1.
Featured Article: Why AMGA Is the Most Vitally Important Physician
Organization in the U.S.A. Today, BY
FRANCIS J. CROSSON, M.D. Executive
Director, The Permanente Federation, LLC, and Chair, Board of Directors,
American
Medical Group Association
An
Address to the AMGA's 2006 Annual Conference. March 17,
2006, San Antonio, Texas.
Why is AMGA the most critically important physician organization in the
U.S.A. today?
Simply put, our nation is in a health care
crisis, a crisis each of us will see evolve in the next five or so years. It is
a crisis of cost, of affordability, of access, of fairness, but most
importantly, a crisis of confidence.
There is a growing crisis of confidence in
the land about whether our country has a workable plan to achieve rational,
sustainable health care for all Americans.
It is a crisis of confidence made worse by
the fact that the physician voice, the responsible voice of the profession of
medicine, is often absent from or ineffective in the public debate. I believe
that this void of physician leadership can and must be filled by America's
proud multispecialty medical groups, by their leaders, and by their
association, AMGA, if our national healthcare system is to evolve in a sound
manner.
Pick up this challenge we must. Because I
believe that the next five years are going to be absolutely critical for the
direction of American medicine. I believe that through AMGA, the medical group
community must work collectively to influence that direction, for the benefit
of each of our own revered institutions, for the benefit of our patients, and for
the benefit of the nation as a whole. Tip O'Neill, the former Speaker of the
House of Representatives, said once that "all politics is local."
We know that all health care is local, and
each of us who are at this meeting is engaged in a daily, weekly, and monthly
struggle to make our medical groups the best they can be, to provide our
physicians a satisfying and productive environment for the practice of
medicine, and to provide responsible leadership in our communities.
But many of us know from experience that
despite our best efforts, despite hard work, and despite careful planning, our
medical groups, indeed our patients and our communities, can be impacted, for
better or worse, by changes in the marketplace of health care - changes in the
commercial marketplace, the world of employers, employer coalitions, health
plans, insurance companies, and public payers such as Medicare and Medicaid -
but also by changes in the marketplace of ideas.
New business concepts, heathcare financing
changes, and legislative initiatives, which appear seemingly from nowhere, can
change our world quickly, positively or negatively.
Medical group physicians and managers who
lived through the advent and evolution of the managed care industry and the
rise and dissolution of the physician practice management industry (PhyCor and
MedPartners) are well aware of the impact of such changes.
Today at the midpoint of the first decade
of the 21st Century, spurred by the sense of crisis in health care,
the marketplace has begun to present us, the medical group community, with a
new set of challenges.
First is the change underway in the
financing of health care, a change driven by cash-strapped employers, away from
comprehensive benefits in favor of higher coinsurance, higher deductibles, and
savings accounts. Whatever value this change can have in moderating long-term
cost trends, it clearly will create new financial burdens on families, perhaps
higher levels of bad debt for medical groups, and the potential loss of
continuity of care, as patients forego needed healthcare services for financial
reasons.
A second growing challenge is a trend
toward further fragmentation of care delivery. Multispecialty medical groups
are organized to coordinate care among specialties for patients with multiple
health conditions, and to assume longitudinal responsibility for patients and
families. This is what our nation needs. So-called "focused
factories" and certain single-specialty groups are not organized to manage
these critical accountabilities and have come to be viewed by many purchasers
and health economists as being primarily organized for financial purposes. This
view, in turn, can create confusion about, and adversely impact, the reputation
of our multispecialty medical group community.
Fragmentation is also manifest in the
growing emergence of care delivery by ancillary providers and, on occasion, by
physicians in retail commercial space, particularly drugstore chains and
discount commercial retailers. It is not to say that such care is necessarily
undesirable; simply that the emergence of this business model can, again,
create a trend away from continuity and care coordination.
Each of us should watch or perhaps even
seek to constructively guide the evolution of this trend in our communities.
Finally and most importantly, our medical
group world is presented with a challenge and with an opportunity by what I
think of as the three-leaf clover of performance - performance measurement, pay
for performance, and the newest entry from the insurance industry, something
called "high performance networks," essentially contract lists of
lower cost doctors and hospitals, without regard to patient continuity of care
or care coordination. It is in this triple entry from the marketplace of ideas
that our medical group community has the greatest opportunity to shape our
collective future for the better. I believe that there are still open
questions: Who will decide in the end what quality of care really is and how it
should be measured?
What does efficiency in healthcare delivery
mean and how should that be assessed? And how should commercial payers or
public payers, like Medicare, adjust payments to physicians and organized
delivery systems in response?
