1. Featured Article: Tulane Was Saved by Terminating 166
Faculty Positions, Including 61 with Tenure, But Can It Survive the AAUP
Bureaucracy? Where Is
The Storm After the Storm Jennifer Reingold, Senior Writer, Fast Company, April 2006
Tulane University President
Scott Cowen was at the tail end of a respected career when Katrina hit. The
hurricane almost destroyed his institution--and gave him the chance to reinvent
it. . .
It's a cloudy, foggy day
in New Orleans, but at least it's not raining. That wouldn't bode so well for
freshman move-in day at Tulane University. After all, the last time these
students arrived, on August 27, 2005, they were here only a few hours before
Scott Cowen, Tulane's president, told them to get the hell out of town. The
rain that Hurricane Katrina brought--and the terrible wind, and the broken
levees, and the chaos, and the devastation--not only shuttered Tulane for a
semester but also spawned the largest diaspora from a natural disaster ever to
befall an American city. . .
Most crises that affect
an organization affect only one part. A computer virus might cripple a
company's intranet but not its phone lines. A train derailment might delay one
component of a product, but there should be alternative sources. Katrina was an
assault on all fronts at once. Tulane had no functioning IT infrastructure, no
way to communicate with its 12,500 students and 6,000 employees, no news on
federal funding, no way even to assess the damage. Some of the staff had no
homes, clothes, or news of relatives. But Cowen and his team plunged in, fueled
by little more than adrenaline. "Why wait for the government?" he
says. "If we did, we'd be out of business.". . .
(Emphasis ours.)
Cowen put in place a
triage system centered on a daily 9 a.m. meeting. "Scott would say, 'We
have 1 million things on our plate, but what are the top-five things that need
to get done today?' " says Luann Dozier, VP for development, who lost her
home. "You go and come back with the recommendations and move on. So you
could see progress every day." The first order of business was to retrieve
the school's IT files from the 14th floor of a downtown New Orleans building
with massive flooding, no working elevators, and chaotic surroundings. A posse
of Tulane employees, escorted in SUVs by police officers, spent hours lugging
the disks down the darkened stairways. They needed the records to find students
as well as to figure out how to pay staffers and faculty, many of whom had been
displaced and presumably needed the money right away. "If we didn't make
payroll, everyone would have thought we were gone," says Cowen.
Yet some 15% of the
employees were not on direct deposit, and there was still no central Web site
for students seeking information about whether and when the school would
reopen. Cowen reached out to alumnus David Filo, cofounder of Yahoo, for help.
Filo donated some manpower and Web-hosting resources, and soon a makeshift Web
site came to life, along with a relentlessly cheery blog from Cowen. Privately,
however, he had doubts. Why would freshmen, about to be dispersed to hundreds
of different colleges, feel loyalty to a school they'd attended for just a few
hours? Who would want to come back to a campus with absent professors, few
services, limited pizza joints, and, possibly, no Mardi Gras? To make it easier
to come back (actually, harder to leave), national university organizations
asked other schools to accept students affected by Katrina, but only for one
semester. The school also took out a $150 million loan to hire a
disaster-relief firm to fix the damaged campus. . .
"As I was going to
say before Katrina interrupted me…, " begins Cowen, looking resplendent in
his president's robes. "We are absolutely delighted that you are here with
us finally… No major research university, or for that matter, any organization,
has ever been confronted with the challenges we've faced. Yet we have
recovered, we have survived, and we have charted a path to the future."
With equal parts grit,
creativity, and optimism, Cowen has resuscitated Tulane--formerly the largest
private employer in New Orleans and, since Katrina, the largest
altogether--even as the rest of the city remains mired in the literal and
figurative muck. But Cowen has also decided to do something more than merely
rebuild his institution as it once was. Using the powers granted him as a
result of the school's financial emergency, he has enacted a bold, controversial,
and wrenching "renewal plan," with which he hopes to remake Tulane
from a very competitive school into a truly elite one. "I wouldn't wish
this on anybody," he says. "But out of every [disaster] comes an
opportunity. We might as well take the opportunity to reinvent ourselves."
. . .
