Sunday, August 31, 2014

New York Times Attacks “Hate Consuming” ObamaCare Opponents

Clergyman: “ I was interested to see a Bible by your bed. You actually find time to read it?” General Patton. “I sure do. Every goddamn day.”

From the movie Patton (1970)

Both read the the Bible day and night,

But thou read’st black where I read white

William Blake ( 1767-1827¬), The Everlasting Gospel

I read the New York Times every day. It is the Democrats’ Bible.

Its health reporters, like Robert Pear, are excellent. But its editorial writers are ideologues who never pull their punches when supporting ObamaCare. Their attitude is that conservatives are hateful moral degenerates for opposing the health law.

Take these opening paragraph in today’s editorial "Endless Assault on Health Reform."

“The opponents of the Affordable Care Act make secret of their consuming hatred for the law that has already provided health care to millions of lower-income people.”

The phrase “consuming hatred” is over the top. Conservatives are not hateful people. They are ordinary Americans. They oppose ObamaCare 55% to 37% in the latest poll averages. The majority of Americans do not like rising premiums, loss of doctors and health plans, millions of health plan cancellations, negative effects on employment, which are turning 90% of new U.S. workers into part-time employees, and the wholesale redistribution of health benefits from the middle-class to lower income people.

In its editorial, the Times is “tarring and feathering” conservatives and the federal appeal court in D.C. for voting 2:1 that the ACA could only offer subsidies to members of state health exchanges, rather than federal exchanges, because that’s what the precise wording of the law said. The Times calls the D.C. court decision a “ridiculously crabbed view” to take the exact wording of the law seriously.

Well, now, I do not know what “ridiculously crabbed view” means. But to call conservatives “ridiculously crabbed” sounds profoundly condescending to me. It smacks of moral superiority, of effete snobs at work. Belittling your opponents by referring to them as full of “consuming hatred” for a flawed law and having a “ridiculous” view of the law are not hallmarks of tolerance and fairness.

Perhaps future editorials in the liberal Bible will explain. The Bible teaches tolerance towards others, rather than doing unto them what you think they are doing unto you.
Ten Key Health Reform Words

The clock. aligned with the computer, is key to reforming care, to increasing efficiencies, to saving time, and to improving outcomes.

Saving time, with proper computer use, and with doctors spending more time with patients, is key to improving health care efficiencies and to saving money.

That is the message I have sought to convey in my blog posts using the following key words.

Health Reform - My blog’s slogan is “Where health reform, medical innovation, and medical practices meet.” Where they meet is at the clock, for time is a perishable asset. There is only so much time to spend with patients.

Medical Innovation - There are always better, simpler, and less costly ways of doing things. These things, through they may be disruptive, invariably save time and make time for the right things.

Primary Care Shortages - Despite arguments and substitutes to the contrary, an adequate supply of primary care doctors and more time to spend with patients is key to a better health system.

• Patient Engagement
- Engaging patients by informing them what’s at stake for their health and what to do to improve their health is fundamental to more effective health reform.

• Concierge Medicine
- Concierge physicians, with enough time to spend and listen to patients,may be key to better, more compassionate, more understanding care.

• Direct Pay Medicine
- Physicians dealing directly with patients and patients paying directly for routine care while being covered for catastrophic events is key to future health reform.

Health Savings Accounts - Employers ensure 160 million Americans. HSAs are a proven means of saving time and money for employers and workers.

Self-Funded Corporations - These corporations can bypass government and state mandates and save time and money by short-circuiting 3rd party government and private bureaucracies.

Women Physicians - As Margaret Thatcher said, “If you want something said, give it to a man. If you want something done, give it to a woman.”

• Consumer-Driven Care
- We are a consumer-driven nation, and health care is for the benefit of consumers, not government, halth plans, hospitals, or physicians.

Saturday, August 30, 2014

Doctors’ Discontent with ObamaCare

Today medicine is just another profession, and doctors have become just like everybody else: insecure, discontented and anxious about the future.

Sandeep Jauher, MD, director at Heart Failure Program at Long Island Jewish Medical Center, from his book, Doctored: The Disillusionment of an American Physician (Farrar, Strauss and Giroux, 2014) and from an article in the August 30-31 WSJ, “Our Ailing Health System.”

Today the WSJ published excerpts of a book by Dr. Jauher.

These excerpts included:

• In a 2008 survey, only 6% of doctors described their morale as positive.

• Eight –four percent said their incomes were constant or declining.

• Most said they didn’t have enough time to spend with patients because of paperwork,

. Nearly half said they planned to reduce the number of patients they would spend in the next three years or stop practicing altogether.

• This discontent has led to a looming shortage of doctors.

On Labor day, summer ends and fall begins.

With hateful TV ads to see which party wins.

Among the issues will be The Health Law Act,

And on health care if it has had an impact.

After Brown, Ukraine, Hamas,beheading, and ISIS,

ObamaCare may now seem to be less of a crisis,

At this painful juncture doctors know this,

With the profession something is amiss.

Doctors are no longer held in high regard.

Their high reputation has been tarred.

With blame for high costs by media reports.

Of Medicare fraud and abuse of all sorts.

A feckless and reckless health law reform,

has failed the health system to transform

Because of its many big government flaws,

It has caused doctors from practice to withdraw.

Ir has resulted in lost doctors and cancelled plans,

It has raised premiums and created benefit bans.

It has forced doctors to adopt EHR systems.

Disrupting routine relationships and rhythms,

Destroying physicians' clinical autonomies

Interfering with normal market economies,

While ignoring frivolous malpractice suits,

While licking courtroom attorneys' boots.

No wonder doctors are so discontented.

Their problems the health law has either been

By political rhetoric or facile pen been,


or circumvented.

Friday, August 29, 2014

More On Direct Patient Care

Plain directness can go a long way.

Anthony K. Tjam. “Have the Courage to be Direct,” HBR Blog Network, 2012

Healthcare providers are discovering strategic opportunities with large employers that are self-insured, but they need to be willing to partner more directly with payers and employers.

Phillip Betbeze, "Targeting Self-Insured Populations, " Health Leaders Media, August 27. 2014

I keep running across examples of “direct” patient care.

• Formation of organizations touting “direct primary care.”

• Self-funded corporations contracting “directly” for concierge and ambulatory surgical services.

• Independent “direct pay” providers bypassing 3rd party government and health plan middlemen.

• Physicians striking out and signing “direct contracts” with local businesses to provide comprehensive “direct primary care” to employees.

What does it all mean?

I suspect:

One, "being direct" is borne out of frustration with the current complex regulatory system, which seems to drive costs higher ever passing day.

Two, "being direct" is a bold attempt by businesses and providers to cut costs by cutting to the chase of health care matters by KISS (Keep it simple, stupid!),

Three, "being direct" exemplifies the American philosophy of “disruptive innovation,” i.e., there is more than one way to skin a cat by making things simpler, more direct, more convenient, more bundled, and less specialized.

I came across this direct way of doing things while interviewing “direct pay” concierge physicians and directors of ambulatory surgery centers for my book Direct Pay Independent Practices: Medicine and Surgery ( Amazon, Kindle book, $9.97).

Kindle books or e-books, by the way, are another example, of “directness" of bypassing traditional publishers by dealing directly with authors online.

If you give the matter any thought at all, you will realize “direct online care,” in the form of virtual medicine or telemedicine, has the potential of cutting out many health care middlemen.

Walmart and GE now directly contract for hip and knee replacements by contracting directly with health systems rather than going through health plans – it is simpler, more direct, and far less costly.

In Oklahoma City, many self-funded corporations and even public or government health agencies save money by sending patients directly to the Surgery Center of Oklahoma for routine surgeries for ambulatory patients.

In Wichita, Kansas, concierge physicians contract directly with local businesses for bundled primary care services. New corporate-provider partnerships are cropping up everywhere to simplify relationships and decrease costs, complications, and regulations of doing health care business.

Partnerships are replacing partisanship. Cooperation is replacing confrontation. And physicians and surgeons are learning the fundamental rule of health care nailing, "If you have a health care nail to hit, hit it on the head." Or, as Ben Franklin observed, "For want of a nail the shoe was lost; for want of a shoe the horse was lost; for want of a horse the rider was lost."

Thursday, August 28, 2014

Everything You Ever Wanted to Know about Direct Pay Independent Practice But Were Afraid to Ask

Ask, and it shall be given to you; seek and ye shall find; knock, and it shall be opened unto you.

Matthew 7:7

Because of a book David Racer and I wrote about direct pay medicine, Direct Pay Independent Practice: Medicine and Surgery, I am often asked about the current state of the direct pay medicine.

As a retired pathologist, health reform commentator, and bystander, I am not directly involved in the movement, so I am not the person to ask.

The people to ask are those actively engaged in organizing the Free Market Medical Association with members in all 50 states, organizations consulting in making the transition from traditional practices now driven by 3rd party payments – MD-VIP, Special Docs, Signature MD, and Access Health, and Jeffrey Bendix, a senior editor of Medical Economics, who has just written a comprehensive article on the subject : "Direct Pay: A Promising Model with Challenges, Medical Economics, August 21, 2014.

The statistics I am about to share with you are from his article.

• What types are direct pay practices are now operational?

1. The first is a straight cash model. Patients pay out-of-pocket, Sometimes the practice will give the patient a superbill that the patient can submit to his or her insurance company for reimbursement.

2 Under the second model patients pay a monthly fee to be included in a physician’s panel. The fee covers unlimited office visits and 24/7 access to the physician, including via text or e-mail. In most cases it also includes whatever in-office procedures and tests the physician offers, although some practices charge extra for these.

3. The third form, generally known as concierge medicine, includes a monthly or annual fee. Patient receives services such as 24/7 access by telephone or e-mail, a comprehensive annual physical exam, and no-waiting appointments. Some practices maintain contracts with insurance companies but most disengage from 3rd patients.

How long does it take to transition from a traditional practice to a direct pay practice?

Three to six months.

What specialties participate in direct primary care?

Sixty percent are internists, but family physicians also are switching to concierge practices, along with certain specialties, like psychiatry and certain surgical specialties, especially surgeons operating in direct pay ambulatory surgery centers. Many surgeons also accept direct pay discounts.

What incomes can direct pay physicians expect?

Less than $100,000, 33%; $100,000 to $200,000, 40%; $200,000 to $300,000, 14%; $300,000 to $400,000, 5%; over $400,000, 8%.

What are the average ages of direct pay physicians?

Under 30, 13%; 40 to 49, 32%; 50 to 59, 45%, over 60, 10%.

What are the average monthly subscriptions charged to patients?

Under $50,11%; $51 to $100, 14%; $101 to $135, 31%; $135 to $180; over $180. 36%.

What are the challenges involved ?

The challenges are (loss of loyal patients, criticism by colleagues and policy makers) and economic (loss of income during transition, lack of guaranteed success, no certainty direct pay movement will catch on, though some are predicting a 10% to 15% annual growth rate; and bureaucratic hassles from government and insurers while making the transition).

Read our book, Direct Pay Independent Practice Medicine and Surgery (Kindle book., $9.97) and Medical Economics article for details).

My book features interviews with 12 participants in the direct pay movement – their experiences and their expectations

Pre-Labor Day Lull and Health Care Reform Sleepers

Come Labor Day, the political campaigns begin in earnest.

At issue will be:

• Foreign policy decisions (Should we bomb ISIS in Syria?).

• Ukraine v. Russia (What should we do, if anything?),

• Obama end-runs around Congress on immigration and climate change regulations( Can the president do what he wants to do?).

• The state of the economy (What’s real – 4.5% growth in 2nd quarter or 1.5% project for all of 2014).

• ObamaCare ( Are premium hikes and health plan cancellations and switches worth the 5% drop in number of uninsured?)
According to Real Clear Politics polls on Senate and Government races without tossups (9 seats are too close to call), the political races shape up like this ( pundits are hedging their bets whether midterms will be a sweeping wave election or a mere GOP ripple),

Senate: 52 Republicans, 48 Democrats
Governors: 29 Republicans, 21 Democrats

For the moment, ObamaCare is dormant, but there are these big time sleepers.

• How much will double digit health care premium increases influence Red States Senate elections?

• Will health plan cancellations and forced switches to other health plans anger voters?

• Would a GOP Senate with vote for repeal really mean anything in view of certain Obama veto?

Only one thing is certain, after Labor Day, America will awaken from its temporary political slumber over matters of foreign affairs disarray, domestic economy troubles, and ObamaCare controversies.
Richard L. Reece, MD, now have 2 Kindle E-books available on Amazon.

The books are:

1. Direct Pay Independent Practice: Medicine and Surgery, $9.97

2. Understanding ObamaCare: Travails of Implementation, Notes of Health Reform Watcher, $3.99

In addition these books are available in paperback or hardcover:

Health Reform Maze; A Blueprint for Physician Practices

Innovation-Driven Health Care: 34 Concepts for Transformation

Obama, Doctors, and Health Reform

A Managed Care Memoir

And Who Shall Care for the Sick?

Wednesday, August 27, 2014

Key Health Care Reform Phrases and Issues

Communication – the human connection – is key personal and career success.

Paul J. Meyer (1928-2009), Texas Philanthropist and Founder of Success Motivation Instituute

Programmers tell me the key to online success are certain key words and phrases.
With this in mind, I revisited my 3650 blogs composed over the last seven years, and these three blogs popped to the top.

"Health Reform, Women Physicians, and the Doctor Shortages"

Jun 13, 2011 7640 page views

"Texas and the Future of Health Reform in America"

Jul 1, 2012 4710 page views

"Health Reform, Primary Care Shortages, and the Coming Political Crisis"
Mar 21, 2011 3991 page views

If you so desire, you may read these blogs by clicking on titles, which are blue and underlined.
What do these three blogs share in common?

1. They all contain the phase “Health Reform".

2. They were all published after the Patient Protection and Affordable Care Act, the ACA or ObamaCare, passed on March 23, 2010.

3. They all address three hot health care reform issues – women, Texans, and for primary care physicians.

That these three issues should rise to the top should not surprise.

• Women physicians because half of graduates of medical school are now women. The AMA now has 67,000 women members. Women now dominate primary care and the specialties of obstetrics and gynecology and dermatology. Women are more likely to be employed. Women in general practice shorter hours and retire earlier. And by doing so, contribute indirectly to t doctor shortages.

• Primary care shortages are topic number one in health care education and policy circles. Primary care physicians comprise only one-third of American physicians, yet they are the entry point for care for Medicaid and Medicare patients and for those millions of previously uninsured slated to enter the health system in the next three years.

• Texas, because of its physician-friendly environment, its robust business climate, its malpractice reform laws, its low cost of living, its relative shortage of doctors, its low taxes and lack of a state income tax, has become a magnet and destination of physicians from other parts of the U.S. and foreign physicians.

It is self-evident why readers are attracted to these three blogs. My other blogs featuring women physicians, primary care physicians, and Texas medicine have also been heavy draws. I invite you to read the three blogs listed above by entering their titles in the search box on the upper left on each Medinnovation blog – where health reform, medical innovation, and physicians practices meet.

Health Reform and The New England Journal of Medicine’s Agenda

Everybody has an health care and health reform agenda.


I avidly read each issue of the New England Journal of Medicine. The Journal is the world’s most prestigious medical journal. Each issue features meticulously edited scientific and general articles.

In recent years, the Journal has contained a Perspective section. The section precedes original articles, editorials, special reports, and correspondence.

The Perspective section features comprehensive pieces on reform and health care issues of the day.

In reading the Journal, I am aware of its hidden agenda – to advance the causes of government and global health care and health reform without, of course, being overtly political about the agenda. Its articles on health reform invariably have multiple authorship for government agencies and academic institutions , voluminous data, charts and graphs, multiple references, and content evaluating top-down government or academic reform.

Rarely do the articles reflect the point of view of independent practitioners. There is nothing wrong with this agenda. It simply reflects a nearly universally held world view in government and academic circles, as opposed to bottom-individual physician practice point of view, which more often than not, looks askance at ObamaCare.

To show what I mean, consider the titles and sources of authorship in the six articles in August 28 issue.

One, in Perspective, “A VA Exit Strategy,” by William Weeks, MD, and David Auerbach, Ph.D., from the Dartmouth Institute of Health Policy and Clinical Practice and RAND, Boston.

Two, in Perspective, “Reforming the Financing and Governance of GME G.R. Wilensky and D.M Berwick, co-chairs of the Institute of Medicine Commmittee on the Governance and Financing of of Graduate Medical Education, with 19 members of the Committee.

Three, in Perspective, “ Innovation in Medical Education,” David Asch MD and Debra Weinstein, MD, from Center of Health Care Innovation, Pennsylvania School of Medicine, Wharton School, Department of Medicine, Massachusetts General Hospital, Partners Health Care System, and Harvard Medical School.

Four, in Perspective, “Updating Cost-Effectiveness The Curious Resilience of the $50,000-per-QALY Threshold,” (QALY stands for Quality –Adjusted life-year), Peter Newmann, Sc.D., Joshua Cohen, PhD, and Mllton Weinstein, phD, The Center for the Evaluation of Value and Risk in Health, Tufts University, and Department of Health Policy and Management, Harvard School of Public Health.

Five, in Health Law, Ethics, and Human Rights Section, “Money, Sex, and Religion – The Supreme Court’s ACA Sequel,” George Annas, JD, Theodore Ruger, JD, and Jennifer Ruger, PhD. Department of Health Law, Bioethics, and Human Rights, Boston University, Pennsylvania School of Law and Leonard Davis Institute of Health Economics.

Six, Special Report, “Health Reform and Changes in Health Insurance Coverage in 2014,” Benjamin Sommers, MD, and five others, Office of the Assistant Secretary for Planning and Evaluation, HHS, and Department of Health Policy and Management, Harvard School of Public Health.

I will not get into the details of these articles. Suffice it to say, the authors view health reform from the top-down government and academia perspective. Most question but favor national health reform, e.g. the last article notes “These results are consistent with studies of previous insurance expansions that have shown that gains in coverage can lead to rapid improvements in access.” One graph shows the number of uninsured have declined from 20.5% to 16.3% since 2012.
ObamaCare and the Letter of the Health Care Law

Letter of the law 0 noun according to the letter, an orthodox interpretation, by chapter and verse, conservative interpretation, exact words of the law, exactly as written, literal interpretation, literally interpreted, perfectly as written, precise interpretation, precisely as written, strict construction, strict interpretation.