Our interest clearly lies in the evolution
of a system that rewards physician organizations that truly improve patient
care and that foster the responsible use of healthcare resources. There is no
doubt in my mind that the current concept called "high performance
networks," as envisioned by some employers and particularly by some
benefits consultants, has little to do with quality of care and nothing to do
with the kind of organized, patient-centric delivery of health care practiced
by the nation's leading healthcare organizations gathered here today. Yet this
idea is proceeding unchallenged to date.
So we meet together this week in San
Antonio to renew old acquaintances, to learn from some of the best medical
groups in this country, and to be inspired together. But, I believe we also
need to take this opportunity together to reinforce our common interests,
especially our common interest in leading and shaping that marketplace of ideas
that can affect us in the years to come. This is why AMGA is a critically
important organization at this time - critically important to us as member
groups and yes, I believe, critically important to the country.
The AMGA Board of Directors and Don Fisher
and his team intend to lead that effort on our behalf. Much of it is work that
has already been foreseen and planned for, and I hope you will learn more about
it during the next few days of this meeting.
To read the entire address and more about
the AMGA's innovative project, please go to www.amga.org/
and click on The Voice of Medical Groups in America.
To read The Group Practice Journal,
go to www.amga.org/Publications/GPJ/index_gpj.asp.
* * *
* *
2. In
the News: Where Do the Bright People in America Live and Why Does That Matter?
The
Agenda: The
Nation In Numbers: Where the Brains Are, The
Atlantic
America's
educated elite is clustering in a few cities - and leaving the rest of the
country behind
By Richard Florida
America's
social fabric has been regularly reshaped by great migrations - of pioneers
westward, of immigrants and farmers to rising industrial cities, of African
Americans from the rural South to the urban North, of families outward from
cities to suburbs to exurbs.
Today, a
demographic realignment that may prove just as significant is under way: the
mass relocation of highly skilled, highly educated, and highly paid Americans
to a relatively small number of metropolitan regions, and a corresponding
exodus of the traditional lower and middle classes from these same places. Such
geographic sorting of people by economic potential, on this scale, is
unprecedented. I call it the "means migration." . . .
What's behind this phenomenon?
Some of the reasons for it are essentially aesthetic - many of the means metros
are beautiful, energizing, and fun to live in. But there is another reason,
rooted in economics: increasingly, the most talented and ambitious people need
to live in a means metro in order to realize their full economic value.
The physical proximity of talented,
highly educated people has a powerful effect on innovation and economic growth
- in fact, the Nobel Prize-winning economist Robert Lucas declared the
multiplier effects that stem from talent clustering to be the primary
determinant of growth. That's all the more true in a postindustrial economy
dependent on creativity, intellectual property, and high-tech innovation.
Places that bring together
diverse talent accelerate the local rate of economic evolution. When large numbers
of entrepreneurs, financiers, engineers, designers, and other smart, creative
people are constantly bumping into one another inside and outside of work,
business ideas are more quickly formed, sharpened, executed, and - if
successful - expanded. The more smart people, and the denser the connections
between them, the faster it all goes.
The local cultures of most, if
not all, means metros have facilitated the establishment of many loose
connections among people of diverse talents, lifestyles, and social circles (as
opposed to a few tight connections within homogenous groups). They are socially
tolerant and open to new ways of thinking. Job switching is common, as is
periodic unemployment, and free agents find plenty of common spaces in which to
work and meet. The soup is continuously stirred, and newcomers are assimilated
easily.
But the means metros also have a
larger and simpler advantage over other regions: a head start. For a variety of
historical reasons - the presence of great universities is usually one - the
means metros already have a high concentration of highly talented people. And
as more such people are added, their multiplier effect on growth seems to keep
increasing. That's true not just for economic growth in the aggregate, but for individual
incomes and opportunities as well.
Yet the opportunities do not
exist for everyone. In both early agricultural and industrial economies,
overall population growth was the key to economic growth, and economic growth
meant opportunities across the board. But in a creative, postindustrial
economy, that's no longer true. Changing technology, increased trade, and the
ability to outsource routine functions have made highly skilled workers less
reliant on the colocation of the unskilled and moderately skilled. What matters
today isn't where most people settle, but where the greatest number of the
most-skilled people does. Because the return on colocation among the ablest
is so high, and because high-end incomes are rising so fast, it makes sense for
these workers to continue to bid up real estate and accept other costs that
traditional middle-class workers and families cannot afford. As traditional
middle-class households are displaced by smaller, higher-income households,
population can decline even as economic growth continues. America's most
successful cities may increasingly be inhabited by a core of wealthy workers
leading highly privileged lives, catered to by an underclass of service workers
living in far-off suburbs.