The dozens of
meetings--which went on throughout October and into November--were long and
painful, but seven years of experience and a lot of the analysis Cowen had
already done in prior years led the group to some obvious cost savings. It
quickly became clear that the medical school, which had moved to Baylor
University for the year, was in the most trouble, primarily because of the lack
of patients. The group ended its emphasis on clinical work and reduced the school's
faculty and staff by a full 30%. "That was really difficult," says
Dr. Paul Whelton, SVP for health sciences and dean of the medical school,
"to tell people who had been loyal to this university for 20 years that
unfortunately you are not critical to the mission." . . .
Given the scope of the
crisis, Cowen's plan met with little initial resistance. It didn't hurt that he
required Tulane's board to approve or reject the plan as a whole; it passed
unanimously. But now, perhaps because Tulane is perceived to be on the mend,
the critical rumblings are getting louder. In January, the American Association
of University Professors wrote Cowen asking for a full accounting of exactly
how he eliminated 166 full-time faculty positions (including 61 with tenure)--believed
to be the largest number of mass terminations ever at an American university.
Groups have sprung up to fight the changes with petitions and protests. And
chalked in front of the engineering building was a lament: "We survived
Katrina, but not the administration." . . .
Cowen denies having any
sort of master plan to alter the course of the university, but he was prepared
to move aggressively in part because he had launched a financial analysis of
every Tulane department in 2001, giving him data to rely upon once the
hurricane hit. While no one would ever wish the horror of a Katrina on anyone,
it gave Cowen the clout to move faster than any university administrator in
memory. Other university presidents respect that decisiveness. "The first
thing that popped into my mind was the quote from Plunkett, the Tammany Hall
guy," says Madeleine Wing Adler, president of West Chester University of
Pennsylvania. " 'I seen my opportunities and I took 'em.' "
Jennifer Reingold (jreingold@fastcompany.com) is a Fast Company
senior writer.
To read the entire
article, please go to www.fastcompany.com/magazine/104/tulane_Printer_Friendly.html.
* * * * *
2. In the News: Some Convenient Truths, Comment by Gregg
Easterbrook, The Atlantic Monthly
Comment: 
Runaway global
warming looks all but unstoppable. Maybe that's because we haven't really tried
to stop it
If there is now a scientific consensus
that global warming must be taken seriously, there is also a related political
consensus: that the issue is
Here's a different way of thinking about
the greenhouse effect: that action to prevent runaway global warming may prove
cheap, practical, effective, and totally consistent with economic growth. Which
makes a body wonder: Why is such environmental
optimism absent from American political debate?
Greenhouse gases are an air-pollution
problem - and all previous air-pollution problems have been reduced faster and
more cheaply than predicted, without economic harm. Some of these problems once
seemed scary and intractable, just as greenhouse gases seem today. About forty
years ago urban smog was increasing so fast that President Lyndon Johnson
warned, "Either we stop poisoning our air or we become a nation [in] gas
masks groping our way through dying cities." During Ronald Reagan's
presidency, emissions of chlorofluorocarbons, or CFCs, threatened to deplete
the stratospheric ozone layer. As recently as George H. W. Bush's
administration, acid rain was said to threaten a "new silent spring"
of dead Appalachian forests.
But in each case, strong regulations were
enacted, and what happened? Since 1970, smog-forming air pollution has declined
by a third to a half. Emissions of CFCs have been nearly eliminated, and
studies suggest that ozone-layer replenishment is beginning. Acid rain,
meanwhile, has declined by a third since 1990, while Appalachian forest health
has improved sharply.
Most progress against air pollution has
been cheaper than expected. Smog controls on automobiles, for example, were
predicted to cost thousands of dollars for each vehicle. Today's new cars emit
less than 2 percent as much smog-forming pollution as the cars of 1970, and the
cars are still as affordable today as they were then. Acid-rain control has
cost about 10 percent of what was predicted in 1990, when Congress enacted new
rules. At that time, opponents said the regulations would cause a
"clean-air recession"; instead, the economy boomed. . . .
One reason the global-warming problem
seems so daunting is that the success of previous antipollution efforts remains
something of a secret. Polls show that Americans think the air is getting
dirtier, not cleaner, perhaps because media coverage of the environment rarely
if ever mentions improvements. For instance, did you know that smog and acid
rain have continued to diminish throughout George W. Bush's presidency? . . .
