Obama, Doctors, and Health Reform: A Doctor Assesses the Odds for Success - Brossura

Reece, Richard

Brossura

ISBN 10: 1440146764 ISBN 13: 9781440146763

Casa editrice: Authorhouse, 2009

Riassunto

In Obama, Doctors, and Health Reform, Richard Reece, MD explains what patient-centered care, physician demoralization, the entrepreneurial U.S. culture, and our system's complexities portend for reform. Reform and its handmaiden, transformation, hinge on how America's individualistic, entrepreneurial, and innovative culture responds to demands for higher quality, lower costs, and greater access.

When 78 million baby boomers turn 65 in 2011, they will expect the best medical care and a personal physician to care for them, as will the rest of the population. Will the doctors be there? And what will the care be like? Whatever the answers, it will require more personal involvement and personal responsibility on your part.

You may be asked: What plan do you want, a government alternative to a private plan? An HMO, PPO, basic plan, or a high deductible plan linked to a tax-deductible health savings account (HSA)? You may choose to receive your care at a retail clinic at a drug store or in a discount store. You may carry with you a personal hard disk loaded with your medical history.

If present trends continue, you also may have a hard time finding a personal doctor to care for you. What will you do then?

Su questo libro

Informazioni sull?autore

Richard L. Reece, MD is a graduate of Duke University Medical School, a retired pathologist, editor-in-chief of Physician Practice Options, and a member of the Medical Advisory Board of America's Top Doctors. He lives with wife, Loretta, a nurse, and Paris, their French bulldog, in Old Saybrook, Connecticut. Visit his blog at www.medinnovationblog.blogspot.com.

Estratto. © Ristampato con autorizzazione. Tutti i diritti riservati.

Obama, Doctors, and Health Reform

A Doctor Assesses the Odds for SuccessBy Richard L. Reece

iUniverse, Inc.

Copyright © 2009 Richard L. Reece, MD
All right reserved.
ISBN: 978-1-4401-4676-3

Contents

PATIENT-CENTERED CARE - READERS' GUIDELINES..........................................................................................1PREFACE..............................................................................................................................3ONE: Four Obstacles to Reform........................................................................................................13TWO: President Obama and the Big Fix.................................................................................................18THREE: A Rocky Start.................................................................................................................30FOUR: Complexities of 2008 and Beyond................................................................................................32FIVE: Software Grouping of Clinical Derivatives......................................................................................35SIX: Mr. President, Beware Information Technologies' Seductive Powers................................................................41SEVEN: IBM Puts in Its $2 Billion and 2 Cents Worth..................................................................................46EIGHT: A Bottom-Up View from a Health Care Agent.....................................................................................52NINE: View from the Worksite.........................................................................................................61TEN: View of an Ivory Tower Inhabitant...............................................................................................68ELEVEN: View from a Think Tank.......................................................................................................82TWELVE: Views of Consumer-Driven Care and HSAs, Skeptics and Believers...............................................................89THIRTEEN: View of a Family Physician from Rural North Carolina.......................................................................94FOURTEEN: View of a Woman's Doctor...................................................................................................103FIFTEEN: View of a Surgeon Turned Physician Social Networker.........................................................................109SIXTEEN: An Open Letter by Sermo Physicians to the American Public...................................................................117SEVENTEEN: View of Chief Executive Officer of Texas Medical Association..............................................................120EIGHTEEN: Power and Limits of Health Care Computerization, the View of Physicians as Seen Through Gray Eyeshades.....................127NINETEEN: View of the Nation's Number One Physician Blogger..........................................................................132TWENTY: View from Harvard Business School............................................................................................137TWENTY ONE: Paying Primary Care Doctors More.........................................................................................139TWENTY TWO: In Search of Sustainable Physician Business Models.......................................................................142TWENTY THREE: Where Have All the Doctors Gone?.......................................................................................152TWENTY FOUR: Obama's E-Based Health Reform Push......................................................................................157TWENTY FIVE: Medical Home Bandwagon: Expectations and Assumptions....................................................................161TWENTY SIX: Another View, Positive Impact of Private Practice on the Economy of Georgia..............................................168TWENTY SEVEN: Obama Hope: Coverage for All and All for Coverage......................................................................176TWENTY EIGHT: Can Health Care Costs Be Controlled from the Top-Down without Rationing?...............................................179TWENTY NINE: Survey Reveals Despair of Primary Care Doctors..........................................................................184THIRTY: Please Pass the Mayo - The Mayo Clinic, That Is..............................................................................193THIRTY ONE: Two Views on Electronic Medical Records (EMRs)for Physicians.............................................................205THIRTY TWO: Five Physician Mindsets and Trends.......................................................................................217THIRTY THREE: Obama's Comparative Effectiveness Plan - Pluses and Minuses............................................................226THIRTY FOUR: Universal Health Care from the Bottom-Up................................................................................236THIRTY FIVE: Hospitalists and Primary Care...........................................................................................240THIRTY SIX: Personal Health Records (PHRs) - The Next Big Thing?.....................................................................242THIRTY SEVEN: The Litany.............................................................................................................246THIRTY EIGHT: Doctor as Patient......................................................................................................253THIRTY NINE: Self-Interview: An "I" for an "I" and a "Truth" for a "Truth," Wrapping it All Up.......................................263FORTY: A Toast for President Obama...................................................................................................272FORTY ONE: A Prayer for President Obama..............................................................................................276Index................................................................................................................................279