Some of today's means metros could
fall back eventually as housing prices and living costs rise, and new ones
could emerge. But there are powerful reasons to believe that the wealth
disparity between some city-regions and others will continue to grow, and
perhaps even accelerate, thanks to the snowball effect of talent attraction.
"This spatial sorting," says Gyourko, "will affect the nature of
America as much as the rural-urban migration of the late nineteenth century
did." Accommodating that sorting will be one of the great political and
cultural challenges of the next generation.
To read the entire article,
please go to www.theatlantic.com/doc/200610/american-brains.
* * * * *
3.
International Medicine: U.S.
Lags In Several Areas Of Health Care, Study Finds www.ncpa.org/sub/dpd/index.php?page=article&Article_ID=13700
Americans have a harder time than residents
of several other countries getting after-hours appointments with a nurse or
primary care physician without going to an emergency room, according to a study
published in the journal Health Affairs.
Other findings:
- Forty
percent of U.S. primary care doctors said they had arrangements for
after-hours care, according to the survey of more than 6,000 physicians in
seven countries.
- That
compared with 95 percent in the Netherlands, 90 percent in New Zealand, 87
percent in the United Kingdom, 76 percent in Germany and 47 percent in
Canada.
Moreover:
- The
United States trails other countries in adopting electronic medical
records and computerized systems to remind patients about follow-up care,
prompt physicians to give patients test results and warn of potentially
harmful drug interactions.
- Primary
care doctors in America were also less likely to have financial incentives
to improve the quality of the care they provide.
Advocates say greater use of electronic
records would improve patient care, reduce errors, curb unnecessary tests and
cut paperwork. About 28 percent of U.S. primary care doctors said they
use such records, compared with 98 percent in the Netherlands, 92 percent in
New Zealand, 89 percent in the United Kingdom, 79 percent in Australia and 42
percent in Germany. Only Canada ranked lower, at 23 percent.
Source: Christopher Lee, "U.S. Lags in
Several Areas of Health Care, Study Finds," Washington Post, November 3,
2006; based upon: Cathy Schoen et al., "On The Front Lines Of Care:
Primary Care Doctors' Office Systems, Experiences, And Views In Seven
Countries," Health Affairs, November 2, 2006.
For study text: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w555
For text: www.washingtonpost.com/wp-dyn/content/article/2006/11/02/AR2006110201621.html
For more on Health Issues: www.ncpa.org/sub/dpd/index.php?Article_Category=16
* * * * *
4. Medicare:
America's Crisis of Confidence
Survey Finds Doubts about Leaders, and
Nation's Safety by Elizabeth
Williamson, Washington Post Staff Writer, November 7, 2006
Here's something to think about when you
cast your vote today: A new study shows that Americans have lost faith in the
people who lead their federal, state and local governments, and in businesses,
churches and schools. And they are afraid to fly.
"America is in trouble," reads the
introduction to the 2006 National Leadership Index, sponsored by U.S. News
& World Report and the Center for Public Leadership at Harvard's Kennedy
School of Government. According to the report, nearly three-quarters of
Americans think that the nation faces a "leadership crisis."
This is the survey's second year, and it has
been downhill all the way, said Todd Pittinsky, the center's research director.
"Most groups are following the general trend of having low confidence and,
if anything, having that confidence slip further."
The only leaders who earn more than a smidgen
of Americans' confidence, the researchers say, are those in the military and
medical fields. (Confidence in the media didn't slip, but it was in the sewer
already.)
"We could have asked about
grandmothers," Pittinsky said. "Maybe we could have had more
confidence in grandmothers."
The researchers hope the survey will
"contribute to our ongoing civic dialogue -- deepening our understanding
of ourselves and the pressing need for effective, responsible democratic
leadership."
Sounds scary. . .
Perhaps, joked survey researcher and
assistant professor Seth Rosenthal, these are people "so paralyzed they
can't even tell you if they're pessimistic."
The researchers also asked: "If you flew
today, how confident do you feel that you would be safe from terrorist harm on
a domestic flight?" Nearly half sucked it up on this one, saying they felt
confident about flying safely. But 13 percent put a potential evildoer on every
plane. "That's pretty bad," Rosenthal said. "Obviously there
aren't planes being dropped out of the sky every day."
Blending fears of leadership failure and
flying, the study further found that "Americans who are not confident at
all that government leaders in Washington will respond effectively to an
emergency crisis are less confident than other Americans about their safety
from a terrorist attack on a domestic flight."