Definition, Letter of the Law

According to an article in yesterday’s LA Times, “Could A Wording ‘Glitch’ Doom Health Care Law,” ObamaCare may go down in verbal flames.

This headline caused me to look up the meaning of "glitch
, which the dictionary says, is a “minor defect or malfunction in a machine or plan.”

The minor defect or malfunction in the health care law lies its wording that says health care subsidies can only be offered to exchanges “established by the state,” in other words, not by federal health care exchanges. The D.C. Circuit Court of Appeals has ruled in Halbig v. Burwell that ObamaCare must follow the Letter of the Health Care Law.

This ruling, in effect, means that five million people who enrolled in 36 federal health care exchanges and who are not receiving subsidies are not eligible to receive these subsidies. Maybe they would even have to repay their subsidies. That would cause unspeakable political anger, and liberals are outraged by this strict interpretation. They say those who wrote the health care law did not mean what they said. They intended to give subsidies to anyone who enrolled in either state or federal exchanges, and to interpret what they meant to say otherwise, is a figment of the conservatives’ mean-spirited and limited mindset.

The liberal –conservative misunderstanding or misinterpretation has been referred to the Supreme Court. We do not know yet if the Court will accept the case. If the Court does accept the case, given its current 5-4 conservative majority, the Court may rule favor of the conservative interpretation of the Constitution.

This interpretation raises questions. What parts of the Constitution or the Letter of the Law do progressives favor? Or is the Constitution simply a dead document, i.e., not a living. breathing document, that is open to progressives’ current interpretation?

Is the wording in the health law a minor “glitch”? Can the law be changed willy nilly at the whim of the executive branch, which according to the Constitution, must seek Congressional approval before changing, delaying, or re-interpreting a law once in the books?

What’s at stake in the Halbig v. Burwell ruling,

Which side of the Letter of Law is fooling.

Is it those strict Constitutionists?

Is it those loose non-Traditionalists?

Do you mean what you say when you use words?

Or, is what others say strictly for the birds?

Tuesday, August 26, 2014

Online Giants –Amazon, Apple, Google – Enter Healthcare Arena

It was the roar of the real, the crowd of the beasts in the arena.

Vincent Blasco –Ibanez (1867-1928) , Sangre y Arena(1908)

It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.

Theodore Roosevelt, "The Man in the Arena," Speech delivered at the Sorbonne, Paris, 1910

When today’s online giants look at the reality of the health care arena, the lure of fixing a broken system must be irresistible.

The audience is there
– everyone gets sick or wants to take steps to prevent sickness.

The huge revenues are there
– the U.S. spends $ 3 trillion a year on health care.

The specific needs are there
– we spend $273 billion on health disease, $465 billion on diabetes – both preventable with the proper exercise and weight loss and diet.

The dysfunction is there
– it is widely acknowledged the U.S system is wasteful, inefficient, and inconvenient.

The consumer bases are there
– billions of people are already hooked into Apple, Amazon, and Google, which have established brands and are household names.

The technologies are there
– there are already 13,000 health wellness and monitoring apps. Apple is about to release it Apple I phone 6. Google has its Google Kit. Amazon is meeting with FDA officials about introducing computer programs to simplify, rationalize, and bill for health care.

The consumer appetite is there
- people are anxious to don wearable monitoring devices to check their blood constituents, their blood pressure, their steps each day, their heart rhythms and their physiological responses to exercise.

The fitness and wellness craze is there
. Millions are out there jogging, stretching, and sweating to ward off and delay the Grim Reaper.

So for each of the Internet titans, there is a there there. Let the battle for control of the arena begin.

Why not take advantage of the health care fervor for improvement and serve humankind in the process?

Doing well while doing good is an irresistible impulse. There’s nothing wrong with it. It’s the American Way.

And patients and doctors are waiting for mobile technologies and telemedicine communications are there, thirsting to make health care more convenient, more accessible,simpler, more efficient, more flexible, less costly, and to achieve greater awareness of health needs and status and to forge stronger shared purposes between doctors and patients and more strategic relationships between the various sectors of the medical industrial complex.

In any event, the challenges for entering the arena and taming the health care beasts has got to be alluring for the entrepreneurial leaders of these online giants – Tim Cook of Apple, Jeff Bezos of Amazon, and Larry Page of Google.

Cook must be thinking, Apple can serve the patient and with an Apple app a day keep the doctor away.

Bezos must be thinking, Amazon can develop a plan to develop and warehouse products and simplify billing for billions of health care transaction.

Page must be thinking, we can produce more wearable devices like Google Glass and other products in our kit to make people fit.

Monday, August 25, 2014

An E-Mail Message about Health Reform Exchanges and a Response Containing a Definition of ObamaCare

Dave Racer, CEO and founder of DRG Communications, Inc, in St. Paul, Minnesota, and publisher of our book, Direct Pay Independent Practice: Medicine and Surgery, a Kindle book now available on Amazon, sent me the following memo.

Dr. Reece

Why does anyone believe that government exchanges will still be around in years ahead? In Minnesota, 53,077 individuals purchased a commercial health plan thru MNsure. Half of those are tax-subsidized. The other half could have purchased coverage outside of the exchange - same plans, same dollars, but without the hassle.

As exchanges continue to diss professional insurance agents, more of them will take their clients off the exchange to purchase coverage. Frankly, no one is using or is likely to use the exchanges for small group or large group insurance - only individual, which is spiking ever higher.

I'm thinking the exchanges will end up being what the Connector has been in Massachusetts - a place for lower income individuals to sign up for a government health plan. But even that will be threatened within a few years, as states are forced to finance a larger share of Medicaid expansion.

Oh, one other thing - the Hilbig decision. If the Supreme Court rules, as it should, that the ACA does not authorized tax subsidies except thru state insurance exchanges, the federal exchanges will be locked out - and people will be terribly angry.

Maybe the GOP will finally find a way to do insurance vouchers, equalization of tax treatment, and such.

Dave Racer

Dear Dave:

Your message prompts this ObamaCare Definition:

- A massive $2 trillion politically unilateral, perennially unpopular social experiment, or health law, designed to redistribute, reassign, and redefine health insurance benefits from the insured to the uninsured. The experiment is poorly planned, inaccurately written, technologically flawed, incompetently executed, inadequately messaged, incompatible with American culture of individual freedoms and choice, and characterized by cost overruns. It contains coercive, unnecessary elements of individual, employer, and religious mandates and health exchanges. Like most experiments, which, by definition, are tests, trials, or tentative procedures, it may end if it fails or is repealed.

I have been asked about the content and subject matter of the 3640 blogs I have written over the last eight years. The content covers these subjects: ACA, Affordable Care Act,Concierge Medicine, Consumer-Driven Care, Direct Pay Ambulatory Surgery Centers, Direct Pay Medicine,Disruptive Innovation, Doctor Shortages, Health Reform, Health Savings Accounts, Media and Health Reform, Medical Innovation, Medical Trends, Patient-Engagement, Politics of Health Reform, Self-funded Companies and Health Reform, Social Justice, Women Physicians, Worksite Clinics. To review or read these blogs, go to Medinnovation and in the search box type the subject you would like to read about.

Sunday, August 24, 2014

The Big Shift: Trends and Treadmills

Thus times do shift, each thing his turn does hold;
New things succeed, as former things grow old.

Robert Herrick (1591-1674)

I awoke this day thinking of health care trends.

I searched the Net. I found two pieces on the subject.

• One was from Health Affairs (Susan Devore, Health Affairs, February 10, 2014).

Her article contains eight bits of homespun wisdom on where things were going under these subheadings.

1. Chronic Disease, Everywhere (chronic disease will be in vogue)

2. Put Me in Coach ( People will have health care coaches)

3. Health Care at Home (More will get their care at home)

4. On-the- Job Health (And at work too)

5. Changes in the Exchanges (The exchanges will be in constant flux)

6. War of the Words (Reform will remain controversial)

7. Data Liberation ( Data will become available for everybody)

8. Partners R Us ( Look for unusual partnerships between strange bedfollows – corporations, hospitals, and physicians to cut costs).

• The second piece was from a health care consultant, Steve Valentine, MBA. He told health care organizations how to adjust to changing times (Steven Valentine, “Ten Healthcare Trends to Watch, “ Svalentine @the, January 2014).

Here are his 10 trends, as revealed in these ten titles.

1. Insurance exchanges will provide mixed results to providers

2. New care and payment models will continue to develop and expand

3. Consolidation of providers will continue…the big will get bigger

4. Physician shortage begins to take effect, and alignment is a priority

5. Marketing and creating a strong brand will be important

6. Transparency will continue to increase

7. Large employers will increase their partnering with providers

8. Expect continued deployment of new technology

9. Health systems and hospitals will continue to expand their continuum of care within their market

10. Labor relations will continue to be a challenge

Valentine concludes; “The transformation of healthcare is truly upon us in 2014, and we all are anxious regarding its impact. Demand for some services will increase while processes are put in place to reduce resource consumption, and provider consolidation will continue ahead, with systems assessing mergers with other systems. Given the mid-term election, the rhetoric this year will be very loud regarding “ObamaCare” with those who sing its praises and those who feel it is a disaster.”

I do not wish to parse these trends. They speak for themselves. The trends mostly concern consolidation, partnering, and new technologies.

The Big Shift

Underlying these trends is a big shift from payers and providers to consumers and patients. The underlying trends are about patient and consumer engagement. It has dawned that the key to lowering costs and improving health lies with patients not with care givers and care payers.

As my primary care physician told me: “ Your health depends on you, not on me.” He stressed my health depends on what happens before you arrive at the office and once you leave the office, not what goes on in the office.

The big shift involves shift in costs to patients, shift in behavioral responsibilities to patients, shift in choices of care to patients, shift in sites of care to the home and to the workplace, and a shift to more transparent information to patients.

In my mind, the poster child for this new attitude, this shift from health care givers to health care receivers, is exemplified by the current rage over treadmills at work and in front of computers and the TV at home.

James Levine, MD, a Mayo Clinic physician, has pioneered this treadmill concept. Why not, Doctor Levine, asks, gently walk on a desk treadmill at work and in front of your TV and computer at home, while walking at 2 MPH on a treadmill. By doing so, you can get your exercise, save time, get your work done, ward off obesity, and protect yourself against those cardiovascular diseases that plague Americans and consume most of U.S. health care spending. Persons with a sedentary lifestyle are at increased risk for heart disease, diabetes, and lower than average life expectancy.

And so, the big shift is,

Get off your office chair and home TV seat.

Stand up straight, walk on your own two feet.

Shift from the ordinary and sedentary,

To delay your visit to the cemetery.

Saturday, August 23, 2014

Google, Amazon, Multiplier Effect, and Health Care Dilemmas

The vigorous, the healthy, and the happy survive and multiply.

Charles Darwin (1809-1882), On the Origin of the Species

Multiplication is vexation,

Division is as bad,

The rule of three doth puzzle me,

And practice drives me mad.

Anonymous, 1570

Google and Amazon are fighting a vigorous battle for dominance of online ads, which comprise the bulk of Google’s revenues, but not yet of Amazon’s.

These online giants are beneficiaries of the multiplier effect. They reach billions of people instantly, run ads on their content, sell products to billions of people.

A billion customers here and a billion customers there, and pretty soon you’re talking about real money.

Google has revenues of $66.7 billion, $50 billion of it based on search ad results, with many from its growing social network as more users move to mobile smartphones.

Ninety percent of Google’s revenues come from advertising; it has 52,069 employee;, and its operating profit is 27%.

The multiplier impact coupled with instantaneous speed and no need for bricks and mortar is Google-boggling.

Google’s revenues are larger than all but 40 U.S. companies; its net profits exceed all but three, and its market capitalization is one of the largest on earth, nearly $40 billion.

Now along comes Amazon, with $75 billion in revenues, the nation’s largest online retailer with 250 million customers, seeking more ad revenue to supplement its thin profit margins.

And so the battle is joined for first place to where consumers will go to shop for products and services.

Both Google and Amazon used text-base key words to attract health care shoppers and sellers.

Key words for health care today might include : ACA, Affordable Care Act , Concierge Medicine, Consumer-Driven Care, Direct Pay Ambulatory Surgery Centers, Direct Pay Medicine, Disruptive Innovation, Doctor Shortages, Healthcare. Gov, Health Exchange Plans, Health Savings Accounts, Leading Hospitals, Medical Innovation, Medical Trends, ObamaCare, Patient-Engagement, Self-funded Companies, Top Doctors, Women Physicians,Worksite Clinics.

But how to attract does one attract health care shoppers, payers, and providers?

Health care is a notoriously fragmented business, with individuals looking for individual doctors, more than 50% of doctors remaining in individual or small practices, and doctors insisting on retaining individual autonomy.

Besides, medicine is a one-0n-one business, while the Internet can take an unlimited number of orders and serve thousands of orders at once. It comes down to a matter of scale.

Telemedicine, mediated via the Web, is, of course, one answer to the one-on-one dilemma, but that is subject to fraud, abuse, and state regulations.

There are signs, of course, this autonomy is eroding the consolidation tides - hospitals buying practices, health plans forming and narrowing hospital and doctor networks, and doctors and surgeons spinning out of traditional practices to form direct concierge and ambulatory and diagnostic practices.

With doctors, multiplication of medical services can be vexing, for doctors and their patients resist standardization and homogenization of their behaviors, treatment of diseases, and mandating of health care choices.

I have little doubt that Silicon Valley will continue to rule the tech economy, that big data will increasingly dictate how hospitals and doctors practice, that the rule of three – big data, big Internet, and money – will prevail.

I believe that the division of providers into fragmented entities will continue to mystify and perflex Google and Amazon, for humanity does not automatically yield to technology nor can it easily be integrated into personal health care.

Friday, August 22, 2014

“Uniformed, ““Unarmed, “Uninsured, and “Unintended” and "Undermined"

Low information voters, also known as LIVs or misinformation voters, are people who may vote, but who are generally poorly informed about politics. The phrase is mainly used in the United States, and has become popular since the mid-1990s.

American pollster and political scientist Samuel Popkin coined the term "low-information" in 1991 when he used the phrase "low-information signaling" in his book “The Reasoning Voter: Communication and Persuasion in Presidential Campaigns.” Low-information signaling referred to cues or heuristics used by voters, in lieu of substantial information.

Definition, Low Information Voters

The meaning and connotations of words have power when communicating with and persuading low information voters.

- Rush Limbaugh, the conservative talk show host, has popularized the term “low information voter,” to characterize uninformed liberals who do not think like he does and who he thinks are prisoners of their ideology. the term is not original with Limbaugh, and his interpretation is too narrow. To me “low information voter ” applies to anyone - liberal, conservative, or independent- who reacts viscerally and predictably to any political situation or verbal political cue as a consequence of their political bias. Their uninformed gut reaction is usually not substantiated by facts and is rooted in ideological mythology.

Unarmed - An example is the media’s frequent reference to the killing of the “unarmed” black teenager, Michael Brown, in Ferguson, Missouri, by a white policemen. “Unarmed” is a cue for white guilt. Some in the low information crowd immediately assumes the killing was the premeditated act of a white police bigot. Never mind the details that may have led to the killing, such as an 18 year old 6’4” 280 pound black teen punching the face of a small-boned 28 year old police officer and fracturing the officer’s eye socket. The policeman is presumed guilty before the evidence is in or the investigation is completed.

Uninsured - When the word “uninsured” is used, it assumed those being described are poor, immigrants, the young, unemployed, or otherwise disenfranchised. This is usually be the case, but not always. One of five of uninsured Americans have said they do not wish to be uninsured. The premiums and deductibles are too high, the enrollment process is too complicated, it’s just too much trouble, and divulging the details of getting enrolled is simply too revealing.

Unintended - This adjective is frequently rolled out when one is talking about the consequences of ObamaCare – unaffordable premiums, soaring deductibles, cancelled policies or policies that must be switched, part-time employment without benefits, slowing of hiring, economic stagnation , doctor shortages, narrowing of physician and hospital networks. These consequences are acceptable, say proponents of the health law, because the intentions of the law was noble – to cover as many of the uninsured as possible. It does not matter that the planning for suffered from incompetent planning and oversight or that the launch was botched. The intentions were honorable and that, not the consequences, are what counts.

Undermined - Although the Surpreme Court has ruled the ACA constitutional when considered as a tax, critics claim the health laws' mandates and regulations undermine the Constitution's foundation.
Primary Care Choice: Team Leader or Single Player

The difficulty is the choice.

George Moore (1852-1933), The Bending of the Bough

Primary care physicians face a difficult choice:

• Be a leader of a team of physician assistants and nurse practitioners., and a salaried employee.

• Be a direct pay, concierge physician practicing on your own.

Why is this choice difficult?

Because the choices demand a different set of expectations and skills, neither of which is taught in medical school or residency.

• If you take the team route, you will expect the organization that hires you, generally a hospital, to do your marketing and the recruiting of your team for you.

This is a powerful incentive. The hospital has a recruiting and marketing staff and can advertise your presence on television and other media. Furthermore, you have guaranteed benefits and regular hours. You can lead a balanced life. You will have a built-in computer system. You will have to spend time meeting with your staff, training them, leading them. Your staff can handle routine matters, and you can devote your time to complex matters requiring clinical judgment , such as whether to refer to a specialist, who will probably be part of the hospital’s larger medical group. Your employer, the hospital, will take care of the marketing, business, and the insurance-related paperwork.But you may miss doing what you envisioned the role of a primary care physician to be - spending time with patients and making autonomous decisions on your own based on your solo clinical judgment.

• If this is not your cup of career tea, you may choose to become a direct pay/concierge/ retainer physician. Your decision carries risk of failure. You will have to do your own marketing to make your presence known in the community. For this task, you will have to develop marketing skills, which may involve setting up a website, using the Internet, speaking before community groups, informing local businesses about your practice, relating to the local media, or telling your patients to spread the word. On the other hand, you can devote most of your time to your patients, who will probably number 500 or 600 rather than 2000 or more in the usual practice. You can have a small staff, one or two rather the 5 or 6 in the traditional practice You can cut your overhead by 50% or more because you no longer have to deal with insurance companies or government Medicare and Medicaid bo-betweens. You no longer will have to deal with such business matters as accounts receivable. Patients will pay you by monthly or annual retainer or by cash-only. You can make your own clinical decisions. You can spend as much time as you want with patients. You can assure them you are available 24/7 by email or cell phone. You are your own person rather than an employee of a larger organization. Clinical decisions are strictly between you and your patient. Your time is your own, you can choose your patients, and they can choose you. You will not be overwhelmed and overloaded by those new crowds of Medicare, Medicaid, and health exchange patient generated by government programs.

It is a hard choice, and only the primary care physicians can make it, whether they are ready or not.

Thursday, August 21, 2014

Ten Reasons ObamaCare Has Legs

If a story in the news has legs, it will continue for a long time.

Idiom, Has legs

Come November, will ObamaCare still have legs as a campaign issue?

Or will it fade in the background with the ISIS chaos in Iraq, beheading of an American journalist, racial tumult in Ferguson, Missouri, and immigration turmoil on the Mexican border.

My hunch is that it will still have legs.

For ten reasons.

1. It affects everybody, and its persistent disapproval rating has sunk to a low of 37%.

2. Big premium hikes are in the offing, and will be announced well before November.

3. It will become clear these premium hikes, which will vary from state to state, are due to income redistribution from the middle to the lower classes from the well to the sick, from the young to the older.

4. ObamaCare will be the central issue in a number of states with close Senate elections, where negative ObamaCare ads will dominate television.

5. Distrust in government has reached an all-time peak, and it is clear the Obama administration is fudging the roll out numbers.

6. It may be announced that 300,000 of those enrolled are not eligible for subsidies because the clumsy wording of the law.

7. People will be upset as they lose their doctors and hospitals because of narrowing of networks and failure of their plans to meet the law’s requirements, and many physicians will not accept Medicare, Medicaid, or health exchange patients.

8. The issue of an “imperial Obama presidency” will be much in the news, as he issues more executive orders and his critics point out he has single handedly changed the ACA on 24 separate occasions.

9. Pocketbook and employment issues will be the overriding issue in the campaign, and talk of ObamaCare harming job creation will be prevalent.

10. President Obama’s low job approval ratings and his perceived ineptness in foreign affairs will raise questions about his over-all competence and the validity of his signature domestic achievement, setting the stage for a possible wave election.

Wednesday, August 20, 2014

Health Reform, Economic Prosperity, Social Justice

Social prosperity means man happy, the citizen free, the nation great.

Victor Hugo (180101185), Les Miserables

Without prosperity, there is no happiness, no social justice, and no national greatness. Lack of prosperity is the root cause of the Jefferson, Missouri riots, racial divide, unrest over ObamaCare, and America’s intense political partisanship.

That is why we have a hollowing out of America’s middle class, why American business resisting ObamaCare with its financial penalties for not offering unnecessarily expensive health plans for all employees, and why ObamaCare with its unaffordable premiums is perpetually unpopular.

There is no mystery to all of these things. After six years of the ObamaCare presidency, economic growth averages 2.5% instead of 3% to 4% required to recover from severe economic recessions, the track record for recovery from previous recessions since World War Two.
It is no longer sufficient politically to blame the Bush administration and Republicans and to absolve one’s self from personal responsibility from one’s failed policies. Something has to give. And that may be a new party with policies leading the nation out of the political wilderness with no hope for American successes, domestic and foreign.

Domestically, for health reform, this may entail abandoning the individual and employer mandates, embracing health savings accounts and consumer responsibilities for choices and health behavior, permitting health plan competition across state lines, allow private experts to run the flawed health exchanges, guaranteeing price and information transparency in the private and government sectors, and lowering corporate taxes averaging 35% or more, prompting American corporations to relocate their headquarters abroad and to hire foreign workers and sacrifice American workers.

It would also help to OK the Keystone pipeline, encourage fracking, and promote energy independence.

In foreign affairs it may involve a leadership based on the perception of strength rather than weakness, on leading from the front rather than the back, on strengthening rather than weakening the military, on decisive military actions rather than tentative passive decisions.

And it may take a rereading of classic books outlining the importance of prosperity in assuring social justice. In Benjamin Friedman’s 2005 book The Moral Consequences of Economic Growth, he says,

“The moral value of a rising standard of living lies not just in the concrete imporvments it brings to how individuals live but in how it shapes the scoical, political, and ultimately the moral character of a people…More often than not, it fosters greater opportunity, tolerance of diversity, social mobility, commitment to fairness, an dedications to democracy…When living standards stagnate or decline, most societies make little or no progress towards any of these goals.”

What we have now is partisanship and class hatred. This is why economic growth is the best formula for lifting economic boats of all classes of society and avoid the clashes that beleaguer us now.

In the words of William A. Galston of the WSJ (“Shared Prosperity Is A Moral Imperative, “ (Aug. 20),

“Broad prosperity is the the oil that lubricates the machinery of government and the glue that binds our society together. Economic stagnation mans gridlocked, zero-sum politics and a turn away from the spirit of generosity that only a people confident of its fture can sustain.”

Key Words: ACA, Affordable Care Act,Concierge Medicine. Consumer-Drive Care, Direct Pay Ambulatory Surgery Centers, Direct Pay Medicine,Disruptive Innovation, Doctor Shortage, Health Reform, Health Savings Accounts, Medical Innovation. Medical Trends, Patient-Engagement, Self-funded Companies,Women Physicians,Worksite Clinics

Health Reform Law Under the Dome

Here’s one for the old dome.


These days the word “dome” is much in the news.

I think of this because I am old, bald, and sport a bald dome.

To begin, there is the Stephen King science fiction novel Under the Dome and the CBS TV series based on the novel. The plot concerns what occurs in a small Maine town, when town's inhabitants try to cope with the calamity of being suddenly being trapped under a dome, cut off from the outside world by an impassable, invisible barrier that drops out the sky.

Then, there’s Israel’s “Iron Dome.” That’s the mobile electronic defense system, consisting of 10 mobile radar units guided by a sophisticated computers that permit the Israeli government to identify the precise site from which Hamas rockets were launched, to show the rockets’ trajectory and direction, and to shoot down those rockets that would land in populated areas.

Of course, there’s always the Teapot Dome, a generic term referring to any political scandal that take place.

Finally, there’s all the capital domes in Washington, D.C. from whence all health laws flow. Well, not all.

There’s all those state capitol domes, 30 of which Republican governors or state legislatures control. These states have their own sets of health care laws, have jurisdiction over health plans in their states, and, according to the wordage of the Affordable Care Act, are the only government entities, that can offer subsidies to those enrolling in the health exchanges. The states can also decide whether or not they participate in the federally funded Medicaid program. Twenty six states have decided to participate.

As noted in Stephen King’s novel, this state of affairs - a dome dropping out of the sky cutting off citizens from the real health care world - causes confusion and dissension. The confusion and dissesion exists not only between the federal government and the states but also among the inhabitants of health care community itself.

As Tip ONeil , the late Democratic leader of the House of Representatives, observed,” All politics is local.”

It has been said “All politics is local.”

By one who was partisan and vocal.

Who will win, those who remain at home?

Or those who roam in U.S. capitol dome?

Who will prevail: state locals or U.S. bicoastals?

Tuesday, August 19, 2014

Retreat from Social Welfare Utopia

To arrest a downward movement is the utmost to which a Utopia can aspire, since Utopias seldom begin to be written in any society until after its members have lost their expectation and ambition of making further progress and have been cowed by adversity into being content if they can succeed in holding the ground which has been won for them by their fathers.

Arnold J. Toynbee( 1889-1975 ), A Study in History

Yesterday I joined a meeting of twelve senior citizens. The group was discussing how to best use Internet technologies to their advantage.

they learned I was a doctor, the meeting quickly deteriorated into an exchange concerning government’s role in health care. The seniors unanimously distrusted government – its motives and its methods. The language was sometimes profane and was flavored with dark conspiracy theories, such as the government will withdraw all cancer treatment for those over 75. I tried to correct their misconceptions but to no avail.

It was clear to me that ObamaCare had lost its momentum among these small group of seniors. And so, I maintain, have social welfare reforms across the globe. It was always Utopian to believe governments could provide universal health care to all citizens without adversely affecting private economies, or antagonizing demographic subgroups receiving government assistance, and such has proven to be so. Governmentcan giveth, but it cannot taketh away.

Everywhere social welfare states are struggling to goose their economies and salvage their nationalized health systems without giving away the goose that laid the golden social welfare egg.

Everywhere these states are turning to the private sector for help. In Britain, NHS-funded hip and knee replacements by private doctors have increased by 19%. The Swedish government is aggressively introducing private market forces to improve access, quality, and choices. In the U.S, the government has agreed to spend $17 billion, mostly for private referrals, to shorten VA waiting lists to prevent veterans from dying on the VA waiting list vine.

The reality is, as Scott W. Atlas, MD, physician and senior fellow at Stanford University’s Hoover Institute, says,

“The key goals for health reform -reducing spending, preserving personal choice and portability of coverage, promoting competition in insurance markets, and maintaining excellence in medicine – do not require government to directly provide insurance or health care.” (Scott W. Atlas, “Where ObamaCare Is Headed, WSJ, August 14, 2014).

How to preserve these goals without government? It has become obvious bloated governments cannot, at the same time, resuscitate the economy, generate jobs, micromanage health care, and change health care behavior and health care choices of individual citizens through individual and employer mandates.

One answer is to let consumers, using their money, through health savings accounts, to take responsibility for their own health and to choose their own doctors and health plans after being fully informed through transparent pricing, transparent information about quality, and transparent competition among care providers.

In other words, give consumers sufficient information, trust consumers to choose the best providers and to make the right choices for their health. Let the marketplace and consumers decide. Meanwhile, the U.S. government is struggling to hold its ground on the safety net gains it has won for Medicare and Medicaid patients without alienating 85% of the population who must pay for those gains by giving away some of their benefits to others. Only economic prosperity can lift all boats, and economic prosperity is something governmeent is not good at.
Chronic Disease Costs

The total medical care costs for people with chronic disease accounts for 70 percent of the nation’s health care expenditures.

George Halvorson, Chairman and CE of Kaiser Foundation Health Plan and Hospitals, Health Care Reform Now! John Wiley and Sons, 2007

When I read this comment in the New York Times:

“ In a policy change, the Obama administration is planning to pay doctors to coordinate the care of Medicare beneficiaries amid growing evidence that patients with chronic illness suffer from disjointed, fragmented care ( Robert Pear, “Medicare to Start Paying Doctors Who Coordinate Care, “ NYT, August 11),

I immediately thought of George Halvorson's work at Kaiser. George contends it takes systems thinking and systems implementation – cooperation and collaboration among physicians and health plans – to coordinate care.

In his book Health Reform Now! Halvorson cites a list of five chronic diseases that make up these costs.

1. Diabetes

2. Congestive heart failure

3. Coronary disease

4. Asthma

5. Depression

To these I would add cancer and chronic obstructive lung disease.

Halvorson notes it is not only these disease, but the co-morbidities that go with them. Chronic diseases come in clusters. Most patients have two or more of these diseases at the same time. It often takes five or six different doctors to take care of them, an even more if the patient comes down with an intervening related acute event, a myocardial infarction, a stroke, kidney failure, or gangrene requiring amputation.

These complications demand coordination, cooperation, collaboration, and unexpected costs. To minimize and rationalize these costs, Halvorson says we need to face four hard truths and to focus more on managing the chronic disease to avoid acute episodes.

These hard truths are:

One, costs are unevenly distributed 91% of the population accounts for 70% of costs).

Two , care coordination deficiencies exist (many doctors don’t communicate with other doctors).

Three, economic incentives significantly influence care (if you are not paid to coordinate care, you may not do so).

Four, systems thinking, coordinating care of chronic disease among doctors and hospitals and others may not be on the radar screen (instead we tend to concentrate on acute events, which are more dramatic and demanding of more atte4ntion.

Given these truths, CMS may be on right track when, starting in January 2015, they will pay doctors $42 for coordinating care of chronically ill Medicare patients. Unfortunately, this CMS move, like many government programs, may be subject to misinterpretation, malfunction, and abuse. It depends, for example, on doctors having electronic health records that communicate with other doctors’ electronic records. This is not yet the case in America. One doctor’s EHR may not communicate with another doctor’s EHR, and the hospital’s EHR does not talk to the multiple EHRs of its medical staff.

Monday, August 18, 2014

Transcending ObamaCare

To rise about or go beyond the limits of; to outdo or exceed in excellence.

Definition, To transcend

I have spent the morning trying to get my arms around Avik Roy’s “Transcending ObamaCare: A Patient-Centered Plan for Near-Universal Coverage and Permanent Fiscal Coverage, “ a white paper published by the Manhattan Institute where Roy is a senior fellow.

I have not yet grasped the full sweep of Roy’s proposal. Small wonder. The executive summary is 11 pages, and the report itself is 61 pages.

In essence, as its title suggests, “Transcending ObamaCare” goes beyond ObamaCare. It does not suggest repealing the law but in gutting it and restructuring it.

Roy says ObamaCare has four major problems:

One, it makes health insurance unaffordable for middle-income Americans.

Two, it causes long-term fiscal instability, i.e. cost overruns, for the U.S. budget.

Three, it dramatically expands Medicaid, with poorest outcomes of any health care system in the industrialized world.

Four, it spends over $2 trillion in the next decade but leaves 23 million lawful U.S. residents without insurance.

Roy proposes “ The Universal Exchange Plan,” or simply “The Plan.”

The “Plan” does not call for a full or formal repeal of the ACA. It has roots in the marketplace plans of two wealthy nations – Switzerland and Singapore.

These two countries have market-oriented plans offering universal coverage at a fraction of U.S. costs. Switzerland spends 45% of what we do and Singapore 25%. Switzerland fully subsidizes low income individuals, moderately subsidizes middle-income individuals, and gives no subsidies to high income individuals. Singapore funds catastrophic coverage for all citizens and reroutes a portion of payroll taxes through health savings accounts to pay for routine medical expenses.

The key reforms for Avik Roy’a “plan” include.

1. Repeals ACA individual and employer mandates.

2. Frees exchanges from most federal regulations.

3. Combats hospital monopolies.

4. Moves Medicaid enrollees and retirees into reformed exchanges.

Avik Roy projects his plan will:

1. Reduce 30 year budget debt by $8 trillion.

2. Reduce 3o year spending by $2.5 trillion.

3. Make Medicare Trust Fund permanently solvent.

4. Reduce private sector premiums.

5. For Medicaid population, improve public access by 98% and medical productivity by 159%.

6. By 2025, increase coverage by 12.1 million above ACA levels.

I do not know if “The Plan” will work as proposed, if it will be acceptable politically for the next administration or for the public at large. But Avik Roy impresses me. Liberals consider him “thoughtful;” he is author of “The Apothecary,” Forbes widely read health policy blog; he writes regularly for The National Review and a number of other major publications, and he was educated in molecular biology at MIT and in medicine at Yale University School of Medicine.

Sunday, August 17, 2014

President Obama – Lame Duck or Dead Duck

Lame duck – an elected official, often powerless in the final term of office.

Dead duck – a person or thing beyond help, redemption, or hope

Is President Obama a lame duck?

Or is he destined to be a dead duck?

Does his lowly job approval rating,

indicate his power is quickly abating?

Will the ACA see its final death knell?

Only the November midterms will tell.

Should he happen to lose the Senate.

He’ll veto repeal in New York minute.

We’ll know at his desk the buck stops,

And we’ll know health law’s repeal flops,

But then again, will he be a lame duck.

Or will he be a political dead duck

Saturday, August 16, 2014

Health Reform Game Changer: Interview with Mitchell Brooks, MD, Orthopedic Surgeon, Dallas, Texas

The chess-board is the world, the pieces are the phenomena of the Universe, and rules of the game are what we call the rules of Nature.

T.H. Huxley (1894-1963), A Liberal Education

Doctor Mitchell Brooks, an orthopedic surgeon who has practiced in Dallas for 30 years, is a man of deep convictions and fundamental beliefs.

He believes Americans consider health care a right, ObamaCare is wrong for America because of its adverse consequences, downsizing of our hospitals can be a health reform game changer, reform ought to focus first on the patient, catastrophic insurance is essential, and life is short and ought to be preserved at all costs.

These beliefs stem from his diverse life experiences: growing up in Brooklyn, college education in Toronto, Canada; medical education at the Medical College of Virginia; a spinal surgery fellowship at Bellevue; visiting lectureship at the University of Cardiff in Wales; private practice in Massachusetts and Texas, legal and compensation consultant for law firms, a leader in a real estate development company, associate for Directions International, an international management consulting firm, and recipient of a heart transplant in 2007.

He is perhaps most proud of his work at an innovator and designer of a 45,000 square foot “jeep hospital,” which he believes will be capable of providing 70% to 80% of the surgical procedures now performed in traditional hospitals at 30% of the fixed costs with much greater convenience.

Q: Why Dallas?

A : Before I came here, I was practicing in Massachusetts. The governor at that time, Michael Dukakis, basically told physicians “It’s my way, or the highway.” I chose the highway. I did a market study of states that were physician-friendly, and Texas came out number one.

Q: You had a heart transplant in 2007. Based on that experience and your multifaceted career, what would you say your working philosophy is?

A: My working philosophy is:

One, as a physician, we have very special responsibility because people trust us. That comes first. It is paramount. It is the raison d’etre for what we do. When patients lie prostate on the operating table, they are absolutely vulnerable. Most patients know little about health care. It is our job to teach them.

Two, I received nothing from the government to be educated. Government should not be able to tell me what I ought to be paid.

Three, because I set my own fees, I have to give value, and value-added services for those fees. That includes pre-operative, operative, and post-operative care. To me the most important thing is the history, and only I can take that. You can’t do a history on a drive-by visit. Your PA can’t take that history It may take an hour and a half to get a good history.

Q: You have said a lot of people who write about health reform don’t write about it from the patient’s point of view. What is that point of view?

A: It depends on the patient. It is incumbent upon us to educate the patient. The patient is your customer more and more these days because of the high deductibles. You have to put yourself in the patient’s shoes, where I have been, and find out what the patient wants and what the patient needs. That determines who you approach the patient and the manner in which you make suggestions. If the patient thinks their wants and needs are attended to, it is incredible what happens. I have been practicing orthopedic surgery since 1982, and I have never been sued. I am very selective. If the patient is not a good fit for me. I will see them for the first time, and I won’t charge them for the visit. I will suggest they see another doctor.

Q; You frequently appear on Fox News and Fox Business. Among other things, you talk about why the young invincible are not flocking to ObamaCare, why ObamaCare is killing the middle class, how innovation will reduce health costs, why ObamaCare has so many unintended consequences, and why the doctor shortage will surely worsen.

Have these media appearances been productive for you?

A: Yes, they have. The appearances have permitted me to get information out to a large number of people, and it has allowed me affect change. Change one person’s mind, the saying goes, and you have changed the world. I seek to get people to see things through a different set of eyes. I don’t want people to change their minds. I want people to think about something in a different manner. I think that’s critical in changing health care.

Q; You have been critical of the health law because it “robs the middle class.”

A: Absolutely. Because of the changes in ObamaCare and the way the law was written, of the various classes in our society – lower, middle, and upper class – the middle class is going to be hurt the most. The income taxes are going to hurt them the most, the hidden taxes are going to hurt them the most, the higher deductibles are going to hurt them the most, the stifling of the economy is going to hurt them the most, and ObamaCare approaching reform from the supply side rather than the demand side will hurt them the most. They have done that in Canada and Great Britain, and it doesn’t work.

I’ll let the statistics about cancer survival in Great Britain, and the waiting lists to be seen by a doctor or have a treatment speak for themselves, In Buffalo, New York , Canadians flock across the border to get their CT scan or MRI. In Ontario, the largest province in Canada 54% of the budget goes to health care. That is unsustainable. And it results in rationing. Call it what you will, it is what it is.

Q: You spent time in Wales. What did you bring away from that experience?

A: One of things I came away with was a design for a self-pay sports medical clinic. What I also took away was a good knowledge of the British system. When you consider my experience there, as a general practitioner, in Canada, in Massachusetts, my experience as a patient paying up to $60,000 for a heart transplant, those experiences give me a very special perspective of what works and doesn’t work, both from a patient’s and a physician’s perspective. I look at things from my own and my patient's perspective, and that is critical.

Q: You have made a number of talks about the importance of innovation, and one of your personal innovations is something called “The Jeep Hospital.” Why is that such a big innovation? What does this innovation bring to the table?

A: It retools the idea of a hospital as a “factory.” People pretty much agree the present hospital system, where everything is done in big hospitals, is outdated. Yet all of these bricks and mortar are constructed, and have to be paid.

But wait a minute, even given the embedded costs, do we really need beds anymore? More than 70% of surgical procedures done in the U.S. are done on an outpatient basis. Why do we need complex buildings of 100 of thousands of square feet,where you are charged for parking with detailed instructions of how to get to the ER or a doctor’s office, where you spend a substantial amount of time to get into and out of out of a complex hospital system. It may take an hour to two to navigate the complex, and that is productive time. Like their doctors, patients are busy people, and they need as much productive time as they can get.

That’s silly. If you take the same “factory”, redesign, decentralize, and downsize it, and apply it to 70% or more of surgical procedures, soon to be 80% or even 90% of surgeries you can do the same procedure at 20% to 30% of the fixed costs, and you reduce hospital costs by 35%.

The change I am suggesting is threatening. It represents what Joseph Schumpeter ((1883-1950) called “creative destruction” and what Clayton Christensen of Harvard Business School now calls “disruptive innovation.”

The analogy is the United States automobile industry in the 1970s and 1980s. The industry had to change to meet foreign competition.
The hospital industry is where the automobile industry was in the eighties. When interest rates go up, occupancy goes down, and Medicare and Medicaid payments get squeezed, hospitals will start falling like a stack of cards.

Only the large systems will be left standing. Of the 3500 current separate small hospitals, perhaps 700 of the larger systems will survie , which I personally believe was one of the goals of the Affordable Care Act.

I don’t care what the government wants. It is our government, our money, and our taxes. Government derives its power from us. If we don’t vote, we have no power. I believe if the private sector can offer a better product at a lower price with added-value and more convenience, we have something that is a game-changer, and people will vote for it.

Dr. Brooks can be contacted at

The Alternative

Old age isn’t so bad when you consider the alternative.

Maurice Chevalier (1888-1972), French singer and entertainer

ObamaCare supporters argue the health law isn’t so bad when you consider the alternative.

The alternative, as they see it, is going back to the bad old days when the old, the sick and the uninsured were left unattended on the mean streets to die.

Then, supporters are likely to add, ObamaCare opponents have no alternative – no single master plan to cover the uninsured. They seldom add that ObamaCare will leave 30 million uninsured, even when carried out as planned.

The problem with this line of reasoning is two fold:

One, maestro Harry Reid never allows GOP plans to be brought to a vote in the Senate and the media seldom acknowledges the alternative.

Two, there is no single alternative to ObamaCare, only a series of alternatives based on market forces, rather than a single government law.

John Mackay, co-founder and CEO of Whole Foods, Inc, has neatly packaged these series of alternatives into a single package of eight alternatives ( “The Whole Foods Alternative to ObamaCare: Eight Things We Can Do to Improve Health Care without Adding to the Deficit,” WSJ, August 11).

He prefaces his argument with the Margaret Thatcher quote, “The problem with socialism if that eventually you run out of other people’s money.”

That, of course is the market argument, that government control drives up deficits and only economic growth can cure these deficits.

There may be some substance to this reasoning as countries with socialized systems turn to market-based alternatives and private plans to cut entitlement spending, stimulate their faltering economies, satisfy their people, and offer quicker access and improve results for the sick in a timely manner without rationing.

In a recent WSJ Op-Ed, Scott W. Atlas, MD, a physician and a senior fellow at Stanford University’s Hoover Institute, asserts:

“ The single-payer model that liberals aspire to for the U.S. is increasingly in trouble around the world.(“Where ObamaCare Is Going,” WSJ. August 14).

Here is John MacKay’s marketplace Whole Food’s basket case of eight alternatives to ObamaCare.

1. Remove legal obstacles to Health Savings Accounts (HSAs).

2. Equalize employer-covered and individual-owned health plans.

3. Repeal state laws prohibiting shopping across state lines.

4. Remove government mandates.

5. Enact tort reform.

6. Make costs transparent.

7. Enact Medicare and Medicaid reforms.

8. Revise tax forms to make it easy for people to make tax-free donations to the uninsured.

But you may say, to do all these things at once would be complicated. It is equally complicated, perhaps even more so, to take ten years to carry out the 2700 pages of mandates inherent in the Affordable Care Act. Competition and transparency is no more complicated than control and bureaucracy, and it may be quicker and more compatible with individual liberties.

To quote Paul Ryan (R-Wisconsin, author of The Way Forward: Renewing the American Idea,

" There is an alternative: the Founder’s vision, which puts individuals, their families and communities – not government – at the center of American life..What does this vision look like in action? For starters, it favors choice and competition over government-run would make health are a true market over government-run solutions."

Friday, August 15, 2014

Bleak November

No warmth, no cheerfulness, no healthfulness,

No comfortable feel in any member –

No shade, no shine, no butterflies, no bees,

No fruits, no flowers, no leaves, no birds,

November! No!

Thomas Hood (1799-1845), English engraver, writer, and poet

November is shaping up as a bleak time for President Obama.

He may lose the Senate and fail to regain the House in the November midterm elections.

Health care premiums will be on the rise, often by double digits in states with key Senate elections states, further alienating the electorate.

His poll numbers continue to plummet to all time lows on job approval, economic performance, and conduct of foreign affairs.

There are doubts as to how many will re-enroll once their first premiums have been paid, and once they learn how much their premiums have gone up.

As many as 300,000 who enrolled in health exchanges the first-go-around may be declared ineligible and have their subsidies withdrawn, which will give a negative spin on the political merry-go-round.

Health care costs for businesses will up 6.5% or more, and many businesses will shift those costs to unhappy employees.

Real unemployment remains in the 12% to 13% range, and the most recent WJ/NBC poll indicates “widespread economic anxiety.”

The next health exchange sign-up starts on November 15, in the heart of the upcoming holiday season, when economic anxieties are at the worst.

Rumors persist that the Supreme Court may rule health plans subsidies on the federal health exchanges are illegal and violate the health law.

The first act of the new Congress, if Republicans have the majority in both House and Senate, will be to repeal ObamaCare, which President Obama will veto and will set the stage for a nasty New Year.

All in all, November promises to be a month for Republicans for ObamaCare to try to dismember and for President Obama to disremember. Of course, things could turn around by November, and Obama’s prospects could re-peak but for the moment things look bleak.

Thursday, August 14, 2014

Obama’s Broken Promises Coming Back to Haunt Him

The woods are lovely, dark and deep,

But I have promises to keep,

And miles to go before I sleep,

And miles to go before I sleep.

Robert Frost (1874-1963), Stopping by the Woods on a Snowy Evening

President Obama has less than three months to go before the midterm elections, and he has promises he cannot possibly keep.

These promises include keeping your doctor and your health plans and lowering your premiums.

The Republicans will keep reminding voters of those millions of cancelled policies, even though the President has now promised they can keep them.

Health plans will keep raising premiums to compensate for losing those millions of young voters who have decided to keep their old policies and whose enrollment in expensive exchange plans was needed to keep premiums down for others.

The world of broken political promises is cruel.

As Robert Blendon, a policy expert on public opinion who hangs out at the Harvard School of Public Health, notes,” If there are double-digit increases, they will show up in ads, and people will take it as another sign that the law is going badly.”

Executives of for-profit health plans have their own promises to keep – market share growth, profits to make, and investors to satisfy. And they have another promise in their political hip pocket - if things go badly, the Obama administration has promised to bail them out.

The bailout is another promise President Obama may not be able to keep. Republican presidential candidates and candidate for the House and Senate, are already calling for a cancellation of the insurance bailouts.

Politically, how do you cancel a federal promise that was designed to cancel the effect of failed health plan cancellations? When you are out in the Open, in the midst of a political campaign, cancelling a promise that the public may not have been previously aware of, can be a tricky business.

President Obama is deep in the political woods, and he has promises to keep. How he and Democratic candidates for the House and Senate finesse these promises or cancel them will require political skill.

The ObamaCare woods are dark and deep,

President Obama has promises to keep,

With less than three months to go before he sleeps,

With less than three months to go before he sleeps.

Wednesday, August 13, 2014

A Quote to Note: Government +

The Obama SWAT team is here to help you. No doubt many Washington offices could use a tech upgrade. One place to start would be E-verify, the data service that is supposed to tell employers if their job applicants are legal residents. Congress wants to mandate the program though it continues to give employers false results. The real problem with ObamaCare isn't the website. It's the belief that bureaucratic mandates, regulation, and price controls can better deliver health care than a system based on individual and market choice. No amount of digital savvy will fix a government health service that inevitably rations care and then gives bureaucrats the incentives to lie about the waiting lists.

"Government +", Wall Street Journal, August 13, 2014
Self-Funded Companies: “Sweet Spot” for Direct Pay Care

Under the self-funded model and the 1974 Erisa law, businesses and many unions bypass commercial plans and pay directly for medical claims of workers. Self-funding isolates companies from federal and state mandates and lowers health benefit costs for businesses and premiums for workers. State mandates, which number in the 100s for such things as chiropractic care, acupuncture, and contraceptives, sharply drive up costs.

R. Reece, “Self-Founded Companies,” Medinnovation Blog, September 13, 2013

Self-funded companies are mandate-killers. The mainstream media has been mute on this point.

But it is widely appreciated among small and medium sized companis that self-funding can cut 25% to 30% off your health coverage costs.

Lately self-funded companies have begun to contract directly with direct pay ambulatory care centers for a variety of minor operations - hernia repairs, laporoscopic gallbladder removals, cosmetic procedures, removal of skin lesions, urological intrusions, colonoscopies, noninvasive back operations injections, knee replacements, arthroscopies, cataracts, ENT and gynecologic surgeries, and a host of other procedures that can be performed safely and efficiently on an outpatient basis without overnight stays and without third party administrative fees and management. It is estimated 90% of surgery procedures can be performed in outpatient settings outside of hospital operating rooms formerly reserved for hospital inpatients.

To make a long story short but sweet, physician and outpatient site entrepreneurs have found a “sweet spot,” a chink in ObamaCare in the ObamaCare and third party armor of regulations, an opportunity to perform operations safely, efficiently, without the usual “fuss and bother” of third party payments outside of traditional hospital settings.

For those of you not in the know, a “sweet spot,” may be defined as:

• The point or area of a bat, club, or racket at which it makes the most effective contact with the ball. In this case, the “ball” being third party regulations, restrictions, and bureaucratic rules driving up costs, causing delays, inffeciencies, and inconveniences.

• An optimum point or combination of factors or events that impede performance, e.g , a market may have reached its “sweet spot,” when the prices are high enough to discourage buyers (high premiums and deductibles induced by ObamaCare health exchanges, but still low enough to promise a good return for direct pay surgeons, ambulatory surgery centers, and independent direct/pay physicians and surgeons.

This new, rapidly evolving approach to care, is most often promoted in the names of “competition”, “transparency,” and “cost savings.” It has caught the attention of a Silicon Valley entrepreneurs, as it apparent from this story ”Silicon Valley Startup Launches Self-Insurance Option for Smaller Firms”(Baltimore Sun and Reuters, August 12).

The lead two paragraphs in that story go as follows:

“SAN FRANCISCO (Reuters) - The founders of Collective Health, a Silicon Valley startup, say they can help employers save money by self-insuring rather than paying premiums to a health insurance company.”

“Collective Health has developed software to help companies pay workers' health costs directly. Collective Health describes its "sweet spot" as companies with a few hundred or a few thousand employees, typically in the tech sector.”

Collective Health will begin collecting members and offering its service in January 2015.
ObamaCare Begins to Fill in The Cracks As to Who Is Covered

To get lost or to be forgotten or to not be noticed.

Idiom, Fall Through the Cracks

The government is beginning to fill in the cracks in the health law.

Crack One, Proving One is Eligible was widely criticized for being too loose for defining who was eligible for subsidies. Of those who enrolled, 87% received subsidies. But critics said eligibility depended too much on the word of the enrollee rather than on records. Now the Obama administration is asking for proof of citizenship, immigration status, and income. If enrollees are unable to do so, they will be dropped from the health exchanges rolls. By September 30, some 300,000 are expected to lose their eligibility and their health plans (Abby Goodnough, “Over 300,000 Must Prove Eligibility or Lose Health Care,” New York Times, Aug. 12).

Crack Two, Proving One is an "Employer"

Until now, most criticism of health law provisions has been directed at the provision that says businesses with 50 or more employees must provide coverage. But what of those small businesses with less than 50 employees, the overwhelming majority of American small businesses. According to new guidelines, “employers” are defined as having at least 2 full-time employees, not including a spouse, to qualify for group plans. Yet 78% of America’ 28 million small businesses have not employees at all. These small businesses must now seek individual coverage rather than group coverage, and individual coverage has much higher premiums and deductibles. This new guideline especially hits sole proprietors . The Small Business Association in Michigan, which has 4000 members recently had to kick 700 sole proprietors off its plan. (Angus Loten, “Small Firms Hit by Big Changes in Health Coverage,” Wall Street Journal, Aug.6).

Tuesday, August 12, 2014

New Kindle Book

The newly released Kindle book, Direct Pay Independent Practice: Medicine and Surgery, is now available on for $9.97. The book describe the ascent of direct pay medicine and surgery as an alternative to ObamaCare which has led to unaffordable premiums for unsubsidized patients, especially those in individual and small group markets. The book surveys the current state of direct pay independent practice. It features interviews with 12 participants in the direct pay movement.
Robin William’s Death

The world is a comedy to those who think, a tragedy to those who feel.

Horace Walpole (1717-1797), English historian and member of Parliament

Robin Williams’ death reminds us comedy

Is never far removed from tragedy,

That what we call improvization,

Is the essence of humor’s foundation,

That the truly creative and gifted,

Often have the rest of us uplifted.

And that the tragedy of mental illness,

Is that it may end in premature stillness.

Most Pressing Issues Facing U.S. Physicians – The Hows and the Whethers

On its website,, the Physicians Foundation has asked physicians to share their thoughts about the future. Here are my thoughts.

• How to care for the 8 million consumers who have signed up for health exchanges, 5 million for mostly subsidized coverage and 3 million for Medicaid, given physician shortages and overworked primary care physicians.

• Whether to sign up for exchanges with their lower reimbursements and with the knowledge that may not include them as providers to be paid., given the glitches and misinformation of the back end of

• How to prepare for the future if the Sustainable Growth Rate (SGR) formula is followed and 25% cuts in Medicare fees occur.

• How to become more efficient and productive in wake of more ObamaCare regulations and demands for more electronic health record data, both of which steal time from taking care of patients.

• Whether to become hospital employees even though hospital owned-practice decrease autonomy and raise costs of physician care by charging more for hospital-owned facility fees.

• How to deploy the social media, Facebook, Twitter, other online sites, to market one’s practice and to compete with consumer-oriented sites and retail clinics, without compromising professional ethics.

• Whether to switch to direct pay/concierge practices to maintain incomes, take the risks entailed, abandon significant numbers of patients, in order to spend more time with patients and to practice in the fashion that one was trained.

• Whether to follow the dictates and provisions of the health law, which involve joining accountable care organizations, bundling services with hospitals and physicians, and “saving ” money for Medicare and ObamaCare.

• Whether to continue to accept Medicare and Medicaid patients even though reimbursements for those programs may not meet the costs of running a practice.

In the words of Lewis Carroll, author of Alice in Wonderland’ Through the Looking Glass, “the time has come to talk of many things: of shoes – and ships – and sealing wax- of cabbages and kings – and why the sea is boiling hot – and whether pigs have wings.”
In this case, the time has come for physicians to decide whether ObamaCare has wings, whether it can fly on one wing in our three pronged legislative system – executive, congressional, and judicial system – of checks and balances, and how to survive in a boiling political sea in which physician practices are potentially being cooked.