Chapter One

Four Obstacles to Reform

Ride on! Rough-shod if need be, smooth-shod if that will do, but ride on! Ride on over all obstacles and win the race!

Charles Dickens, 1812-1870

A man does what he must - in spite of personal consequences, in spite of obstacles and dangers and pressures - and that's the basis of all human morality.

John Fitzgerald Kennedy, 1917-1963

What President Obama proposes to do - overhaul the entire structure of the health system from the White House and make it more uniform will not be easy. We are a vast continental nation with marked regional differences and culture. The care you receive in your community will not be same as in distant, or even adjoining communities.

President Obama faces four major reform obstacles. I call them the four "Cs."

Culture, American style, abhors the word "rationing." Our health care culture cherishes unlimited choice, quick access to the latest and best in medical "cures," and proven lifestyle restoring technologies. These traits conflict with a centralized, command-and-control, federal expansion of health care.

Complexities, American health care is a whirling Rubik's Cube, with millions of interrelated moving parts, institutions, and people, each with agendas, axes to grind, and oxen to gore.

Costs, Obama says prevention, electronic medical records, and paying only for what works, as established through comparative research, will save billions of dollars, yet scant evidence exists that these measures work. Proposed savings remain hypothetical.

Consequences, of curtailing health costs, may be worse than the cure, because health care institutions and private practices in many communities are the biggest and fastest growing employer in town. Collectively, health care profoundly impacts most communities' economies. Health care's building blocks can't be downsized quickly or dramatically.

"Special Interests" and Their Lobbyists

Obama seeks to neutralize political opposition of these "special interests" and their lobbyists by setting them up as straw men opposed to the best interests of good health for U.S. citizens and dedicated to preserving their own profits by maintaining the status quo.

These "special interests" and lobbyists are from industries who may be hurt and who may oppose certain aspects of his plan represent millions of employees in health plans, drug companies, device manufacturers, imaging equipment makers, and thousands of other suppliers.

His stance is understandable but of arguable strategic value in a political food fight for pieces of the health care pie. In the rush to cast blame, it's convenient to forget one man's meat is another man's poison, one man's livelihood is another man's Robin Hood, and one man's "vital" interest is another man's "special" interest, and health care employment a major strut holding up our economy.

According to the Bureau of Labor Statistics, health care employment and employment in related industries may grow by 3% in 2009 while total nonfarm employment may drop by 5%. Health care employment may reach 13 million, while overall un-employment in the U.S. may top 10 million or more. These aren't inconsequential numbers.

The Health Reform Duck

Health reform resembles a duck. In reformists' eyes, the health system should glide smoothly and efficiently on the water's surface with everyone covered, everyone with affordable care, but underneath patients, doctors, and suppliers are churning furiously to keep the duck and their bottom lines afloat.

Health reform can be viewed from top-down, from policymakers' and politicians' point of view. Policymakers, sometimes described as wonks or gurus, or simply politicians, are mostly hell-bent on developing an all-purpose system that glides smoothly along the surface. These well-intentioned and idealistic policymakers and status quo breakers envision primary physicians, modern day Marcus Welbys, working seamlessly as teams; delivering more effective, and affordable services for everyone; public and private entities working in tandem to prevent chronic disease through prevention; all making sure that what we pay for what works through comparative effectiveness research.

Or you can look at it from below, where hospitals, patients, doctors, and big suppliers, like health plans, drug companies, and businesses are paddling frenetically and sometimes individualistically under water to adapt and adopt to government-imposed policies, as the Obama administration rewrites the rules, decreases pay to hospitals and doctors and health plans and drug companies, while promising to expand coverage through Medicare and Medicaid and to save billions of dollars.