Any bright spots? . . . To read the entire article, go to www.washingtonpost.com/wp-dyn/content/article/2006/11/06/AR2006110600889_pf.html.
* * * * *
5. Medical Gluttony: FP-HMOs - the Biggest Waste of Health-Care Dollars
The
For-Profit Health Maintenance Organizations came into being some three decades
ago to compete with Kaiser Permanente. Kaiser was a staff model non-profit HMO
wherein all of health care was totally integrated. Initially the hospital,
doctors' offices, laboratory, x-rays were all within one complex. This was an
efficiency that couldn't be duplicated in a FP-HMO, consisting of hospitals,
offices, laboratories, x-ray facilities distributed over a wide geographic
area, each with their own medical records. The FP-HMOs are essentially on life
support while the Kaiser system has evolved into a totally integrated health
plan (IHP).
The push for electronic medical records (EMR) is
directed to the FP-HMOs in an effort to unify the medical records of the
various disparate offices. It will still be unsuccessful. The patients that
desire their own personal physician generally will not support having their
records widely available among offices they don't use. Some of my patients
asked me not to enter their records into my computer. However, that is where my
patient records reside and I just assure them that no one has access to my
computer.
This past week, the FP-HMO's gluttonous cost of health
care was brought sharply into focus. Unfortunately it was not recorded as a
cost by any organization that surveys costs or tries to direct health-care
policy.
I wrote a simple prescription for a glucometer for a
diabetic patient to monitor her glucose, which is necessary to manage her
diabetic drugs. This was an HMO patient. My receptionist spent 20-30 minutes a
day for four days navigating the phone lines at the HMO and MCO (Managed Care
Organization) offices to help this patient. After four days, she breathed a
sigh of relief thinking she had helped this patient to manage her diabetes. She
then got a phone call a few days later wanting justification for the
instrument. Wouldn't that be apparent without taking up the doctor's and office
staff's time?
The following week, we received a call from this
patient that her glucometer was no yet available. On further investigation, the
HMO had changed suppliers and all the work was for naught. My medical assistant
redid the above routine with the new supplier. After considerable time on the
phone, she again thought everything was in order. She had barely hung up the
phone when the patient called and stated the original supplier had just
notified her that the glucometer was being shipped. This was the supplier that
she had spent the time with the previous week that the HMO and MCO said were no
longer their favorites. The current series of repeat phone calls were for nix.
The harassment time was now two hours and twenty minutes.
Meanwhile, a similar event took place at Kaiser
Permanente. The doctor stated that with the patient still in front of him, he
accessed the electronic script program, scrolled down to glucometers, and saw a
dozen or so that were listed. He saw that two were approved by this patient's
level of insurance, clicked on one and sent it to the pharmacy electronically.
While the pharmacy printer was still printing, the patient walked down to the
pharmacy, obtained her prescriptions and her glucometer, and was home in less
time than one phone call to the FP-HMO. It took less than one minute at Kaiser,
an Integrated Health Plan (IHP), to accomplish the same thing that it took more
than 140 minutes at an FP-HMO. Unfortunately, those 140 minutes are nowhere
recorded as a health-care cost. It is a non-reimbursable physician's expense.
The For-Profit HMOs are on life support. It's time for
private doctors to stop their resuscitative efforts.
* * * * *
6. Medical
Myths: Single-Payer Medicine Will Decrease Health Care Costs
If that were true, why do the large
government programs, such as Medicare and Medicaid, contract out to private parties
to run their programs? Why should the non-profit Medicaid program become a
For-Profit HMO? Can they really give the same quality of care at a reduced fee
and still make a profit? Let's take a look.
Healthy Industry: In Medicaid, Private HMOs Take a Big, and Profitable, Role;
Managing Care for the Poor, They Prosper by Cutting Beleaguered States' Costs;
Dr. Polack Seeks an Antibiotic; By BARBARA MARTINEZ, WSJ, November
15, 2006;
Some 55 million poor and disabled
Americans are covered by Medicaid. With an annual price tag topping $300
billion, it's among the biggest government programs around.
It's also a lucrative business
for some private companies that act as middlemen between the government and
patients. Instead of directly paying the bills when a Medicaid patient goes to
the doctor, state governments increasingly outsource the job to private
contractors. More than one in three Medicaid beneficiaries now receive care
through a private insurer. . .
Four of the biggest Medicaid HMOs
-- WellCare, Centene Corp., Molina Healthcare Inc. and Amerigroup
Corp. -- have seen their shares surge on the New York Stock Exchange over the
past few years, although prices of the latter three have been volatile.
WellCare's stock price has tripled since it began trading in July 2004,
bringing the value of stock and options held by its chief executive, Todd S.
