to ensure the testimony juries receive is presented by an individual with particularized expertise in the matter in question.

The AMA is committed to finding a solution to the challenges of the broken medical liability system, including federal reforms based on proven state solutions like California and Texas as well as alternative liability reforms like health courts. The AMA also supports protecting patients’ access to care by working in concert with
state medical associations to enact and defend strong medical liability reform laws.

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Broken healthcare and broken lives - DFA's Alex Blum

Broken healthcare and broken lives -

In the middle of one night during my training at a county hospital outside of Los Angeles, a 12-year-old boy arrived at the emergency room. He was having a seizure. From a brain scan, we made the terrible diagnosis: He had suffered a massive stroke. At best, he would be severely disabled for the rest of his life.

When I sat down with his mother to tell her the bad news, she told me that he had been a happy, healthy child through most of grade school. But there had been one other trip to the hospital. When he was 7, he'd had a stroke from which he recovered quickly and completely. His mother had been instructed to take him to a specialist to find out what was wrong so he would not have another stroke. But she was the family's sole provider and simply could not afford the expensive out-of-pocket bills.

At first I was shocked and angry to learn she ignored a physician's advice that could have prevented this tragedy. I quickly realized, though, that the true culprit was our broken healthcare system. Because this system denies millions of Americans access to care, my patient's mother was forced to take a gamble on her child's health. The result was a debilitating stroke that should have been prevented.

Until the system changes, health catastrophes like this will continue to be commonplace in America. Until we reform the system, Americans will continue to be forced to choose between feeding their families and taking them to the doctor.

From Doctors for America's Alex Blum...

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Saturday, September 12, 2009

The Most Outrageous U.S. Lies About Global Healthcare | Foreign Policy

The Most Outrageous U.S. Lies About Global Healthcare Foreign Policy

As the U.S. Congress this summer holds its first serious health-care reform debate since the Clinton era, the resulting public furor has featured increasingly overheated claims about everything from so-called "death panels" to the supposed prowess of America's homegrown medicine. Many of the most wildly inaccurate statements have been directed abroad -- sometimes at the United States' closest allies, such as Britain and Canada, and often at the best health-care systems in the world.

The lies rebutted include:

1. Stephen Hawking and Ted Kennedy would be doomed outside the US.
2. Canadians come to the US for urgent care.
3. All European health care systems are single payer.
4. Canada and Britain restrict health care choices.
5. The US has The Best Healthcare In The World. (TM)

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Thursday, September 10, 2009

The Ayn Randers and HC Reform

I was on a couple web sites today, the Mayo Clinic Health Policy Center's and Ezra Klein's, and looking at the comments is so disheartening. That people who consider themselves good people (Christians, secular humanists, whatever) can swallow the Ayn Rand crap and not have their heads explode from the cognitive dissonance is amazing.

One particular line of attack that disgusted me was this smug argument that food is necessary for life, why don't we have national food insurance or some similar drivel.

My response on Ezra's blog:

The difference between food and health care is several orders of magnitude.

I don't see patients in my ICU beds due to lack of food, but due to lack of access to care. People rarely lose their homes, their cars, or file for bankruptcy due to food costs.

We have, as a nation, decided to help those in hunger with food stamps, WIC and other programs, we decided in 1965 that allowing the elderly to die and suffer without access to health care was no longer acceptable, and in 1935, we decided allowing the elderly to really suffer in poverty and hunger was not acceptable.

We are the only modern nation that still seems to believe, based upon our lack of action, that our poor do not deserve access to good quality health care on at least a comparable footing with the rest of us.
Go find a physician or a nurse and have a laugh with them with your comparison. Nearly all will be aghast at your callousness. You will find some who support you, but their numbers are thankfully dwindling. Those in the leadership of medicine KNOW that we must advocate for high quality health care for all Americans, not just those who can afford it.

I've compiled a list of physicians organizations advocating for health care, to give you an idea of how cold your statements are to those of us in the front lines actually taking care of those "undeserving sick."

And some anecdotes for you and your friends to have a laugh about.

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Wednesday, September 9, 2009

Robert Reich Explains the Public Option - Concisely

Thanks to Firedoglake for this link! Robert Reich does an excellent job of explaining the public opition in under 3 minutes...

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Tuesday, September 8, 2009

Organized Medicine on Reform

***Update: Now 8 of the 10 largest organizations are on board!***

Welcome to the blog. To make this a bit easier for everyone, here are the physician organizations FOR either HB 3200 or something close to it: AMA, AOA, ACP, AAFP, ACOG, ACS, AAP, ACC, AGA, ASCO, and SHM.

Squishy middle: AAO, AAOS, ACEP

Mo' money, then we'll talk: ASA, ACR.

Details below...

The American Medical Association, ~240K members:

[After passage of HB 3200 out of committee -cmhmd]... the American Medical Association sent a letter to House leaders supporting H.R. 3200, "America's Affordable Health Choices Act of 2009." "This legislation includes a broad range of provisions that are key to effective, comprehensive health system reform," said J. James Rohack, MD, AMA president. "We urge the House committees of jurisdiction to pass the bill for consideration by the full House." H.R. 3200 includes provisions key to effective, comprehensive health reform, including:

  • Coverage to all Americans through health insurance market reforms
  • A choice of plans through a health insurance exchange
  • An end to coverage denials based on pre-existing conditions
  • Fundamental Medicare reform, including repeal of the flawed sustainable growth rate (SGR) formula
  • Additional funding for primary care services, without reductions on specialty care
  • Individual responsibility for health insurance, including premium assistance to those who need it
  • Prevention and wellness initiatives to help keep Americans healthy
  • Initiatives to address physician workforce concerns
"The status quo is unacceptable," Dr. Rohack said. "We support passage of H.R. 3200, and we look forward to additional constructive dialogue as the long process of passing a health reform bill continues."

The American Osteopathic Association ("represents" 67K, per their website; not clear if this is actual membership)

Why is the AOA supporting H.R. 3200?
The “America’s Affordable Health Choices Act” (H.R. 3200) contains several provisions that reflect AOA priorities forhealth system reform. These priorities include: expanding the availability of affordable health care coverage to the uninsured, increased support for prevention and wellness services, investments in the physician workforce, increased Medicare payments for primary care services without cutting payments for other services and, importantly, it represents our best hope for eliminating the current sustainable growth rate (SGR) formula for updating Medicare physician payments. The AOA continues to work with members of the House of Representatives to improve the bill by seeking additions and changes in the legislation. Specifically, we are working to include expanded graduate medical education provisions, medical liability reform, and student loan financing reforms. Favorable action on a House bill is necessary to move the process to the end game negotiations that will determine the specifics of a final bill.

American College of Physicians (ACP, represents 126 K internal medicine physicians including primary care and medical subspecialists like me):

H.R. 3200 does much of what ACP asked Congress to do in terms of coverage, support for the primary care workforce, payment and delivery system reform, based on long-standing policies that have been adopted by this organization. No bill is perfect, but H.R. 3200 delivers on our major priorities in a way that is remarkably consistent with ACP policies, policies that were developed by the College's leadership over many years and always guide how ACP’s leadership, Key Contacts and staff advocate for internal medicine physicians and their patients.

American Academy of Family Physicians, 94K members:

On behalf of the 94,600 members of the American Academy of Family Physicians, thank you for the positive steps you have taken toward broader, affordable coverage that will mean improved health care based on primary care. We believe that the America’s Affordable Health Choices Act (H.R. 3200) will make significant progress toward payment and delivery system reforms and contribute to building a primary care workforce for the future. AAFP supports this legislation and we will be pleased to work with your committees to improve it further.
The public plan option developed by your committees reflects most of these principles very well.

American Academy of Pediatrics, 60 K members:

“The American Academy of Pediatrics (AAP), which represents 60,000 pediatricians, pediatric medical subspecialists, and surgical specialists, praises the U.S. House Energy and Commerce Committee for its vote today on H.R. 3200, America’s Affordable Health Choices Act, and applauds all three House Committees for their continued and steadfast work in the effort to pass significant health care reform.
“The Academy continues to support the process of bringing comprehensive health care reform to America’s children. While there is still work to be done, H.R. 3200 makes significant progress in achieving the Academy’s priorities of covering all children in the United States, providing children with age-appropriate benefits in a medical home, and establishing appropriate payment rates to guarantee children have access to covered services.

American College of Surgeons, 76 K members:

They have a letter of support for HR 3200, but you can't copy and paste... maybe a little gun-shy about letting the membership see it!

American College of Obstetrics and Gynecology, 52 K members:

"ACOG President Gerald F. Joseph, Jr. MD provides ACOG endorsement of HR3200 (proposed America's Affordable Health Choices Act of 2009)."

[The rest is behind a password protected section.]

American Academy of Ophthalmology, 7 K members:

Have not yet taken a position on any specific bill, but:

Meanwhile, the Academy, AMA and the American College of Surgeons have been up on the Hill pushing medicine and ophthalmology’s agenda. The Senate bill is expected to contain a rate-setting commission proposal that the Academy helped defeat in the House bill and other troublesome provisions affecting medicine and surgery.


Acknowledging that the status quo in health care is unsustainable and that issues of access to coverage, quality of care and cost control must be addressed, and given legislative momentum in Congress, the Academy is advancing components for bills that protect patients and physicians. While reform discussions are still ongoing and no pending legislation is perfect, we are committed to continue collaborating with health leaders in Congress to improve bills being considered. The Academy is actively engaged with other physician organizations as key House and Senate committees debate legislation that puts a long-term sustainable growth rate (SGR) fix in play, in addition to other top issues.

American Association of Orthopedic Surgeons, ~17 K members:

The AAOS is committed to ensuring that the final bill be as beneficial as possible to the Orthopaedic community, including our patients. We will not make any decisions in support or opposition until something closer to a final bill is available.

Ooops! Perhaps phrased poorly!

American College of Cardiology, 37 K members:

On behalf of the American College of Cardiology (ACC), representing 37,000 cardiovascular members, I am writing to commend you for H.R. 3200, the "America’s Affordable Health Choices Act of 2009.” This legislation makes a significant financial commitment to comprehensive health system reform and we are committed to working with you on this effort.
ACC is especially pleased that H.R. 3200 takes extraordinary measures to extend coverage to every American and takes positive steps to strengthen Medicare. Among the Medicare provisions the College supports include:
• Funding to eliminate the accumulated debt from the flawed Sustainable Growth Rate (SGR);
• Establishment of a positive Medicare physician payment update (MEI) for 2010
and favorable spending targets for updates in the future;
• Significant payment and delivery reform models such as incentives for physicians to participate in Accountable Care Organizations; and
• Expansion and improvements to the Physician Quality Reporting Initiative (PQRI) to encourage successful participation;

American Society of Clinical Oncology:
Can't find anything on their website. The American Cancer Society, on the other hand, has made access to health care via serious reform their top priority. And, by the way, on palliative care? They're for it.

American Gastroenterological Association, 17 K members:

On behalf of the American Gastroenterological Association (AGA), representing over 17,000 physicians and scientists who research, diagnose and treat disorders of the gastrointestinal tract and liver, I am writing to express our appreciation and support for several provisions in H.R. 3200, America’s Affordable Health Choices Act. The AGA appreciates your leadership and shares in your goal to expand health care coverage to the uninsured, improve coordination of care, and enhance quality.

American College of Emergency Physicians, 27 K members:

"It is important to note, however, that a common theme supported by members of the House and Senate (Democrats and Republicans), as well as the White House, is to extend coverage to nearly all Americans, although there are differences of opinion as to how this objective is best achieved. ACEP supports this endeavor to provide universal health care as a benefit for patients and its outcome of drastically reducing the burden of uncompensated care provided by emergency physicians.
ACEP encourages you to discuss and promote these issues with your members of Congress during the August recess. Your message to lawmakers:
These provisions will improve your constituents' access to vital emergency medical care services and they must be part of the final health care reform package that is sent to President Obama.
Due to the fragmented, unpredictable nature of the process, and the lack of a final product in the House or Senate, ACEP has refrained from taking a public position on the overall legislative proposals. This has been, and remains, a very fluid process and we want to assure you that ACEP will continue to monitor these plans and advocate
for the needs of emergency physicians and your patients."

American Society of Anesthesiology, 43 K members:

"ASA members may be confused by a request for support of H.R. 3200 by other medical associations, including most recently the AMA. ASA CANNOT AND WILL NOT SUPPORT THE BILL IN ITS CURRENT FORM. Members are strongly encouraged NOT to respond to AMA’s request to support H.R. 3200. The bill, the ‘America’s Affordable Health Choices Act,’ includes a public plan option based upon Medicare payment rates for anesthesia services. A Medicare rate-based public plan would be detrimental to the medical specialty of anesthesiology.

“ASA has consistently urged lawmakers to address anesthesiology’s ‘33 percent problem’: the fact that Medicare pays 33 percent of what private insurers pay for anesthesia services (while Medicare pays an average of 80 percent of what private insurers pay for most other medical specialties). This 33 percent payment level simply does not reflect the costs of providing anesthesiology medical care. As such, Congress must not use this payment level as a model for any health care plan.

“We acknowledge that there are many laudable provisions included in H.R. 3200. Still, many issues remain unresolved, and questions linger about how various provisions would impact anesthesiology. We must remember that there is no other organization involved in the reform debate that is speaking for anesthesiology. In fact, some groups are actively lobbying for provisions that would harm our specialty. Anesthesiologists’ shared voice is the only way to ensure that the important and unique concerns of our specialty, our practices and our patients are heard in the halls of Congress. "

American College of Radiology, 32 K members:

Best I could find on their website:

Unfortunately, it seems ACRs position regarding the House version of healthcare reform, HR 3200, has been incorrectly characterized. As many of the details of overall health care legislation remain fluid, the College has not taken a position, for
or against, any of the current overall congressional proposals, including HR 3200.
Regarding HR 3200, we continue to educate congressional leaders that the imaging and radiation therapy provisions, including a raise in the equipment utilization rate assumption to 75 percent and a further 25 percent cut to contiguous imaging, are flawed ideas that will ultimately harm patient access to care particularly in rural areas.
Until negotiations regarding such provisions are complete or are clearly at an impasse, ACR will not take an official position on the entire House bill. Any information that ACR has offered its support or opposition to HR 3200 is incorrect.

Update: I almost forgot to include some rather contrarian sentiments from the South Carolina Medical Association, as well as some "Old School" conservative physicians to round out the round up. They are not alone, as some other deeply red states' Medical Societies have expressed similar dire warnings. But for them, this is really about ideology, not solutions.

Update II:

Society of Hospital Medicine ( ~6 K members, represents hospital based physicians):

On behalf of the Society of Hospital Medicine (SHM), I am writing to express our support for provisions in H.R. 3200, the “America’s Affordable Health Choices Act of 2009” regarding delivery system reform. SHM represents the nation’s hospitalists—physicians whose primary professional focus is the general medical care and management of hospitalized patients. We agree that the time has come for comprehensive health reform and appreciate your leadership and commitment in pursuit of this worthy goal.

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