As everybody knows, we're all part of the same duck, joined at the waterline and bottom line. The public and payers perceive doctors differently, either as cure heroes and cost villains. Perhaps this book will help observers understand doctors when political idealism meets clinical realities. Perhaps the book may even help demoralized doctors, who may regard themselves as lame ducks, realize they're not yet dead ducks.

Difference between Physicians and Reformers

As you read this book, keep in mind the fundamental differences between physicians and those who would fundamentally reform the system.

Physicians are trained to treat and to cure disease and to alleviate pain. That's what they're paid to do, and from experience, they know it's hard to persuade patients to change unhealthy lifestyles once they leave the office or the hospital. Controlling in-patient and in-office care is one thing; controlling out-of-hospital and out-of-office behaviors are quite another. That's one reason doctors are reluctant to be judged by outcomes when they know full well that many patients don't comply with orders or change old habits. Some things are simply beyond the reach of the health system.

Policymakers, on the other hand, tend to think that prevention should automatically be part of the physicians' "toolbox," and that care should be coordinated across the entire health spectrum from womb to tomb, inside and outside hospitals or offices, but physicians shouldn't necessarily expect to be paid for time spent in discussing prevention or in coordinating or offering comprehensive care outside their realm. It's part of their work. It goes with the territory.

Policy people often talk of converting our "sickness system" to a "wellness system." Trouble is, people tend not to go to doctors when they're well, but when they're sick.

Summary

President Obama faces four great obstacles to reform. These obstacles may be why sweeping change will be difficult in the short run. The four obstacles go by the names of culture, complexities, costs, and consequences. They are all connected and inner tangled and have been building for a long time. Getting hospitals and doctors to change direction - to focus on prevention and chronic care outside their traditional ways of doing things - will take time.

Chapter Two

President Obama and the Big Fix

By launching broad federal initiatives for biomedical and comparative effectiveness research, the adoption of health information technology, and the protection of privacy and security of medical records, the stimulus law should have major and immediate effects. It directs $150 billion in new funds, most of which will be spend within two years. The spending includes $87 billion for Medicaid, $24.7 billion to subsidize private health insurance for people who lose or who have lost their jobs, $19.2 billion for health information technology, and $10 billion for the National Institutes of Health (NIH).

Robert Steinbrook, MD, "Health Care 2009: Health Care and the American Recovery and Reinvestment Act," New England Journal of Medicine, March 12, 2009 (for details of Obama proposals for the complete fix, see table at end of this chapter)

The economic recovery package recently signed into law by President Obama will provide bonus payments of $44,000 to $64,000 to physicians who adopt and effectively use EHRs from 2011 through 2015, and it's likely that penalties will be introduced for physicians who don't adopt the technology. These incentives will probably make the use of EHRs common among all but the most resistant physicians during the next several years.

Paul C. Tang, MD, and Thomas H. Lee, MD, "Your Doctor's Office or the Internet? Two Paths to Personal Health Records," New England Journal of Medicine, March 26, 2009

A million here and a million there, and pretty soon, we're talking about real money.

Senator Everett McKinley Dirksen (1896-1969)

If you're like me, you're wondering what President Obama's Big Fix for the economy and health care is going to be. David Leonardt, an economics columnist and staff writer for the New York Times, thinks he knows. It's going to be massive government investment in medicine, education, energy.

Whether this unprecedented outpouring of federal funds will spark economic recovery or result in higher taxes and more federal debt for our children and their children is an unanswerable question at this point, but it preys on the mind of the American people, as evidenced by the recent Tea Parties on Tax Day, April 15.

Four Medicare Strategies

In health care, the big fix will focus on four Medicare strategies.

One, initially investing heavily ($44,000 to $64,000 per doctor) in Electronic Medical Records (EMRs) for doctors and hospitals.

Two, within five years, restricting or reducing Medicare payments to those doctors and hospitals that do not have EMRs.

Three, using Medicare-acquired data to pay doctors and hospitals, at the prevailing rates in the least expensive part of the U.S., e.g., the same in urban New Jersey as in rural Mississippi.

Four, stopping or reducing Medicare payments for expensive treatments that don't work, as determined by a federal Comparative Effectiveness Research Institute using EMR-generated Medicare data and governed by a Federal Health Board.

There you have it, a Medicare EMR data-driven solution. I may be overstating this, but I don't think so. Here I quote Leonardt in his February 1, 2009, New York Times Magazine article "The Big Fix: What Can Obama Do to Transform an Economy that Can No Longer Count on Wall Street or Silicon Valley."

In what follows, the text that appears in quotes is Leonhardt's. The subheadings are mine; words in italics are mine. To put his words in context, I recommend you read his 7800 word piece in its entirety.