Farha, to $77 million.
The companies are growing fast.
Centene boasts nearly 1.2 million members and posted $1.5 billion in revenue
last year. That compares with 142,000 members and $200 million in revenue six
years earlier.
With the growth has come
criticism from some doctors and patients who accuse Medicaid HMOs of scrimping
on care. Even as they restrict medical tests and use of prescription drugs, the
companies spend the money they get from states on items that don't have an
obvious connection to patients. Centene has funded a multimillion-dollar arts
center in St. Louis and paid to put its name on stadiums in Montana and
Missouri. The HMOs are also big donors to political campaigns.
Executives say their profits are
justly earned and don't come at patients' expense. Traditional Medicaid is a
fee-for-service program: The government pays each medical bill the patient
racks up, with little or no effort to manage the costs. Medicaid HMOs, like
other HMOs, seek to save money by eliminating unnecessary care and paying for
preventive treatments. Centene Chief Executive Michael Neidorff says the
company sometimes gives free child-safety car seats to pregnant women who attend
all of their prenatal exams. "We save millions" by preventing
premature births, he says.
Mr. Neidorff earned $1.85 million
in salary and bonus last year and as of the end of last year held restricted
stock valued at $26 million. The company also recorded $135,547 last year in
compensation for Mr. Neidorff representing the value of personal trips he took
on the corporate jet, a Bombardier Challenger that features an espresso machine
on board, according to the lease agreement. . .
Each state runs its own Medicaid
program but the majority of funding generally comes from the federal
government. When states sign up HMOs to manage care, they often calculate what
they would spend on Medicaid patients directly and pay the HMOs a per-patient
premium below that amount. Florida, for instance, sets its HMO premium rates
about 8% below what it would cost the state. WellCare, a big operator in
Florida, says it saves the state $75 million a year. HMOs have an incentive to
keep their costs under the premium because they keep the difference as profit .
. .
States began experimenting with
using managed care for Medicaid patients in the early 1980s, and the idea took
off in the 1990s. Now many states are moving aggressively to put more Medicaid
patients in HMOs. Last month, Ohio chose the winning bidders to provide
Medicaid HMO services to 120,000 of the state's aged, blind and disabled
population -- a group that traditionally hasn't been placed in HMOs. . .
Many doctors refuse to take
patients in Medicaid HMOs because reimbursements are so low. (The same problem
occurs in traditional Medicaid.) Noha Polack, a pediatrician in Union City,
N.J., has an arrangement under which Centene pays her a fixed monthly sum per
child to handle basic medical needs. Until a few months ago, that sum was
$11.50 per month, equal to $138 a year -- about half of what other Medicaid
insurers pay, says Dr. Polack. A child who had a few colds or scrapes during a
year would quickly put her in the red.
Dr. Polack threatened to drop all
her Centene patients and recently got a raise -- the amount of which is
confidential, she says -- but she still stopped accepting new Centene patients.
The HMO is stingy about drugs
that others approve with little question, says Dr. Polack, naming the
antibiotic Ceftin as an example. "Many times we have to make treatment
decisions not depending on what would be best for the patient but what the
patient can afford," she says. While she could ask for an exception to use
Ceftin, "they are so notorious for not getting back to you" and
there's little time when a child has an infection, she says . . .
Research on the quality of care
in Medicaid HMOs is thin. A study of infant health last year by researchers at
the University of Illinois-Chicago and the Urban Institute found that Medicaid
managed care was correlated with a slight increase in inadequate prenatal care
in some women but in general showed little difference from traditional
Medicaid.
While some doctors and patients
complain of Centene's stinginess, the company has been generous in regions
where it has offices. Centene last year was the biggest donor for a $9.5
million renovation of an arts building in St. Louis, now called the Centene
Center for Arts and Education, according to a spokeswoman for the center. The
company paid $200,000 last year for the naming rights of a minor-league
baseball stadium in Montana, where Centene employs 100 claims processors but
doesn't have Medicaid clients. Centene also pledged $400,000 this year to the
school district in Clayton, Mo., where the company has its headquarters, to
rename the district's stadium.
Cynthia Schultz, director of the
Great Falls International Airport in Montana, says Mr. Neidorff, the Centene
CEO, once walked through the airport and heard that it couldn't afford artwork.
Centene then commissioned and donated a $7,000 welded-metal sculpture of an
eagle with a 16-foot wingspan that now hangs prominently in the airport, she
says. The company confirmed the donation. "It's a great gift from someone
who doesn't even live here," says Ms. Schultz.
Mr. Schenk, the Centene
spokesman, said the donations show Centene is a "responsible and publicly
focused corporation" and they help make the communities better places to
live. . .