Does it matter that so many in politics
seem so pessimistic about the prospect of addressing global warming? Absolutely. Making the problem appear unsolvable encourages
a sort of listless fatalism, blunting the drive to take first steps toward a
solution. Historically, first steps against air pollution have often led to
pleasant surprises. When Congress, in 1970, mandated major reductions in smog
caused by automobiles, even many supporters of the rule feared it would be
hugely expensive. But the catalytic converter was not practical then; soon it
was perfected, and suddenly, major reductions in smog became affordable. Even a
small step by the
And to those who worry that any greenhouse-gas
reductions in the
Americans love challenges, and preventing
artificial climate change is just the sort of technological and economic
challenge at which this nation excels. It only remains for the right politician
to recast the challenge in practical, optimistic tones. Gore seldom has, and
Bush seems to have no interest in trying. But cheap and fast improvement is not
a pipe dream; it is the pattern of previous efforts against air pollution. The
only reason runaway global warming seems unstoppable is that we have not yet
tried to stop it.
Gregg Easterbrook is a contributing editor of
The Atlantic, a visiting fellow at the Brookings Institution, and the
author of The Progress Paradox.
The URL for this page is www.theatlantic.com/doc/200609/global-warming.
* * * * *
3.
International
Medicine: Will the National Health Service Become Kaiser
Permanente
Curing
European Health Care, By HELEN DISNEY, The Wall Street Journal -
Reform of health services in Europe is as controversial
a topic as you can find, stoked by headlines like "American firm hired to
do all National Health Service shopping" in one British newspaper. As the
private sector is called on to play a new health-care role, though, should
Europeans really be alarmed?
The news that a
Critics claim these developments are the beginning of
the end of the welfare state -- a drive toward the "Americanization"
of health care -- and the antithesis of equity, solidarity and everything else
good that European systems are meant to represent. They also note,
legitimately, that reforms should be about driving up the quality of service,
not just cutting costs.
The strength of European feelings against liberalization
was made quite clear in February, when the EU Parliament amended the services
directive. In the process, lawmakers threw out the directive's public health
and social services element, which would have created a more competitive
internal market in health care.
Though introducing market mechanisms may seem radical
now, it likely won't in a decade's time. A combination of demographic changes,
increased consumer demand, rising medical costs and the resulting bankrupt
welfare systems makes further market-oriented reform of European health systems
highly likely. In fact, as in the
Many countries are introducing what would have been
seen as heretical moves a few years ago. Some, like "left wing"
For the most part, the reforms have turned out to be
good for both health-service users and staff. Why? First, they make systems
more responsive to individual needs. Second, they introduce more investment in
the system. Third, and perhaps most important, they lead to more sustainable
health systems for the long term without sacrificing access for all.
To the north, in
Yet this development would never have come about
without the so-called
Similarly, in
Last but not least, the
Despite the scare mongering, many of these efforts
have little to do with copying the
Ms. Disney is director of the Stockholm Network, a
pan-European think tank.
Read the entire article at http://online.wsj.com/article_print/SB115507043277230264.html (subscription required).
The NHS does not give timely access to health care;
it only gives access to a waiting list.
Kaiser Permanente, the
world's leading totally integrated health-care system, is known for giving
immediate, same-day access to a physician or nurse practitioner and improving
quality.
What a logical and sensible
way to eliminate waiting lists that extend over years.
* * * * *
4. Medicare: Saving Health Insurance from the Minimum
Wage by John C. Goodman
and Richard B. McKenzie
Political support is growing in Congress for another
increase in the federal minimum wage. A bill now under consideration would
raise the minimum hourly wage from $5.15 to $7.25 over the next two years.
According to the Economic Policy Institute, an estimated 6.6 million workers
currently earn less than $7.25, and a total of 14.9 million workers would be
affected by 2008.
What are the likely consequences? Economists have
traditionally warned that a higher minimum wage causes more people to be
unemployed. [See, for instance, David R. Henderson, "The Negative Effects
of the Minimum Wage," NCPA Brief Analysis No. 550.] But a number of
studies point to an even more serious consequence: fewer fringe benefits,
including health insurance.
An unintended consequence of a minimum wage increase
would likely be a rise in the number of Americans without health insurance.
Congress can avoid adding to the ranks of the uninsured -
in fact, it can make progress toward reducing their number - by
giving employers and employees the option of using the amount of the minimum
wage increase for health insurance in lieu of wages.
Wages versus Other Benefits. Workers
tend to get paid a wage equal to the value of what they produce. So employees who
produce $5.15 worth of goods and services per hour will tend to be paid $5.15.