The Doctor Problem

"Doctors, drug makers and other medical companies persuaded the federal government to pay for expensive treatments that have scant evidence of being effective. Those treatments are the primary reason this country spends so much more than any other on medicine. In these cases, and in others, interest groups successfully lobbied for actions that benefited them and hurt the larger economy."

This is typical reformer talk - those greedy doctors and their avaricious allies, not needy patients, drive overuse of unnecessary and expensive procedures. In reality, many patients expect procedures be done, since their health plans pay, and many procedures may restore a fuller lifestyle. In addition, patients and their families understandably want everything possible to be done, even though odds for success may be statistically slim.

Government's Successful Investments

"But government investment seems to have one of the best track records of lifting growth. In the 1950s and '60s, the G.I. Bill created a generation of college graduates, while the Interstate System of Highways made the entire economy more productive. Later, the Defense Department developed the Internet, which spawned AOL, Google and the rest. The late '90s Internet boom was the only sustained period in the last 35 years when the economy grew at 4 percent a year."

Government, in other words, is the true source of economic growth - a debatable point considering government still only comprises 22% of the economy. It's growing at 28.5% with Obama's first budget, and, let's face it, government is notorious for stifling innovation that produces new industries and new jobs.

Curing Health Care Inefficiencies

"On health care, the challenge is keeping one of tomorrow's industries from growing too large."

"For almost two decades, spending on health care grew rapidly, no matter what the rest of the economy was doing. Some of this is only natural. As a society gets richer and the basic comforts of life become commonplace, people will choose to spend more of their money on health and longevity instead of a third car or a fourth television."

When it comes to health, money is no object, particularly when it's your body and somebody else's money.

"Much of the increases in health care spending, however, are a result of government rules that have made the sector a fabulously - some say uniquely - inefficient sector. These inefficiencies have left the United States spending far more than other countries on medicine and, by many measures, getting worse results. The costs of health care are now so large that it has become one problem that can't be solved by growth alone. It's qualitatively different from the other budget problems facing the government, like the Wall Street bailout, the stimulus, the war in Iraq or Social Security."

Regulations breed inefficiency and grow costs. Complying with government regulations make up about 25% of hospital operating costs. In some instances, maybe government should get out of the way and let private innovation thrive.

Unsustainable Government Medicare Promises

"The unfinanced parts of Medicare, the spending that the government has promised over and above the taxes it will collect in the coming decades requires another decimal place. They're equal to more than 200 percent of current G.D.P."

"During the campaign, Obama talked about the need to control medical costs and mentioned a few ideas for doing so, but he rarely lingered on the topic. He spent more time talking about expanding health-insurance coverage, which would raise the government's bill."

Expanding coverage adds to the entitlement mentality, which drives costs off the roof and into the sky.

Peter Orszag, Budget Director's Vision

"After the election, however, when time came to name a budget director, Obama sent a different message. He appointed Peter Orszag, who over the last two years has become one of the country's leading experts on the looming budget mess that's basically about health care. "

"Orszag explains that the problem is not one of demographics but one of medicine. 'It's not primarily that we're going to have more 85-year-olds,' he said during a September speech in California. 'It's primarily that each 85-year-old in the future will cost us a lot more than they cost us today.' The medical system will keep coming up with expensive new treatments, and Medicare will keep reimbursing them, even if they bring little benefit."

"In his talks, Orszag puts a map of the United States on the screen behind him, showing Medicare spending by region. The higher-spending regions were shaded darker than the lower-spending regions. Orszag would then explain that the variation can't be explained by the health of the local population or the quality of care it receives."

This comes directly out of the Dartmouth Institute playbook, which says that most cost and practice variations by region are "unwarranted." Never mind the profound socioeconomic differences between regions.

"Darker areas didn't necessarily have sicker residents than lighter areas, nor did those residents necessarily receive better care. So, Orszag suggested, the goal of reform doesn't need to be remaking the American health care system in the image of, say, the Dutch system. The goal seems more attainable than that. It's remaking the system of a high-spending place, like southern New Jersey or Texas, in the image of a low-spending place, like Minnesota, New Mexico or Virginia."

(Continues...)

Excerpted from Obama, Doctors, and Health Reformby Richard L. Reece Copyright © 2009 by Richard L. Reece, MD. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Dettagli dell'edizione

• Editore: Authorhouse
• Data di pubblicazione: 2009
• Lingua: Inglese
• ISBN 10: 1440146764
• ISBN 13: 9781440146763
• Rilegatura: Copertina flessibile
• Numero di pagine: 308
• Contatto del produttore: non disponibile
• Persona responsabile: non disponibile