--- Raymund Flandez contributed to this article.
To read the entire report, go to http://online.wsj.com/article_print/SB116354350983023095.html.
Write to Barbara Martinez at Barbara.Martinez@wsj.com.
* * * * *
7. Overheard in the Medical Staff Lounge: How Do Doctor's Think the Election Will
Affect Healthcare?
Dr Sam: I think the answer is in how the government cut costs
in September. They refused to pay us for the last two weeks in September. It
was a delaying tactic for accounting reasons. [Doesn't the government prosecute
business for accounting manipulations?] Well, just as I told you, we would
never see payment for those two weeks. I've been waiting two months to see the
smallest blip in my Medicare income. Did I see any? Not any that I or my
billing clerk would notice. In fact our income in October was less than our
usual monthly income and our November income seems to be even less.
Dr Michelle: Well I think I saw a small increase in October
Medicare receipts. Not much. Probably not enough to make up for the loss in
September.
Dr. Yancy: Well, we surgeons took a big hit. I did 16 major
operations those two weeks. We've gotten paid for three of them in October and
we're waiting for the other 13. But while we're waiting, we've got every one of
those operations pegged and we'll get every bloody cent from Medicare even if I
have to lose money doing it.
Dr Sam: But it's easier for a surgeon to track every charge
since yours are in the high three-figure or low four-figure range. But for us
Internal Medicine doctors, trying to make a living on $110 office calls for
which we get paid $65, a number of patients are batched to include a number of
patients lumped into one.
Dr Milton: And if a patient has several charges, e.g. an office
call plus an injection, the payment may be one or both or none. So it takes a
lot of billing clerk's time to sort this out. So after a month or two of
hassling, we just give up and never know just how much the government cheated
us.
Dr Dave: When this new Congress gets in gear, we'll probably
have one of those non-payments for a half month every three months?
Dr Sam: You're being too kind. We'll probably drop two weeks
of income every month.
Dr Rosen: Why do doctors still trust the government? Why would
any doctor want the government to be his sole payer, as in single payer? And
our own California Doctors Organization supported the single-payer initiative.
Why would any doctor join that group?
The R's must be devastated.
Not so. For the D's politics is their life, their vocation.
Government is the be-all-and-end-all of "goodness." So being part of
the government is the culmination of their lives. What in the world would Henry
Waxman or John Dingell do with themselves if they weren't in Congress? That is
why they were willing to abide the humiliation and frustration of 12 years in
the minority. They had nowhere else to go. –HBR
An Outside Perspective From the HealthBenefitsReform
I see next to no impact at all.
The Ds, even if they take the Senate, will have smaller margins than the Rs
have had. And many of the new Democratic members of Congress are as
conservative as the Rs have been. It will take them a while to get organized
and the presidential elections start today. The one real power the Dems will
have is the ability to orchestrate hearings, and they are FAR better at that
than the Republicans have ever been. Pelosi will have to curb the instinct of
Stark, Waxman, Dingell, et al, to make up for lost time and go overboard—and
embarrass the party.
The next two years will be
consumed with political posturing to set the stage for the '08 elections.
Greg Scandlen, President,
Consumers for Health Care Choices
442 N Potomac Street, Hagerstown, MD 21740, 301-606-7364
Greg@CHCChoices, www.CHCChoices.org
* * * * *
8. Voices
of Medicine: A Review of Local and Regional Medical Journals
California Society of Anesthesiologists: CSA
Bulletin, Fall 2006: Laughing Gas
Gaseous Planet - Medicare Man by Harrison Chow, M.D.
It is widely known within the Washington
Beltway that the real political divide in the United States is not between
Democrats and Republicans, nor rich and poor, but rather between young and old.
The elderly Medicare generation, represented by the American Association of
Retired Persons, is purported to be the wealthiest and most powerful political
force in the history of American politics.
I spoke with long-time AARP President Cunningham "Medicare
Man" Grey at the AARP's corporate office off the lush 18th green
of the Palm Springs Country Club about the dramatic impact that elderly
Americans and the AARP are having upon American health care.
HC: Thank
you for meeting with me. I'm surprised that the AARP moved its office
cross-country to Palm Springs from Washington, D.C.
CG: One of
the advantages of modern technology is that we can relocate to a venue that is
warm year-round and yet still stay intimately connected to the federal
government.
HC: How's
that? Medicare and Social Security policy is made on the East Coast, not in the
sand trap of the 18th green.
CG: I have
one phrase for you—"IRDs."
HC: What is
an "I-R-D"?
CG: An IRD
is an "improvised reminder device." As you know, terrorists use cell
phone-activated "improvised explosive devices" or "IEDs" to
blow up targets. We wondered: What if we had the power of the IED magnified by
60 million voting retirees? What would happen? That's how we became excited
with the idea of the IRD.
HC: You
threaten to blow up Senators and Congressmen?
CG: Hardly!
Our IRDs, when dialed and activated by the cell phone, only give off a 12-volt
shock—just enough to make you wince.
HC: How did
you get federal legislators to agree to carry this IRD device?
CG: The AARP
made Washington politicians an offer that they couldn't refuse: Get an IRD and get elected, or refuse and be
voted out next term. They don't even have to worry about carrying them. They
simply fly out to Palm Springs to get their IRD surgically implanted after a
round of golf or a visit to a spa.
HC: Wow, the
IRD gives new meaning to how to stay "connected" to your elected—or
should it be "electrified"?—representatives. The IRD should certainly
spark them into action. But now I must ask, what is the AARP's position on the
deepening fiscal crisis that threatens to bankrupt Medicare?
CG: Our down
home position is really very simple. We've paid our dues, and we should get
medical care for free—free, nada, zip, zero, complimentary. Comprende, amigo?
HC: Hey, I
get it, but with a surging elderly population, and the advances in the medical
sciences, and a resultant massive boost in medical costs, Medicare soon will be
unable to meet its obligations.
CG: Now just
try to understand. Medicare and America's goals are the same—to provide the
elderly with the best health care available for free. Everything, and I mean
everything, else is secondary. For example, this year we had the Congress
eliminate the school lunch program from the federal budget to pay for the new
generation of titanium pacemakers. We need titanium. You can go into an MRI
with titanium.
HC: But,
respectfully, you know that recent studies have shown that the average Medicare
recipient's contributions in today's dollars would buy, at best, a single
bottle of outdated penicillin tablets, not the latest pacemaker.
CG: Doctor,
let me remind you that my generation, the Medicare generation, defeated Hitler,
Mussolini, Hirohito, Stalin and Mao, landed on the moon, invented the computer
chip, the Internet—Al Gore is one of us, isn't he?—and cell phones, and created
what we call "modern medicine." What has your generation done?
HC: Uh, let
me think. My generation invented the iPod?
CG: What's
an iPod?
HC: Someone
told me that the iPod is a mysterious and magical device that allows spoiled
suburban kids to listen to urban gangsta' rap at the mall.
CG: Doesn't
sound too impressive to me. Oh, please excuse me. I have to make a phone call.
The Medicare Man, while on the phone, turns on a 60-inch high definition
flat screen T.V. in his office: We see on C-SPAN that Senator Ted Kennedy from
Massachusetts is speaking before Congress about the need to increase Medicare
taxes. It is quite obvious that Senator Kennedy is sweating profusely.
HC: I notice
that Senator Kennedy is sweating a lot; are you calling his IRD right now?
CG: Yes, but
that's not why he is sweating. I've called Senator Kennedy so many times that I
think he is immune to a single shock.
HC: Well,
why is he sweating so profusely? I hope that he's OK.
CG: He's
sweating because I've threatened to post his IRD's cell number up on the AARP
Web Site.
Dr. Harrison Chow is a practicing
anesthesiologist in San Jose, California. He also teaches regional anesthesia
at Stanford when nobody is looking. You may reach him at <hchow@stanfordalumni.org>.
Recently, he received notification from Medicare that he will qualify for
benefits when he turns 90 years of age.
To read the original, please click on
Laughing Gas at www.csahq.org/pageserver.cgi?tpl=internal.tpl§ion=publications&name=bulletin_view&idx=14.
* * * * *
9. From
the Physician/Patient Bookshelf: Redefining Health Care
"Redefining Health Care," by
Michael Porter and Elizabeth Olmsted Teisberg is a must read for anyone
interested in health policy. The authors have identified the single most
important problem in health care and it is a problem health economists tend to
routinely ignore. To wit: We don't bundle and price health services the
way we would if the medical marketplace even remotely resembled an efficient,
competitive market.
Take diabetes, for example:
- Care
tends to be delivered in discrete bundles, each with its own price.
- No
one provider is responsible for the end result (fewer ER visits, lower
blood sugar level, etc).
- This
is because no one has bundled "diabetic care" as such -- taking responsibility
for final outcomes over a period of time -- in return for a fee.
The authors produce a rich smorgasbord of
other examples of failures to bundle and price in sensible ways, and they argue
persuasively that costs are higher and quality is lower as a result. But
as good as they are in analyzing problems, they are weak on showing us how to
get solutions, says John C. Goodman, president of the National Center for
Policy Analysis.
Where they go wrong is in thinking that many
of these problems could be solved if only we had more entrepreneurship on the
provider side, explains Goodman:
- Doctors
in particular are unable to be entrepreneurial because the bundles and the
prices have already been determined for them by third-party payer
bureaucracies.
- Long
before you ever reach the doctor's office (even with a health savings
account (HAS) card), what will be paid for, what will not be paid for and
how much will be paid has already been determined.
Entrepreneurship will eventually find a way
around our bureaucratic third-party payment system. The more dollars that
are controlled by patients, the faster that change will come, says Goodman.
Source: John C. Goodman, "Review of Porter/Teisberg Book,"
National Center for Policy Analysis, November 6, 2006; based upon: Michael
Porter and Elizabeth Olmsted Teisberg, "Redefining Health Care,"
Harvard Business School Press, May 25, 2006.
For more on Health Issues: www.ncpa.org/sub/dpd/index.php?Article_Category=16
* * * * *
10. Hippocrates & His Kin: The Ethics of Congress: Rob Peter to Pay Paul - More
Votes
Headlines
in the papers after the US elections indicated that Rep Nancy Pelosi and her
city, San Francisco, rose to the top of the congressional political heap this
week. Pelosi's impending elevation by her fellow Democrats to the post of House
speaker . . . that will become official in January, already is generating
national and international attention for the city. It might also mean more
federal dollars from congressional appropriators who inevitably look favorably
on projects from the speaker's home district, even if he or she doesn't overtly
push for them. www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2006/11/11/MNGE4MATQD1.DTL&hw=Edward+Epstein&sn=013&sc=356
Isn't there something unethical in the very concept of
Congress being able to forcibly take money away from some citizens and give it
to others? If you or I or any citizen did what Congress does and brags about
it, wouldn't that be called theft, or burglary or a gun-point hold up?
Isn't this another reason why health care should never
be part of this arena? In Oregon, murder by doctors in the hospital setting
against the weakest is already sanctioned as legal. If murder is allowed,
couldn't just about any crime be made legal with the right combinations of
lawmakers in Washington, DC or any statehouse? We must do everything in our
power to keep lawmakers out of the practice of medicine.
Medical
Costs of HIV
Life expectance of a symptomless person infected with
HIV has increased from less than seven years in 1993 to 24 years at an average
annual cost of $25,200. Our thanks go to a vigorous pharmaceutical industry
that has been able to develop and market about two dozen HIV-fighting
anti-retroviral drugs that has changed a disease that once was considered a
death sentence. The average life time cost of an HIV patient is calculated at
$618,000 which is equivalent to the lifetime medical care cost for heart
disease and some other chronic conditions in women, who incur more costs than
men because they live longer. A 2003 study concluded that 55 percent of HIV
patients were on drugs. www.wtop.com/?nid=106&sid=971262
www.theolympian.com/101/v-print/story/50096.html
What do
the Medicaid FP-HMOs spend the money they get from states on? See Section 6
above.
Centene has funded a
multimillion-dollar arts center in St. Louis and paid to put its name on
stadiums in Montana and Missouri. The HMOs are also big donors to political
campaigns. . .
While some doctors and patients
complain of Centene's stinginess, the company has been generous in regions
where it has offices. Centene last year was the biggest donor for a $9.5
million renovation of an arts building in St. Louis, now called the Centene
Center for Arts and Education, according to a spokeswoman for the center. The
company paid $200,000 last year for the naming rights of a minor-league
baseball stadium in Montana, where Centene employs 100 claims processors but
doesn't have Medicaid clients. Centene also pledged $400,000 this year to the
school district in Clayton, Mo., where the company has its headquarters, to
rename the district's stadium. . .
Cynthia Schultz, director of the
Great Falls International Airport in Montana, says Mr. Neidorff, the Centene
CEO, once walked through the airport and heard that it couldn't afford artwork.
Centene then commissioned and donated a $7,000 welded-metal sculpture of an
eagle with a 16-foot wingspan that now hangs prominently in the airport, she
says. The company confirmed the donation. "It's a great gift from someone
who doesn't even live here," says Ms. Schultz. Mr. Schenk, the Centene
spokesman, said the donations show Centene is a "responsible and publicly
focused corporation" and they help make the communities better places to
live. . .
Isn't there an ethics issue
involved when people who get tax money to provide health care to the poor spend
it so arrogantly on their own aggrandizement? Can any public dole be spent
ethically?
* * * * *
11. Physicians Restoring Accountability in Medical Practice, Government and Society: