Sunday, August 30, 2015

Is America’s Diverse Culture Ending?b>

If we are to achieve a richer culture, rich in contrasting values, we must recognize the whole gamut of human potentialities, and so weave a less arbitrary social fabric, one in which diverse human gifts will find fitting place.

Margaret Mead (1901-1978), Sex and Temperament in Three Primitive Societies

America is a diverse society, a culture that works best when immigrants assimilate, learn the language, and obey the laws. This is easy to forget when gun violence explodes, partisanship prevails, and accusations fly of the GOP as a terrorist organization exploiting women.

In my view, at our best, we are a fair, non-racist society, and non-ideological society. We twice elected a black president. Today the New York Times Magazine celebrated Serena Williams as “Her Excellency.” Ben Carson, a black neurosurgeon, rose to second place in Republican primary polls. Bernie Sanders, an avowed socialist, was leading Hillary Clinton in New Hampshire, and closing in on her in Iowa.

We are also a center-right society that fears big government will hamper personal freedoms and retard the opportunity for all citizens to rise, based on their skills, not on their race or gender. This belief produces social inequities. But we are a society that believes in diversity and choice and entrepreneurial skills as opposed to uniformity and equal outcomes for all.

This belief system may produce a political counter revolution that says the system is rigged for those with skills and money and oppresses minorities. And center-right thinking may lead to nation that regards itself as the first among nations rather than just a nation among equals and thinks of itself as superior to nations will less wealth and resources.

Former vice-president and his daughter, Liz, herself a former government official, expressed this view with these words in an August 29-30 Wall Street Journal Op-Ed with this argument.

“Our children need to know that they are citizens of the most powerful, good and honorable nation in the history of mankind – the exceptional nation. They must know that they are the inheritors of a great legacy and a great duty. Ordinary Americans have done heroic things to guarantee freedom’s survival . Now it is up to us.” (“Restoring American Exceptionalism, ” WSJ, August 29-30, 2015).

The Cheneys end by quoting President Reagan on the 40th anniversary of the D-Day landings, “ We will always remember. We will always be proud. We will always be prepared, so we may always be free.”

The proud words of the Cheneys were designed to mobilize opposition again the Iran nuclear deal.

Opponents will surely retort by saying that Pride always goeth before the Fall, that diplomacy must always replace confrontation , that you must always trust rather than vilify, and that unity must always supersede diversity when negotiating with foreign powers.

It is difficult to change a diverse culture that holds two opposed ideas equally in mind at the same time - government care and private care, second amendment gun rights and strict gun control . But we must. As President John Kennedy remarked in a 1963 address at American University, “If we cannot end now our differences, at least we can help make the world safe for diversity.”

Is America’s cultural diversity ending ? Perhaps. Something is happening out there, 71% of Americans say the country is moving in the wrong direction.
The political tectonic plates are shifting. We seek something or somebody new, fresh, and different – something that will bring us together again and make us great again, something we seem to have lost.
Call it what you wish - anger, angst, or anxiety - Americans distrust everybody on both sides of the political establishment. Into this vacuum has moved non-politicians offering something better , a better America, better business deals, better government - anything but what we have now. We have new Wizards of Oz. The questions surrounding those behind these new curtains are these: Is there any there there? And if so what?

Friday, August 28, 2015

Political Word Games

This week the Quinnipiac national polling firm ran a poll asking 1563 people the first word that came to mind when thinking about 3 national political candidates.

For Hillary Clinton, the first word was “liar,’ for Bush “Bush,” and or Trump “blowhard.” These word associations partially explain why Clinton’s numbers are dropping, Bush’s are drooping, and Trump’s are booming.

Trump may be a blowhard, but he is lighting up the polls, and sucking up the oxygen from the other GOP political candidates.

Why is this?

Donald Trump is blatantly outrageous.

But his message is proving to be contagious.

On the campaign podiums he may be a blowhard

But at reading voters’ feelings he is a Mozart.

Critics say his promises are bombastic,

But he counters- my results are fantastic,

He claims all other candidates are stupid,

Only he has the God-given smarts to be lucid.

In debates he says he is the only adult,

And he has mastered the art of the insult.

He says he speaks for the silent majority,

And he speaks for them with authority.

People are mad as hell and won’t take it anymore,

This giving away of the U.S. company store.

In the bully pulpit, we will have a deal-maker,

Not a political puppet, but a mover and a shaker.

Voters as this stage love him on the stump,

Will they love him when their ballots they dump.

The Truth about Doctor Demand Dilemmas

As scarce as truth is, the supply has always been in excess of the demand.

Josh Billings (1818-1885)

As the physician shortage grows, technology advances, and government-subsidized care expands, the truths of the law of supply and demand become evident.

The demand side of the supply and demand equation states says that as the quantity of a good demanded falls, the price of the good rises.

Costs of care are rising, as premiums spike, often by 20% or more. Demand for physician services is growing. This demand stems from an aging population with more chronic diseases, technologies proven to alleviate those diseases, physician shortages across the board, expanding government programs - Medicare, Medicaid, and health exchange plans, more physicians not accepting those in government subsidized plans.

The truth is that the physician shortage is growing. It stands at 50,000 today and may exceed 100,000 by 2015. How could this be? Physicians are among the top 5 % in income, with top-earning specialists making $300,000 or more, and primary care doctors pulling down $150,000 or more. And physician recruiting firms report doctors finishing residencies get 100 or job offers, mostly from hospitals or large physician groups. These jobs generally come with health benefits , malpractice coverage, time off for vacations, and help paying off educational debt.

What’s not to like about becoming a physician? Well, as a recent “summit at the summit” meeting of physicians sponsored by United Physicians and Surgeons highlighted, there’s a lot not to like, including intervention into the patient-physician relationship, loss of physician autonomy, unreasonable credentialing requirements, unnecessary installation and use of dysfunctional electronic health records, time and effort spent searching for arcane IDD-10 codes to get paid, and second guessing at every step of the authorization of procedures and billing process.