But what happens if the law makes employment illegal unless the wage is at
least $7.25 per hour? No employer is going to pay $7.25 for $5.15 worth of
productivity. So employers and employees will seek ways around the law - by reducing nonwage
compensation:
- About one in every three employees near the
minimum wage has access to such benefits as vacation time, health
insurance, holiday pay, employee discounts, uniforms and credit toward
college tuition.
- Overall, fringe benefits account for up to 30
percent of total employee compensation.
- Fringe benefits are not subject to payroll and
income taxes; thus, after taxes, $1 of fringe benefits can equal $1.25 or
more of wages.
Employers can also reduce labor costs by spending less
on working conditions or employee training. Employers may also impose more
rigorous work requirements, insisting that employees work faster or work
harder.
The net effect of these adjustments is to largely
neutralize the cost impact of the minimum wage hike. For example, when the
minimum wage increases by $1, the cost of labor may, on balance, rise by only 5
cents. Workers who retain their jobs are unlikely to be any better off than
before. They get more money, but they also get fewer benefits and have to work
harder for their pay.
- A 1982 study by
- Economists Linda Leighton and Jacob Mincer concluded in a 1981 study for the American
Enterprise Institute that minimum wage increases reduce on-the-job
training and, as a result, dampen growth in the real long-run income of
covered workers.
Of course, if employers can't reduce fringe benefits
(say, because there are none) or are unable to make other adjustments (such as
increased work demands), employees are in danger of losing their jobs.
Wages versus Health
Insurance. One of
the most important employer benefits that substitutes for money wages is
employer-provided health insurance. But health insurance premiums are rising
and some employers no longer offer this benefit. Low-wage workers are
particularly affected:
- A recent study analyzing the impact of various
federal minimum wage increases over a decade found that a 20 percent
increase in the minimum wage reduces employer-sponsored health insurance coverage
by 4 percent.
- In most cases the trade-off is dollar for dollar
- thus, a $1 per hour increase in the minimum wage could result in a $1
per hour decrease in employer-provided health insurance, according to a
recent study for the Board of Governors of the Federal Reserve System by
economist Louise Sheimer.
- Nationwide, about 27 percent of people below the
poverty line lack health insurance, according to the U.S. Census Bureau,
and the percentage is much higher in some states. [See the figure.]
A minimum wage increase will induce even more
employers to drop or reduce health insurance benefits, resulting in a further
increase in the number of uninsured.
Solution: Creating an Option for Employers. If there is an increase in the minimum wage, employers
should be able to count their spending on health insurance for their employees
- dollar for dollar - against the minimum wage increase. Specifically, all
employers should be allowed to count up to $2.10 per hour per worker in health
benefits toward meeting the minimum wage level. As a result, employers would
not have to reduce health insurance benefits to meet the wage mandate.
This option would allow an employer to substitute a
nontaxable benefit for taxable wages. For a person working 2,000 hours per
year, a $2.10 increase in nonwage benefits would
amount to $4,200, enough to purchase an individual health insurance policy in
most places. A couple, both working at the minimum wage,
would have $8,400, enough to purchase a family policy in most places.
Solution: Individually-Owned Insurance. In many states, individual and family insurance is
less expensive than group insurance (usually because there are fewer
cost-increasing regulations). However, employers currently cannot buy
individually-owned insurance for their employees. If they were allowed to,
employers could pay some or all of the premiums for insurance employees could
take with them as they move from job to job.
Insuring the Uninsured. Market
forces will largely neutralize the impact of a minimum wage increase, and the
minimum-wage employee is unlikely to be much better off than before the
increase. However, if the health insurance option is part of the legislation,
it offers an opportunity to reduce rather than increase the number of Americans
without health insurance.
To read the entire article,
go to www.ncpa.org/sub/dpd/index.php?page=article&Article_ID=10061.
Government is not the solution to our problems,
government is the problem.
- Ronald Reagan
* * * * *
5. Medical Gluttony: Feed the World - Pour Money on the
Problem (A Debate)
Billy Shore: Founder and executive director of Share Our
Strength, a leading antihunger organization
William Easterly: New York University professor, author
of The White Man's Burden (Penguin Press)
Resolved: We can feed the world.
Shore: Americans can't feed the world,
but we can do much more to help the world feed itself. Some of the most
effective antihunger and antipoverty programs in developing nations are
small-scale projects run by local or regional social entrepreneurs innovating
in ways governments can't. We saw this in Ethiopia with an organization called
Action for Development, which was introducing new crops, innovative farming
methods, and water projects into the community. Such local programs may be less
glamorous than global antipoverty programs, but in the long run, they're more
effective. But we'd be in a better position to advance such efforts if we
closed the economic gap that exists in our own country, one that leaves too
many families with children seeking emergency food assistance. Hunger in the
United States is one issue that is eminently solvable.
Easterly: Whenever I hear that a tragic
problem is "eminently solvable," I feel the urge to reach for my
intellectual shotgun. If hunger in the U.S. is so solvable, why didn't decades
of antipoverty campaigns already solve it? And what does this have to do with
Ethiopians? I am sympathetic to your program to address the much more serious
hunger problem in Ethiopia--it sounds like just the right kind of thing to do.
Let the people who know the problem best--the poor people themselves--solve
their own problems. However, I hope you are resisting the official-aid-agency
syndrome:
Do lots of symbolic
things that play well to the rich-country public but don't let yourself be held
accountable for whether the intended beneficiaries are better off or not.
Shore: When I hear a catchall phrase
like "decades of antipoverty campaigns," I reach for my protective vest.
But fortunately, we're not debating antipoverty programs. The antihunger
programs in the U.S., which I suspect you are lumping into that broader
category, have actually done an amazing job of reducing hunger, which is why
school lunch, school breakfast, food stamps, and the Women, Infants and
Children supplemental feeding program (WIC) are among the few to enjoy so much
bipartisan support. In the U.S., we are able to measure progress, hold
ourselves accountable, and invite our stakeholders to judge us upon those
results. I'm not sure how one would best do that globally. Are you?
Easterly: You have put your finger on the
problem with foreign aid: Official aid agencies have virtually no feedback
from, or accountability to, the voiceless poor of the world. I hope
nongovernment organizations like yours can do better--such as subjecting
yourselves to independent evaluation of the impact of a random sample of your
projects by third parties. In short, if you want to know if you've helped the
poor, try asking them.
Shore: You've put your finger on what
seems like a dilemma. There are a lot of things NGOs can do that the government
cannot: They can innovate, take risks, and be closer to the people they serve.
But even the best NGO efforts probably won't reach all of those in need without
broader public and government support. And that's when things get muddy. I have
been encouraged by the eagerness of antihunger leaders in developing countries
to access help. On my last trip to Ethiopia, a young man whose agricultural
project we visited followed us back to our small plane. He said, "If you
know anyone who could give us just two weeks of training in marketing and
communications, it would be a great boost." Creating chances for people to
share their strengths this way seems like a huge opportunity. . .
To
read the rest of the debate, please go to www.fastcompany.com/magazine/105/open-debate.html.
Feed the world, but not by throwing money at the
problem.
On that, Share Our
Strength's Billy Shore and William Easterly of New York University agree.
* * * * *
6. Medical Myths: Single Payer, Like Medicare, Is
More Dependable than Other Insurance.
Payment Delay Looming: Physicians should be aware Medicare will not pay any
claims for the last nine days of the federal fiscal year (
Held claims will be paid on October 2. No interest or
late-payment penalty will be paid to physicians or other health care providers
whose payments are delayed by this one-time hold. Physicians with large numbers
of Medicare patients should prepare now for this cash flow interruption.
[When we have single-payer medicine, the government,
which is not adverse to delaying one-third of a
physician's monthly income, an involuntary short term loan without interest,
will have no trouble delaying a month's income and then one week out of each
month, and then "Only God Knows." When the State of
Come on Docs, Let's Get to the Federal Trough - There Aren’t
Enough Husks For Everyone.
Tell Your Member of Congress to Stop the Payment Cut
and Give Physicians a 2.8% Increase.
Physicians, CMA needs you to turn up the heat on your members of Congress and
motivate them to fix the Medicare payment problems before Congress adjourns in
September. As you know, CMA has for years been fighting for a long-term fix to
Medicare's flawed sustainable growth rate (SGR) formula.
If Congress fails to act before the end of the year,
physician rates will be cut 5 percent on January 1 of next year, and rates will
be cut by a total of 35 percent during the next six years. The cuts are an
unintended consequence of a formula, established under laws passed in 1989 and
1997, that was supposed to establish a "sustainable growth rate" for
spending on doctors' services. The formula allows Medicare spending on
physician services to grow at the rate of the gross domestic product (GDP), but
it actually penalizes physicians because the cost of physician services rises
more rapidly than the GDP.
Reimbursement for all other Medicare providers is
calculated using the Medicare Economic Index (MEI), which is a market index of
actual medical practice costs. Health plans, hospitals, and nursing homes are
all seeing payment increases, while physician payments are being slashed.
2007 Medicare Provider Payment Updates: Health Plans: + 7 percent; Hospitals: + 3.6 percent; Nursing Homes: + 3.5 percent; Physicians: - 5 percent
To read the entire CMA article, please go to www.calphys.org/html/alert083106.asp?anchorID#1.
[Looks like the government's actuaries are smarter than
our actuaries and reducing physician payments while increasing all others are
the real intended consequences of the laws. When will we learn to oppose all
government shenanigans? And why are we the pigs at the trough asking for
government largess? Why don't we let patients handle their problem? As doctors
quit seeing Medicare patients, the Medicare patients have far greater clout
with Congress than we will ever have. We have none - or rather a negative
effect. Medicare patients have 37 million votes; we have less than one million.
It's really a no-brainer.]
Should All Doctors Start Working For The Government?
The Cato Institute's Chris Edwards tracks government
compensation, and he finds that in 1950 the average federal bureaucrat received
$1.19 for every dollar that a private employee earned. By 1990 that ratio had
risen to $1.51 and is now $2. In 2005 federal wages rose 5.8% compared to 3.3%
in the private sector.
[Let's see. Did we say physicians working for the
government's Medicare division were getting a 35 percent cut over the next six
years? But are employed Federal physicians sharing in this rape of the public
till? A fulltime physician told me last week he makes a salary of $60 an hour
or $120,000 for a 2,000-hour work year. He thinks his administrative boss, who
doesn't know in which organ system a seizure fits (is it neurological or
musculoskeletal?), makes more than $180,000 a year and wishes he could put the
disease in the category he chooses. No, Hippocrates, the government hates
employed and Medicare contract physicians equally.
Single Payer, Like Medicare in the
* * * * *
7. Overheard in the Medical Staff Lounge: The Danger of
Doctors Talking Politics!
How About Dropping Some Devices on
Dr Sam: The
Dr Michelle: I
can't believe you said that, Sam. Look at all the innocent women and children
you would kill. And it won't stop the terrorist.
Dr Sam: There
were a lot of women and children killed in
Dr Kaleb: Actually there are a couple of areas in
Dr Michelle: None
of this would have happened if we hadn't gone in and stirred up the pot in the
Dr Sam: How
can you be so naïve, Michelle? Did you have any idea that such a major part of
the globe is so uncivilized?
Dr Rosen: The
mission to establish a beachhead of democracy in that uncivilized society was a
noble idea. But the constitution with law and order should have come first.
Democracy and elections should have come years later. It would take at least a
generation to change the thinking that prevails in that part of the world. Arab
textbooks have first graders recite when the teacher asks: Who are the Jews?
CHILDREN: THEY ARE OUR ENEMY. What do we do with our enemies? CHILDREN: WE KILL
THEM. To have this drilled into the heads of the children from preschool
through secondary school cannot be changed in a few years. We would have to
occupy the country for at least 12-14 years, one entire school cycle, to assure
that the next generation does not grow up to hate and murder for no reason
whatsoever except ethnicity.
Dr Sam: Can't
we learn from the Second World War? After
Dr Michelle: I
think I'll go back to my office and see some patients before I lose my lunch.
http://en.wikipedia.org/wiki/Victory_over_Japan_Day
* * * * *
8. Voices of Medicine: A Review of Articles Written by Physicians
Care by
the Hour, By ROBIN
COOK, The New York Times,
A PRIMARY care doctor I've known since we were
residents 30 years ago recently described for me his typical day as foisted on
him by current economic realities. He rises at
Ten-plus years ago primary care was lauded as the
potential rescuer of a health care system in chaos. Primary care doctors, it
was hoped, would fix what had become an expensive, fragmented specialty system
geared toward treating emergencies and episodes of acute illness. Thanks to new
technologies and treatments, medicine had become a team effort, but the teams
needed captains who would keep patients' overall health in mind, and that role
was to be filled by the primary care doctors: internists, family physicians,
general practitioners and pediatricians. We would all know our doctors, and
they would know us.
But unfortunately, primary care has not flourished,
and the ranks of primary care doctors are thinning. As reported in a series of
articles in The Annals of Internal Medicine in 2003, medical students are
shunning residencies in primary care, and primary care doctors are migrating to
other careers or retiring early. Many who have remained in primary care are,
like my friend, dispirited, disgruntled and disillusioned.
What is the solution? We must make primary care a more
manageable business by changing the way we pay for it. Primary care doctors
should be paid by the hour.
As it is now, insurance companies - following
Medicare's lead - pay primary care doctors according to the number of patients
they see. Each patient visit is generally reimbursed at a flat rate of slightly
more than $50. The payment is the same whether the patient is a healthy, young
person with a runny nose or an elderly person whose multiple chronic illnesses
require many tests, referrals to specialists and detailed explanations to both
the patient and his or her family. . .
A typical primary care doctor spends slightly more than
half of his or her day seeing patients; the other half is spent conferring with
specialists, lab technicians and patients' families, or trying to persuade
health insurance companies to cover some needed treatment. This other half of
his work day must be considered pro bono. Factor in rising overhead costs
(office space, employees and malpractice premiums), and the situation easily
becomes untenable.
No wonder hundreds of primary care doctors have
switched to concierge-style practices, in which patients are charged
subscription fees in return for more personal service in markedly smaller
practices. But this trend only adds to the problem of accessibility by reducing
the pool of regular primary care doctors.
Ideally, the hourly rate would not be the same for all
primary care physicians, but would be assessed on a sliding scale, predicated
on a doctor's level of education. Internists and pediatricians - the primary
care doctors who have had the most training - would receive a higher rate than
general practitioners and family physicians would. . . .
But this expense can be balanced out by cutting the
health care pie differently - as some large, multi-specialty medical groups
already do. Recognizing that Medicare and health insurance companies pay
disproportionately higher amounts for specialty procedures (angioplasties, for
example, or colonoscopies or even freckle removal) than for consultations by
primary care doctors, many practices redistribute their total income according
to each doctor's contribution. Consequently, primary care doctors receive more
than the amount the group is reimbursed for their services. . . .
In the long run, paying by the hour could save money.
It would provide doctors the time they need to investigate symptoms themselves
rather than reflexively refer patients to specialists. After all, every
headache doesn't need to be evaluated by a neurologist; nor does every painful
shoulder require an M.R.I.
It would also increase the pool of primary care
doctors, so that more health problems could be handled in doctor's offices
rather than in emergency rooms, where the cost of care is more expensive. And
finally, better long-term doctor-patient relationships might reduce the number
of malpractice lawsuits. Paying for primary care by the hour would be better
for both doctors and patients, and it would return a measure of rationality to
our health care system.
Robin Cook is a medical doctor and the author, most
recently, of the novel "Crisis.''
www.nytimes.com/2006/08/30/opinion/30cook.html?_r=1&oref=slogin
[We always welcome the wisdom of physician authors and
especially Robin Cook who has entertained us with his Medical Thrillers.
Actually much of what Dr Cook describes has been tried. There was a massive
revision of the Relative Value Scale to make it reflect the time that
physicians spent with a difficult diagnostic problem. The short and
intermediate office calls were subdivided into five levels. Unfortunately, the
government did not trust doctors to use the correct level of service and
proceeded to review a massive number of charts. In their estimation, what
doctors recorded didn't measure up to what Medicare thought the level of
complexity should be. They even sent doctors to jail for fraud when the doctors
thought they were providing the complexity of service billed. If doctors
charged by the hour, the government would have similar problems in trusting
doctor’s charges for a twenty minute charge in one patient and a 40 minute
charge in another. Furthermore, patients can use up an hour of time and think
they've been there only 15 minutes. Until the co-payment is a percentage of the
fee, there will be no patient incentive to monitor his or her
own healthcare costs. So the answer is not an hourly rate, but
patient-driven health care where the patient monitors each and every item of
cost - including his/her own time with the physician.]
* * * * *
9.
Book
Review: THE AMERICAN WAY OF HEALTH - How Medicine is Changing and What it
Means to You by Janice
Castro, Back Bay Books, (Little, Brown, & Company), Boston, 1994, x &
282 pages, including glossary, notes, & index, $9.95, Paperback. Reviewed by Del Meyer, MD
Janice Castro, senior health-care correspondent at
TIME who interviews professionals, patients, and others, opens with "Ask
most people what they think about the state of American medicine, and they will
tell you about their own doctors, or about something that happened to them
during an illness. Chances are, if they see a need for health-care change, it
will be very specific, based on personal experience. On the other hand, listen
to American leaders discussing health-care reform. They speak of providers. Access. Alliances. Competition. Mandates... The concepts seem impossibly
complicated and remote from the experience of one sick person needing
help."
She continues, "This book will help the general
reader understand how the American health system works, why it costs so much...
Medicine is too important, too personal, to be left to economists and
politicians... After all, the health-care debate is really about life and
death. It is about those times when people need help and about whether it will
be there, about one sick patient at a time and the doctor or nurse who provides
care... It is fundamentally a moral problem. Viewed in that light, the
challenge... begins to come more clearly into focus. It is not really that
complicated. We know what we need to do. We need to take care of old people...
Children should see doctors and dentists. A pregnant woman should be able to
check in with a doctor as the baby grows. People should not be dying in the
street... Families shouldn't lose their home over the cost of coping with
medical disasters. Breadwinners should not quit good jobs in order to qualify
for poor people's insurance... People should take responsibility for their own
health and for their family's. Children should not be having children..."
And, "If we are going to ensure that every
American has access to decent health care, while also controlling the
burgeoning costs, all of us must curb our medical greed. All of us must stop
pretending that someone else is paying the bills. 'What do you think most
people would say if one of their parents called up and said they needed a
hundred and twenty-five thousand dollars for an operation?' asks one economist.
'Do you think that son or daughter would think twice and wonder whether that
operation was really necessary? Of course they would. But none of us think we
pay for medical care. And of course we all do.' All of us must pay our share..."
Castro then takes us on a tour de force of
health-care about our country. She starts at Kaiser Walnut Creek's two delivery
rooms where 4,000 infants, mostly delivered by midwives, take their first
breath each year. She interviews a midwife who feels that midwives can deliver
most women in tents, a practice which is prevented by organized medicine. She
then takes us inside the delivery room where the midwife has a complication
with a stuck shoulder. Within seconds, an obstetrician and pediatrician come through
the delivery room doors and deliver a healthy infant two minutes later. Castro
feels it was fortunate this baby was not born in a tent and that the pediatric
ICU is only twenty steps from the delivery room. . .
To read the entire review, please go to www.delmeyer.net/bkrev_AmericanWayOfHealth.htm.
To browse the Doctor/Patient Bookshelf, please go www.delmeyer.net/PhysicianPatientBookshelf.htm.
To review in topical fashion, please go to www.healthcarecom.net/bookrevs.htm.
* * * * *
10. Hippocrates & His Kin: What Is a Morbid Disease?
(after Hart)
Teacher: There's a morbid disease that can grow until
it consumes the body that gave it life! Who in the class can tell me what it
is? Yes, Johnny?
Johnny: The Government
The Slovak parliament adopted new health laws at the
end of 2004, including the introduction of user charges. . . Reformers also instigated a major public
consultation . . . in order to determine what should be covered by mandatory
health insurance. . . Health insurers and providers were given for-profit
status to spur competition, rather than leaving patients to rely on a single
state provider. These changes have already led to a sharp reduction in the
annual health-system deficit by cutting costs . . . In all likelihood, they
will go on to allow patients more and better choices, as the new providers
begin to compete on quality and thereby drive up standards.
What a crazy world. The misguided in our country want
to install government single payer health care to improve quality and decrease
cost. Meanwhile,
In our recent review of the last issue of Sonoma
County Physician, there were excellent articles on sexual dysfunction,
sexual discrepancies, and the health hazards of closets. The photography and
multicolored cover are of the high caliber we've come to expect from Steve
Osborn, the managing editor. To end on a more personal note, the humor in
several of those articles caused me to reflect on my late uncle who was widowed
in his mid 60s. He became serious about a woman he met at a senior citizens'
gathering whom he eventually married. Because she smoked an occasional
cigarette after meals, which he detested, he asked her if she ever smoked after
sex? "Well, Otto," she answered, "I'm
not sure. I don't think I've ever looked."
* * * * *
11. Organizations Restoring Accountability in HealthCare,
Government and Society: