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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