The truth is that many, if not most physicians, are unhappy campers on the federal camping grounds. The truth is that health care has become a huge national business, consuming nearly 20% of GNP. The truth is that health care has consolidated into massive entities, with government, insurers, and large integrated health systems at the controls, rather than independent physicians in scattered practices. The truth is that costs of entitlement programs are becoming unsustainable, that something must be done to control costs, and that those controls begin with controlling physicians. The truth is that it is difficult, if not impossible for government, to dictate and monitor care from the top-down in a system involving billions of transactions at the bottom of the system.

The truth is that physicians are seeking ways through, out, and around the demands being placed upon them. These ways include becoming more efficient by using more physician assistants, nurse practitioners, and data scribes; opting out of the system by foregoing 3rd party participation and contracting directly with employers and patients; and going around hospitals and other competitors, by creating more focused, efficient, convenient physician-owned and directed facilities.
Where the physician Merry-Go-Round stops no one knows.

Thursday, August 27, 2015

ObamaCare Doctrine : No Risk, Everyone Gains, Except for Those Paying Higher Premiums and Deductibles

The ObamaCare doctrine is this: if you end the financial risk for caring for the sick and the needy, if insurers and government guarantee equal access to all regardless of their age, gender, and pre-existing medical conditions, all be well.

The problem with this ideological doctrine is that it doesn’t work very well in the real world. It may work well for the subsidized poor (3% of the population) and those who have neglected care because of costs, but it doesn’t work very well for for-profit insurers, who are beholden to stakeholders, and for the middleclass, who must bear the burden for health care without risks.

Risk is an essential pre-condition of the capitalistic society. Investors and entrepreneur are wary of anyone who urges action in which they incur no risk. You take your chances, and you accept the consequences.

With ObamaCare, consequences of accepting all comers for insurance coverage and guaranteeing that all comers will receive standardized, comprehensive coverage without regard to financial risk, has been and will continue to be increased premiums and deductibles.

It should be no surprise, then, that major insurers in some states have raised premiums in the health law’s third year, despite the ObamaCare’s insistence it will force states to justify these increases. Insurance regulators in multiple states have approved premium increases as “justifiable” because of the hefty increases needed to cover higher –than expected claims for sick people who signed up for health exchange plans.

Among the state raising premiums above 20% are major insurers in Tennessee, North Carolina, Maryland, Idaho, Oregon, and Kentucky. The problem is keeping insurers in business and staying financially sound while providing insurance. Five major insurers – Blue Cross and Blue Shield of Rhode Island, Medical Mutual of Ohio, MVP Health Care, Anthem, and Blue Cross of Michigan 0 have proposed raising premiums by more thatn 10%.

Requiring companies to allow anyone to buy policies, regardless of medical history, age , or gender comes at a cost. The Obama administration says people should shop around, but this is difficult in states where the major insurer dominates the market and where shoppers cannot cross stateliness in search of a better deal.

Tuesday, August 25, 2015

On Moving the Physician Movement Forward

There are always two parties, the party of the Past, and the party of the Future, the Establishment and the Movement.

Ralph Waldo Emerson (1903-1882), Notes on Life and Letters of New England

On July 20-26, 2015, a new physician organization, the United Physicians and Surgeons (UPSA), held a conference, dubbed the Summit at the Summit, in Keystone, Colorado.

The conference featured over 40 speakers. Speakers represented many physicians and physician organizations, both bearing workable innovative ideas. The conference was designed to restore physician autonomy, protect the patient-physician relationship, and reset relationships between overreaching government and corporate entities.

Conference attendees were enthusiastic about this physician Movement to restore the voice of medicine.

But inevitable questions arose: Where do physicians go from here? How do we sustain the movement? Where will funding come from? What form will the Movement take? How will physicians inform hundreds of thousands of fellow physicians and millions of their patients about grievances of physicians, their ideas for the future, and what can be done to improve quality and convenience and confidentially of care?

The challenges are daunting. Private practice and ownership of those practices are declining. Fee-for-service reimbursement is shrinking. Government and the public tend to trust large integrated organizations more than individual physicians. Physicians are not united. They are splintered into numerous state and specialty societies , and many owe their allegiance to their hospital employers. Older and younger physicians think differently, as do male and female physicians, as do specialists and primary care physicians. ObamaCare health exchange plans offering subsidies to 11 million patients already exist. And last, but certainly not least, there is no widely accepted organization, like the American Medical Association, whose membership has dropped from 85% to 15% of physicians, to represent practicing physicians. Given these realities, how do physicians maintain the momentum of the movement?

The Physician Movement has no single driving force. It reflects the general dissatisfaction of physicians of how the system is evolving and where it is going. The Movement is diverse. It will be composed of direct care practices devoid of government and insurer oversight. It will consist of groups of physicians complying with rules of the Establishment. It will feature collaborative ventures between hospitals and physicians, physicians and employers, and physicians and patients.

There was no shortage of ideas at the conference – direct patient care (concierge medicine and all-cash surgery centers), a moratorium of electronic health records, expedited ICD-coding, credentialing changes, independent practice associations competing with corporate entities, physician unions, new forms of health insurance, and national alternatives to ObamaCare should it be repealed or replaced.

The hottest ideas at the moment are to disseminate videos of the various speeches presented at the conference for distribution, to create 30 minute videos for other physicians and the public at large explaining the need for a physician movement.

I have an idea of my own: to transcribe the 40 speeches given at Keystone into a single Kindle e-book for sale to larger audiences.

Finally, I believe physicians need to spend more time developing collaborative ventures with hospitals and insurers and employers without compromising the principles of any of the participants. One form this could take would be bundled pricing for disease episodes or hospital admissions with discounted fees for physicians and hospitals with back-up reinsurance should the total fee exceed estimates. This could be workable alternative to Accountable Care Organizations, which have not worked well because of government regulations. Another form rapidly evolving are primary care practices offering bundled services for a fixed retainer price.

Hospitals and insurers are not going away. They are twin pillars of the current system. Work with them but keep your distance and maintain your core patient-protection principles.

Encourage development of physician-owned and directed focused, efficient, and convenient ambulatory diagnostic, treatment, and surgery centers, The future will be outside hospital walls in convenient community locations.

Meanwhile we physicians should reaffirm our commitment to the principles of individual freedom and choice, to the sanctity of the patient-physician relationships, and to limited government and corporate intervention. But we should distinguish between what we cannot alter, what we must accept, and what we should embrace. We should help design principled reforms that can win majority support to include a diversity of opinion.

For more information on the work and progress of the United Physician and Surgical Association, see
Obama: First Class, Intellect. Second Class, Temperament

America is still the best country for the common man. The common people feel at home here. America is still an ideal country who want to realize their capacities and talents.

Eric Hoffer (1898-1983), In Our Time (Harper & Row)

It was Justice Oliver Wendell Holmes, who observed of President Franklin Delano Roosevelt.

“Second class Intellect, First Class, Temperament.”

By temperament, Holmes meant political instinct or predisposition, doing what comes naturally.

President Obama has a first class intellect, honed by an unusual ethic heritage, a tight circle of progressive advisors, Harvard law school training , and a commitment to organizing minorities to overcome past social and economic inequities, but his temperament – for the America’s center right culture his political instincts may be lacking or off-base.

Nothing, he seems to think, can stand in his way - not Congress, not Republicans, not the Constitution, not peace and prosperity, not international terrorist disarray, not traditional allies, not public unpopularity of his health plan, not compromise with his principles. He has the power, and the glory will be the success of his vision to achieve equal outcomes for society and America’s place in the world.

By Guess and by God and by Obama and the power of sheer political will, he will transform America.

Obama’s mindset brings to mind Eric Hoffer (1898- 1983), the longshoreman philosopher. Hoffer’s take on the presidency was the last thing we need as a president is an intellectual. Intellectuals think of themselves are part of a superior educated minority, a cut above ordinary mortals. Intellectuals see the world in their terms. They think they have the answers and an end product that will right the wrongs of mankind.

There is nothing special about America. It is not a Shining City on the Hill as portrayed by Reagan. It is not exceptional. It is merely one of many nations. And when push comes to shove, it must accede to the wishes of its adversaries and placate them.

But common people do not see themselves or America that way. They think America is a special place. They distrust intellectuals. They are always striving, looking for individual ways up and out of the trap called life. They distrust big government , big taxes, and big regulations that hamper their freedom, cramp their life style, and violate their sense of manifest destiny.
They are interested in the individual good as well the common good and see the two as going together. They believe in innovation and entrepreneurship as a way of rising above it all.

For President Obama, the principled intellectual, the irony of the contradictions between intellectuals and the common man, is that Obama is for the common man.

Monday, August 24, 2015

Tom Coburn, Foe, Critic, and Friend of Obama

On the CBS program, 60 minutes, retired conservative Republican senator, Tom Coburn, of Oklahoma, said he was “proud” America had twice voted for Barack Obama as President. The vote showed America was a great country, largely free of the racial bigotry of which it is accused. Although a frequent foe and critic of Obama, Coburn said he was also a friend of Obama and had worked with him on many issues. Obama, Coburn added, is a serious man, not a glad hander, who deals easily with members of the opposition.

Sunday, August 23, 2015

Trump: Mastering the Art of Cooking the Books of Political Correctness

Donald Trump says the two best selling books of all time are: number one, The Bible, and number two, The Art of the Deal, composed by Donald himself. By citing The Bible, he appeals to Christian Evangelicals, one of his core constituents. By referring to The Art of the Deal, he promotes himself.

The Art of the Deal , part memoir and part business advice, was published in 1987. It stayed on the New York Times best seller list for 51 weeks. It sold over 1 million copies. It may not be the best selling business book of all time, but it shows that Trump has mastered the art of self-promotion. He is leading the polls among evangelicals, Republicans, conservatives, college-educated, the silent majority and people who have never voted before. To his critics, who label him as a self-aggrandizing blowhard, he says in a self-quote on this week’s Time Magazine cover, “deal with it.”

Trump has turned the political world and conventional wisdom upside down. How has he done it? Well, among other things, he has attacked “political correctness,” defined as avoidance of expressions perceived to exclude, marginalize, or insult groups of people who are perceived as socially disadvantaged or discriminated against.

It is, for example, politically correct to say that immigrants are poor, beleaguered souls who flow across the border or die trying, seeking a better life for themselves and their children. “Calling undocumented immigrants ‘illegals’, says Emily Bazelon in the August 13, 2015, politically correct New York Times Magazine, “implies that they are less than human and undeserving of fair treatment. ” Nonsense, says Trump, many illegal immigrants come to commit crime, rape, and pillage.

It is politically correct to protect immigrants with minor crime records from over-zealous, biased, conservative public officials in sanctuary cities. Send them back to their home countries, says Trump.

It is politically correct to say that there exists a war on women in corporate board rooms and in health care facilities. Ridiculous, observes Trump, the U.S. worships women, who are among the best treated and most accomplished in the world and they deserve better than late term abortions with selling of fetal body parts.

It is politically correct to say that the police have declared war on unarmed blacks. Patently untrue, counters Trump, black on black murder is a far greater problem. Policemen are among our best citizens. We need to respect them more, not less, and we need more of them enforcing the law, not less.

It is politically correct to say politicians have the best interests of their constituents at heart. Not true, observes Trump, they only have their own self-interests and getting re-elected at heart, and act in the best interests of their biggest contributors.

And so it goes. Asked if Trump had crossed the line with his language and his attack on politically correct language, Carl Tomanelli, 68, a New Hampshire police officer, commented, “People are starting to see, I believe, that all this political correctness is garbage, and I think he is echoing what a lot of people feel and say(“Why Trump Won’t Fold: What Polls and People Say,” New York Times, August 23, 2015).

Saturday, August 22, 2015

Tectonic Shifts in Politics and Health Care

Last night Donald Trump spoke before 30,000 people in a Mobile, Alabama stadium. This was an unprecedented event in the 2016 presidential campaign. He dwelled on his policies to make “American Great Again”and of how he would create jobs. He touched on ObamaCare . He would repeal and replace it with his “spectacular”policies that would lower health costs, and make health care accessible to everyone across state boundaries.

Some think Trump’s campaign represents a “tectonic shift” in American politics – a shift from political environment to a business environment in which straight talk and quick action replaces compromise and a slow legislative process in which politicians are “puppets” to the rich and corporate interests.

Trump has been masterful at monopolizing television, at attracting media attention without spending his own money, at belittling politicians as “stupid” tools and fools of the corporate and Washington elite , at articulating the anger and frustration of how people feel. And in the process, he has seized the lead in polls. Trump is clearly on to something. No one is sure just what.

But is Donald Trump real, is he a plausible presidential candidate, or is he an egocentric and bombastic phenomonon that will self-destruct? Are his policies workable? His policies on immigration – deportation of 11 million illegal immigrants and their families and changing the birthright policy of making babies born here automatic citizens – raise doubts.

And we have yet to hear the specifics of what he would do about ObamaCare ?

Is Donald Trump like former Secretary of State, John Foster Dulles? Winston Churchill described Dulles as a bull who carried his china shop around with him. Is Trump like Eleanor Roosevelt who said women politicians were like tea bags who grew stronger in boiling water? In Hillary Clinton’s words, the email scandal is a tempest in a teapot created by the “vast right wing conspiracy.” Will Jeb Bush,” the Tortoise,”
as a New York Times columnist, asked, overtake “The Hair”?

Who knows if Trump represents a political or health care tectonic shift? Who knows if he will self-destruct, the victim of his own rhetorical excesses? It’s too early to tell. To date, scientists have not been effective in predicting earthquakes secondary to shifts in tectonic plates.

And political and health care pundits are no better are forecasting human upheavals. In health care, the tectonic plates are ObamaCare, the medical industrial complex, personal health care, and the medical profession. Will they override each other and remain quiescent or erupt and shatter into different pieces?

At the moment, all we know is that Donald Trump has a long record of business accomplishments, he has tapped into how people feel, and he has his own set of solutions which have yet to be announced.

Wednesday, August 19, 2015

11 Pragmatic Observations about U.S. Health System

1. The U.S. health system is the most expensive in the world and will remain so as long as patients demand and expect the latest in hi-tech, pay specialists the most who deliver that hi-tech, and maintain the current legal system which encourages trivial law suits and casino-like rewards should high-tech fail.

2. The health system accounts for only 15% to the nation’s health, the biggest contributors to health and health statistics are poverty, health habits, diet, drug use, violence, lack of exercise, and deteriorating family structure.

3. The key to overall health improvement may lie in the realm of prevention , but prevention depends on the public’s willingness to change their general behavior and the transformation of culture, and most people are much more willing to pay for established diseases rather than theoretical preventive measures.

4. America leads the world in obesity and smoking rates and associated complications; unless obesity and smoking rates decline, these problems may break the health care bank at government, employer, and personal levels.

5. America has the most innovative hi-tech sector in the world, but Gee Whiz Hi-Tech Bang technologies, will not and cannot reverse irreversible chronic diseases, still after age 75, the U.S. produces the best results.

6. Government intervention, corporate consolidation, and the necessity of management skills (marketing, coordination, and capital formation) have contributed to the decline of private practice and physician shortages.

7. In the future, physicians will be among the highest paid and most in-demand professions, but most of the money will continue to go to specialists (orthopedists, cardiologists, gastroenterologists, urologists, oncologists, dermatologists, radiologists, and surgeons) rather than generalists (family physicians, general internists, nurse practitioners and physician assistants).

8. High tech apps – wearable and implantable recording devices, telemedicine virtual visits, non-invasive virtual devices (GI cameras and virtual colonoscopies), patient-owned medical record thumb drives, and ubiquitous electronic health records, are the coming things but must be protected from hackers.

9. A sizable percentage of physicians, frustrated by governmental and corporate controls, will break loose from the system, and 3rd party control and coding and regulatory demands by entering concierge direct cash practices and setting up urgent care and focused diagnostic and therapeutic centers for ambulatory patients.

10. The legacy of ObamaCare will be that its provisions, in particular, individual and employer mandates, comprehensive health plans for all regardless of pre-existing conditions, have changed the U.S. health system, forever, sometimes for the better, sometimes for the worst, and always with unforeseen consequences.

11. Any Republican plan to replace or repeal ObamaCare in part or in its entirety is unlikely to succeed unless it specifically addresses how to take financial care of the 11 million or so who signed up in good feaith for ObamaCare subsidized health exchange plans,

Monday, August 17, 2015

Do Amazon’s Leadership Principles Apply to Health Reform?

Yesterday’s New York Times front-page exposure on Amazon’s leadership principles has made quite a splash ("Inside Amazon" Wrestling Big Ideas in a Bruising Marketplace," Aug. 16, 2015).

The article brings into question whether these principles are too harsh, rely too much on data rather than human relationships, and drive talented people out of the company.

On the contrary, Amazon says. Its CEO and founder, Jeff Bozos, and his followers and investors, claim Amazon has effectively deployed a dazzling array of metric measurements to create discipline among its staff and employees, to select effective leaders, to cut through red tape, bureaucracy, and politics; to focus on outcomes and performance, and to build a premier online high tech company. Amazon employs 183, 000 people and ranks at the number one retail company in the world, now surpassing Walmart in stock market value.

Here are the 14 leadership principles, as explained by Amazon.

1. Customer Obsession
Leaders start with the customer and work backwards. They work vigorously to earn and keep customer trust. Although leaders pay attention to competitors, they obsess over customers.

2. Ownership
Leaders are owners. They think long term and don’t sacrifice long-term value for short-term results. They act on behalf of the entire company, beyond just their own team. They never say “that’s not my job".

3. Invent and Simplify
Leaders expect and require innovation and invention from their teams and always find ways to simplify. They are externally aware, look for new ideas from everywhere, and are not limited by “not invented here". As we do new things, we accept that we may be misunderstood for long periods of time.

4. Leaders Are Right, A Lot
Leaders are right a lot. They have strong business judgment and good instincts. They seek diverse perspectives and work to disconfirm their beliefs.

5. Hire and Develop The Best
Leaders raise the performance bar with every hire and promotion. They recognize exceptional talent, and willingly move them throughout the organization. Leaders develop leaders and take seriously their role in coaching others. We work on behalf of our people to invent mechanisms for development like Career Choice.

6. Insist on the Highest Standards
Leaders have relentlessly high standards - many people may think these standards are unreasonably high. Leaders are continually raising the bar and driving their teams to deliver high quality products, services and processes. Leaders ensure that defects do not get sent down the line and that problems are fixed so they stay fixed.

7. Think Big
Thinking small is a self-fulfilling prophecy. Leaders create and communicate a bold direction that inspires results. They think differently and look around corners for ways to serve customers.

8. Bias for Action
Speed matters in business. Many decisions and actions are reversible and do not need extensive study. We value calculated risk taking.

9. Frugality
Accomplish more with less. Constraints breed resourcefulness, self-sufficiency and invention. There are no extra points for growing headcount, budget size or fixed expense.

10. Learn and Be Curious
Leaders are never done learning and always seek to improve themselves. They are curious about new possibilities and act to explore them.

11. Earn Trust
Leaders listen attentively, speak candidly, and treat others respectfully. They are vocally self-critical, even when doing so is awkward or embarrassing. Leaders do not believe their or their team’s body odor smells of perfume. They benchmark themselves and their teams against the best.

12. Dive Deep
Leaders operate at all levels, stay connected to the details, audit frequently, and are skeptical when metrics and anecdote differ. No task is beneath them.

13. Have Backbone; Disagree and Commit
Leaders are obligated to respectfully challenge decisions when they disagree, even when doing so is uncomfortable or exhausting. Leaders have conviction and are tenacious. They do not compromise for the sake of social cohesion. Once a decision is determined, they commit wholly.

14. Deliver Results
Leaders focus on the key inputs for their business and deliver them with the right quality and in a timely fashion. Despite setbacks, they rise to the occasion and never settle.

Do these leadership principles apply to health care?

Yes, health care needs leadership principles.

Yes, health care needs to be obsessed with patients.

Yes, health care needs to earn the trust of the populace.

Yes, health needs to measure its results, and metrics are one way to measure these results.

No, health care is not a private business and cannot impose its will on its employees.

No, metrics are not the only way to measure value and satisfaction.

No, physicians and other health care professionals are not employees, devoted to carrying out the mission of their employer.

No, health care is not a high tech profit-based enterprise, it is a human relationship between professionals and the American public, who believe a non-profit safety net is an essential part of the human equation.

That said, it Amazon’s leadership principles have much to teach us about the importance of disciple, focus, and data as tools to improve health care performance.

Sunday, August 16, 2015

Data-Driven Future: It May Be Key to Commercial Success But Is It Humanizing?

Since I started this blog in 2006, I’ve been wrestling with question: Is the Internet dehumanizing for health care? Maybe the answer doesn’t matter. The Internet is inevitable.

Get over whether it is a good thing, or a bad thing. It is here to stay, and it will grow and be part and parcel of daily life and daily health care.

Who can argue with instant access to information, with the objectivity of data to determine the best outcomes, with Google search to find the right doctor and right doctor and right health plan, with the magic of metrics to find almost anything you want to know about your health and disease, with making your own diagnosis and selecting your own treatment, with the superiority of artificial intelligence over human intuition, with the triumph of secularism and worldly things over traditional beliefs and values, with quick digital scanning over time-consuming in depth reading? After all, in God we trust, all others use data. Online data, in other words, will empower everybody and is God’s gift to mankind. Data will empower everyone and connect everyone.

I thought about these questions as I read today’s Sunday New York Times.

The Times features two pieces I found relevant to the dehumanizing question.

One is “ Amazon Tests How Far It Can Push White-Collar Staff.” The thrust of the article is that CEO Jeff Bezos uses metrics to measure the performance of his staff and his company.

To Bezos data is everything. Data allows individual performance to be measured continuous, Amazon is running a continual performance improvement algorithm on its staff, data creates clarity around decision making, data liberates the company to focus on what’s important. Data infuses transparency and precision into the workplace and frees the workplace and the marketplace from bureaucracy and politics. Amazon’s employees are held accountable through a staggering array of metrics based on leadership principles, through rigorous feedback on performance, and on competition between staff.

Whether or not one agrees with this focus on metrics, one cannot help be astonished at the results. Bezos is now the fifth wealthiest person in the world, the most valuable retailer in the Country with a market valuation of $250 billion, and the new owner of the Washington Post. Bezos may be dehumanizing in his metric demands on his staff, but his company is humanizing to most of Amazon’s customers.

Two is “Staking the Times’s Future on Digital, “ by Margaret Sullivan, its public editor. Mr. Sullivan says the Times is betting its future on the Net. It is betting its online revenue will offset the inevitable decline of print. It is betting within 5 years, its digital revenue will surpass its print revenue. It is betting an international audience will be drawn to its pages. It is betting more money will be spent of journalism than the past. And it betting constant change and turbulence, triggered by online innovation, will appeal to the new mobile generations of millenials and their successors. It is betting it can blend online and print and prosper.

Saturday, August 15, 2015

Clinical Innovations

In reading my latest New England Journal of Medicine, I ran across this passage,

“Some clinicians see the recent explosion of interest in health care innovation as a fad incapable of yielding sustained contributions…Calls for innovation can sound hollow to practicing clinicians, who know that when it comes to intractable challenges like patients repeatedly admitted for health failure, there’s not app for that (David Asch, MD, and Roy Rosin, MBA, “Innovation as Discipline, Not Fad,” NEJM, August 13, 2015).

Why the pessimism? There are multiple reasons: So far most clinicians have not benefited from the explosion of online Apps. Most have websites and electronic health records (EHRs). Most glean data from the Internet, and more and more use e-mail to communicate with patients. But many find EHRs unwieldy, expensive, time-wasters, non-operative, and non-revenue wasters. And many do not like to be judged by data they enter into the computer. They yearn for professional as well as patient privacy.

There is another seldom-mentioned reason as well, lack of benefits of online scale. Most social media entrepreneurs (Facebook, Twitter, Instagram) and members of the medical industrial complex (insurers, suppliers, hospitals, and drug companies) have advantages of scale. They can reach millions through the click of a mouse.

But medicine is a one-on-one business – one patient visit at a time, one disease episode at a time, one individual problem at a time. It is true, of course, that clinicians can go to the net to find information to supplement these one-time occasions, and it is true one can aggregate this information over their patient populations.

tale of three surgeons comes to mind. Three surgeons were boasting about their accomplishments. The English surgeon said, “I once performed brain surgery on a deaf mute and restored him to full hearing and speaking.” The American said, “I did a spinal cord transplant on a quadriplegic and restored him to full movement.” The Russian said,” I removed a man’s tonsils “The English and American surgeons, astonished, asked, ”What’s so miraculous about that?” “Because, “explained the Russian, “In my country, people are afraid of opening their mouths, and I have to remove them by coming from a different direction.” Innovation is about coming from a different direction, but the results are not always beneficial to the patient.

Note that the three surgeons were all talking about one memorable patient, not a population of patients. Note also that they are not speaking of a clinical team that made the surgery possible. Note that they did not mention the organizational environment in which they operated. And finally note that all were speaking of gee-whiz technologies.

In modern day medicine, innovation is mostly about empowerment of patients and empowerment of organizations using connective online technologies. That is behind the astonishing successes of Silicon Valley companies and social media entrepreneurs. The successes of physicians is also related to technologies – stents, endoscopy surgeries, joint replacements, new cataract surgery techniques, statin drugs, insulin pumps, and wearable and implanted monitoring devices – but for the typical clinician, these technologies apple to a limited number of patients and are ordered or performed one at a time.

So how can physicians expand the scale of what they do?

They can collaborate with hospitals to help them market to larger audiences.

They can initiate “focused factories, “ diagnostic and therapeutic facilities, offering intensive and repetitive services for specific services and in which they have an ownership interest.

They can offer convenient accessible outpatient services, such as urgent care centers, in which all comers are welcome, not matter what their insurance coverage.

They can go into concierge medicine or direct cash practices, devoid of the regulatory impediments and coding requirements – inherent in government or insurance coverage.

They can develop health –related products that can be sold and marketed through commercial online, radio, or television venues.

They can offer different services - home care, virtual telemedicine consultations, and they can develop patient-empowerment products that allow patients to order their own diagnostic tests before consulting with the clinician.

They can bundle their services and offer transparent pricing so patients know exactly what they are paying for.

Thursday, August 13, 2015

Kasich: Standing for Something

In the first GOP debate, John Kasich, the governor of Ohio, had perhaps the clearest message. He stood for “economic growth,” “unconditional love, “ and a return to “America’s values.”

In his 2006 book, Stand for Something: The Battle for America’s Soul, Kasich listed these American values as: honesty, integrity, personal responsibility, faith, humility, accountability, compassion, and forgiveness.

For these values to be preserved and restored, Kasich believes:

1) We must have economic growth. Without growth, we cannot show compassion for the poor by expanding Medicaid, which he has done in Ohio.

2) We must show unconditional love and respect for our political enemies and for policies we oppose. Kasich opposes gay marriage, but he showed respect for his gay friend, by attending his friend’s gay wedding.
Kasich comes across as a compassionate conservative who believes in open and civilized debate and in accepting what he cannot change, e.g. the Supreme Court ruling on gay marriage.

Whether one believes in this philosophy or not, for the moment, it plays well among voter. In the 2014 Ohio governor’s race, he won by 64% to 33% and in 86 of 88 Ohio counties. And by virtue of his debate performance, he is rising in polls in the early primary states and is now considered a serious presidential contender.

He had an impressive record during his 9 terms as a congressman from Ohio. He led the fight to balance the federal budget and to reform welfare. Today he stands for expansion of Medicaid, not a popular issue among Republicans but balances that by advocating replacement and repeal of the rest of ObamaCare. On immigration, he is open to a path for legal status for undocumented immigrants but opposes amnesty. He doesn’t oppose Iran deal, but would put troops on the ground to fight ISIS.

Kasich speaks from the gut and from the heart. He believes in confronting the issues head and promoting and accepting change, whether he wins or loses.

Tuesday, August 11, 2015

Anger Management

Humpty Dumpty sat on a wall.
Humpty Dumpty had a great fall.
All the King's horses.
And all the King's men.
Couldn't put Humpty Dumpty together again.

Lewis Carroll, Through a Looking Glass

Seldom have voters been angrier than they are at the moment. They feel politicians and the political establishment on both sides of the aisle have abandoned them.

Donald Trump has tapped into this anger, which is focused on the direction of the country, the Iran deal, the state of the economy, and the disruptions and disappointments of ObamaCare.

With ObamaCare, anger still festers over its unilateral, some say arrogant, passage without a single GOP vote. Voters are angry over the financial penalties imposed by the individual and employer mandates. They are angry over rising premiums and deductibles. They are angry over narrowing networks, and the inability to keep and choose your own doctors, hospitals, and health plans.

The middle class and the young are angry over stagnant wages and difficulties finding full-time work with health benefits. They feel they should not be wholly responsible to financing those 10 million people who have received subsidies.

There is anger among the states who do not feel capable of carrying the burden of ObamaCare-induced Medicaid expansions. There is anger among the unions who feel their plans should not be penalized for generous health care benefits. There is anger among Republicans who have tried and failed 50 times to repeal ObamaCare.

People are mad as hell, and in one way or another, they are saying they are not going to take it anymore. They fear the American dream is slipping away. Donald Trump is articulating their frustrations.

Donald Trump says America is like Humpty Dumpty, about to take a great fall. Only he can put America together again. But what if he is Humpty Dumpty? And what if he has a great fall? And what if he runs as a third party candidate? Will the Republican party have a great fall? And will the GOP’s king-makers be able to put the party together again?

Monday, August 10, 2015

A Conversation with Elaina George, MD, author of Big Business: The Cost of Corporate Control of Health Care and How Patients Working Together Can Rebuild a Better System, A Kindle Book, $9.99 on Amazon

I just spoke to Elaina George, MD, a 53 year old African American Ear, Nose, and Throat Surgeon in Atlanta, whose book I reviewed in my last blog.

I asked her what she hoped readers would take away from her book. She answered she wanted readers to -appreciate its central theme - to return power to individual patients and physicians rather than to succumb to the power of big government, big insurers, and big hospital systems.

I asked her what she thought of Doctor Ben Carson, the African-American neurosurgeon and a candidate for the Presidency. Carson advocates ObamaCare repeal and universal health savings accounts. She said his theme “sounded good,” but she worried about it because it put power in the hands of big insurance companies , where it does not belong. She said health reform was not a black or white issue.

I asked her what she felt the ObamaCare legacy would be. She commented ObamaCare would have a” monster affect.” It would transfer power to the government and away from the middle class. She added she personally did not take Medicare and Medicaid patients, She preferred to deal with patients individually on a sliding scale payment basis, depending on what they could afford. She added she charges $50 a month for bundled ENT services. She foresaw a 2-tier system, part government for subsidized patients and part private for those who could afford to pay and who wanted better, quicker, and affordable care. She felt the Supreme Court decision affirming the constitutionality of ObamaCare had ignited a “consolidation free-for-all” among the big insurers and big hospital systems. These insurers and hospital would soon become “too big to fail” and too big to offer personalized services.

She said she was raised and educated in Brooklyn, New York and attended small private school there. Her father was from Antiqua and her mother from Ashville, North Carolina. Both believed passionately in education as the way up. Her father owned a construction company and her mother worked in a beauty salon. After her undergraduate education at Princeton and her medical school and residency training in New York City, she gravitated to Atlanta because of lower cost of living and the better quality of life.
A Review of Big Medicine: The Cost of Corporate Control and How Doctors and Patients Working Together Can Rebuild a Better System, by Elaina George, MD, Alethos Press, St. Paul, Minnesota, and ebooks at and Hardcover version printed by Bethany Press International, Bloomington, Minnesota.

Now and then comes a book on how a practicing physician really feels about ObamaCare. This is that book.

For good writing it is a good practice to follow this rule, “If you have a nail to hit, hit it on the head.” Elaina George, MD, an Ear, Nose, and Throat Surgeon, from Atlanta who has been in private solo practice for 17 years, hits several nails on the head in 27 chapters and 134 pages. She describes her honest reaction to reflections on ObamaCare from the viewpoint of the MD at bedside. The purpose of her book is to transmit and justify this reaction, which is generally negative, to patients.

Readable writing is also a product of good editing. In this book , Dave Racer, an author and publisher in his own right, has done a superb job reducing this Doctor George's blogs and thoughts into a coherent book.

Doctor George, is a graduate of Princeton, the Mt. Sinai School of Medicine in New York City, and completed her residency at the Eye, Ear, and Nose Hospital in Manhattan. She says corporate and government control of medicine comes at financial and human costs, but can be remedied by doctors and patients working together.

As I read her book, written by a surgeon, I thought of the words of the poet Emily Dickinson (1830-1886),

Surgeons must be careful
When they take the knife,
Under their fine incisions,
Stirs the Culprit - Life!”

In this case, Life! is the life of the American healthcare system, private practitioners and patients, caught under the regulatory heel of the health law and ensnarled in the web of consolidated corporate entities – the huge insurers, pharmaceutical firms, and hospital chains – and government bureaucrats who carry out and enforce the law.

There is tremendous unease among doctors and patients about ObamaCare and the big medicine it produces. In a Physicians Foundation survey of 650,000 physicians, to which 20,000 responded, 46% of physicians gave ObamaCare a D or F grade. In over 1,000 national polls conducted since ObamaCare passed in 2010, the public has opposed the health law in over 95% of polls, usually by double digit margins.

You get an inkling of these reasons why this unease exists from some the chapter titles in Dr. George’s book: “ObamaCare: Trojan Horse for Socialized Medicine,” “Crony Capitalism Can Be Hazardous to Your Health,” “The Administration’s Answer to High Healthcare Costs...Rationing,” “Cookbook Medicine: The Future of Health Care in the United States,” “Six Ways Your Health Insurers Make It Harder to Take Care of You,” and “A Practicing Physicians Prescription for a Health Care Fix.”

Among Dr. George’s “Prescriptions” are these:

• Change the tax code to allow private physicians to pay off bad debt.

• Change medical malpractice law through tort reform.

• Allow Medicare and Medicaid patients access to cheaper drugs from other countries.

• Refuse to mandate, as matter of licensure, that physicians must accept Medicare, Medicaid, and ObamaCare health plans.

Dr. George does not advocate for outright repeal of ObamaCare, although she strongly points to it as a main hindrance to a restored healthcare system. She clearly wants “Big Medicine” to leave doctors and patients alone to do the right thing instead of the left thing.

By and large, this is not a political book. It is a comprehensive litany of why ObamaCare’s good intentions, to cover costs of the poor and uninsured, comes at the cost to the middle class, patients, doctors, and the nation as a whole. ObamaCare, in short, is an obamanation (my pun, not Doctor George’s).

You cannot fool or please all of the people or all of the doctors all of the time.

By George, this is a fine book. I recommend it. But it will be difficult for most readers to digest in its entirety, for the law affects different groups of Americans in different ways, at different times.

Friday, August 7, 2015

ObamaCare Gets Scant Mention in First Republican Debate

In the first Republican Debate last night in Cleveland, the first of 11 official debates, ObamaCare received only scant attention.

It was mentioned six times in passing. Scott Walker said “Repeal ObamaCare;” Donald Trump commented, “We have to end ObamaCare,” and Jeb Bush said it had to go because of adverse effects on employment. But there were was no in depth discussion, and it was not on the moderators high list of penetrating questions.

Why the relative silence? It may be the questionnaires had bigger and more controversial fish to fry – The Iran deal, lack of economic growth, the war on women, and Trump’s record on women and his businesses bankruptcies.

It may also be Supreme Court ruling that ObamaCare was legal took the wind out of the GOP’s sails. Or it may be the fact that 10 million Americans are now insured because of the signup push and that the uninsured rate has dropped from 18% to 12% made ObamaCare difficult to attack. Or it may simply be, as President Obama has claimed, that ObamaCare is “here to stay.”

As Peter Berkowitz a senior fellow the Hoover Institute as Stanford University, has learned to distinguish “among what they can offer, what they must accept and what they should embrace.”

Wednesday, August 5, 2015

Cutting Health Costs: Evidence Not Policy

Take nothing on its looks; take everything on evidence. There’s no better rule.

Charles Dickens (1812-1870), Great Expectations

A school of thought exists that says: follow health care policies and lower costs will ensue. That is the school of great expectations. This has been the Obama administration’s approach, and it doesn’t work.

There is another school that says: Go to the market, get the hard-ass evidence on outcomes, and examine details in the bills, those who pay the bills will decide what services to use and what to pay.

The latter often requires direct examination of the bills. And it is being increasingly being used by employers to set their own criteria for what they will pay, and it often involves direct contracting between the employer and hospitals and physicians with middle men experts to sort out what is relevant to outcomes.

The direct approach requires a different mindset. It often involves bypassing 3rd parties such as government and insurers and going directly to the details in the payment request from hospitals and doctors. Employers are now looking for management companies that will cut the cost of health care by scouring hospitals and physician bills and asking these hard analytical questions.

One, what do you do that is structurally different, that cuts waste and bypasses policy issues?

Two, show me hard evidence of longitudinal results, that what you’re doing works and cuts my costs and gives equal or better results.

Three, show me clinical and client testimonials that you do what you say you do.

Four, give me data that proves that what you are doing is scalable, that it can be applied across the board for a variety of procedures and types of care.

Five, how long have you been in business, and how likely are you likely to stay in business, given the trajectory of your performance for your clients?

Six, are you willing to go at financial risk to prove you can do what you say you can do?

What you want as an employer seeking these companies is Facts, nothing but Facts. Facts alone are what needed, nothing else. Root out everything else.

A coalition of direct care forces – concierge physicians, ambulatory care surgery centers, employers, and management companies fostering direct care – are coming together to cut costs without sacrificing quality.

At this stage of the health system evolution, it will require management and billing experts to sort through bills and contracts to find what is essential for care and what is not and what constitutes a reasonable and rational charge for services.

Monday, August 3, 2015

Grassroots Private Doctors United. Is It Too Late?

A new non-profit organization, United Physicians and Surgeons of America (UPSA) has been formed. Its purpose it to “protect doctor/patient relationships and to let physicians practice medicine without restraint from non-medical entities. Its website is UPSA just held their first meeting , The Summit of the Summit, in Keystone, Colorado from July 20-26.

Forty one speakers addressed these issues.

1. Disruption of doctor-patient relationships

2. Loss of clinical autonomy

3. Regulatory and paperwork burdens

4. Dysfunction of suboptimal electronic medical records

5. Demands of certification

Forty one speakers included: cardiologists, a Senator, writers and authors, medical society presidents, CEO of the Physician Foundation, the founder of the Free Market Association of America, a Merritt Hawkins representative, concierge physicians, surgeons, family physicians, ophthalmologists, a nurse, an anesthesiologist, political policy and online analysts, internists, gastroenterologists, otolaryngologists, urologists, an endocrinologist, orthopedic surgeons, and physician representatives from the United Physicians and Surgeons of America.

The underlying purposes of UPSA are to unify the medical profession at the grassroots, to develop leaders across the primary care/specialist spectrum, to describe the current threats to medical practice in America, and to introduce problem solvers and entrepreneurs who have developed or led organization producing effective innovations for the private sector of medicine .

I have spoken to those who attended. All agreed it was a bang-up meeting, teeming with useful pragmatic ideas. But most to whom I spoke were tentative when I asked, were the ideas too little and too late? Most agree there was no turning back the clock, and we must go forward from the bottom-up.

Many of the movements affecting physicians – massive consolidation of insurers and hospitals, near-ubiquitous presence of electronic medical records in doctors’ offices, relentless growth of Medicare and Medicaid, aspects of ObamaCare such a protecting those with pre-existing illnesses, supplementing or replacing private physicians with PAs and NPs, emergence of thousands of retail clinics, and decline of private practices with physician hospital employment are already well advanced and irreversible.

But physician innovations - focused outpatient diagnostic and treatment facilities, physician-owned urgent care centers, concierge medical practices, direct pay ambulatory surgical centers, and physician-led virtual telemedicine outreach organizations – are out there and doing well. It is never too late for the right ideas.

It strikes me what physicians are fighting is top-down control by consolidated “outside” organizations like big government, big insurers, and big hospitals . A top-down physician organization like the AMA cannot effectively counter these consolidated entities. But a unified bottom-up physician entity, organizing and coordinating innovative physicians at the grassroots, might be just the ticket for a physician counter revolution.

Sunday, August 2, 2015

Conservatives: Aim at the Heart, Talk about the Pocketbook!

The big problem for Republicans in the 2016 elections, as Arthur C. Brooks, president of the American Enterprise Institute, says in his new book, The Conservative Heart: How to Build a Fairer, Happier, and More Prosperous America (Broadside Books, 2015), is that the left has a monopoly on compassion and empathy.

The solution for conservatives, according to Brooks, is to speak less from the head and more from the heart, and aim more at the pocketbook.

Talk about fighting for the middle class, expanding incomes, increasing job opportunities, and unleashing free enterprise. Be seen as fighting for people rather than against policies.

This is easy to say, hard to do.

It does not lend itself to 30 second sound bites.

Here is my try at a 30 second sound bite.

“Are you happier than you were last year?"

“Do you feel America’s economic system is fair?”

“Are you having difficulty finding full-time job with health benefits?”

“Do you feel safe as you once did in America?”

With pauses, that is a 30 second sound bite, Not only that, it would fits nicely on 4 bumper stickers.