Episode 14 of “The THCB Gang” was live-streamed on Thursday, June 18th. Tune in below!

Joining Matthew Holt were four regulars: health futurist Ian Morrison (@seccurve), writer Kim Bellard (@kimbbellard), MD turned leadership coach Maggi Cary (@MargaretCaryMD), Consumer advocate & CTO of Carium Health Lygeia Ricciardi (@Lygeia), and two guests: Emergency Room MD, IT consultant and so much more Medell Briggs (MedellBriggsMD), and patient advocate CEO of Patient Orator, Kistein Monkhouse (@KisteinM). It was a very thoughtful conversation about patient care, the role of social movements, what to do about structural racism in health care, and what new legislation might come from the federal level. You can watch below right now.

If you’d rather listen to the episode, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels — Zoya Khan

As Patient Centered Medical Homes and Accountable Care Organizations form, the lines between professional and hospital practice become increasingly murky.

CMS has long required that hospital and professional records be separable, so that in the case of audits or subpoenas, it is clear who recorded what.

Today, the BIDMC ACO continues to expand into the community, adding owned hospitals, affiliated hospitals, owned practices, and affiliated practices.

Our strategy to date has been to use our home-built inpatient and ambulatory systems at the academic medical center, Meditech in the community hospitals, and eClinicalWorks in private ambulatory practices which are part of our ACO.

We share data among these applications via private and public HIE transactions – viewing, pushing, and pulling.

The challenge with emerging ACOs is that professionals are likely to work in a variety of locations, each of which may have different IT systems and each of which serves as a separate steward of the medical record from a CMS point of view.

Our clinicians are asking the interesting question – can I use a single EHR for all patients I see regardless of the location I see them?

Our legal experts are studying this question.

I can imagine several answers.

For facilities we own and control, we can tag every note created by every professional with a facility code, enabling us to separate out those records created at given location in the case of audit or subpoena.

For facilities that are affiliated but not owned, clinicians can use their favored EHR, but at the end of the encounter, they must create a paper or digital copy of the record and place it int the hospital record of the location which is the steward of the data from a CMS perspective.

Since it is unlikely that every inpatient and outpatient facility we acquire or affiliate with will have the same HIS and EHR applications, it is not realistic to create one physical shared record across all sites.

Instead, data sharing through the HIE, metadata tagging as to the facility/professional that owns each record, and policies regarding what must be done at each site seems like the logical way to go.

As is often the case with challenging workflow and regulatory issues, I welcome the experience of others.   How have you separated professional and hospital records per CMS regulations, but enabled co-mingling of patient data for care coordination and population health?

John D. Halamka, MD, MS, is Chief Information Officer of Beth Israel Deaconess Medical Center, Chief Information Officer at Harvard Medical School, Chairman of the New England Healthcare Exchange Network (NEHEN), Co-Chair of the HIT Standards Committee, a full Professor at Harvard Medical School, and a practicing Emergency Physician. He’s also the author of the popular Life as a Healthcare CIO blog.

From CurrentMedicine.TV:

With the troubles at the medical doctor social network Sermo, we thought it would be interesting to speak with a healthcare IT venture capitalist about the reasons why the healthcare sector has not adopted Internet technologies such as LinkedIn or Facebook, or other IT business models. We interviewed Bijan Salehizadeh, MD, Managing Director at Navimed Capital in Washington, DC.

By NIRAN AL-AGBA, MD

As southern states entertain legislation granting nurse practitioners independent practice rights, there are some finer details which deserve careful deliberation. While nurse practitioners are intelligent, capable, and contribute much to our healthcare system, they are not physicians and lack the same training and knowledge base. They should not identify themselves as “doctors” despite having a Doctor of Nursing Practice (DNP) degree. It is misleading to patients, as most do not realize the difference in education necessary for an MD or DO compared to a DNP. Furthermore, until they are required to pass the same rigorous board certification exams as physicians, they should refrain from asserting they are “doctors” in a society which equates that title with being a physician.

After residency, a physician has accrued a minimum of 20,000 or more hours of clinical experience, while a DNP only needs 1,000 patient contact hours to graduate. As healthcare reform focuses on cost containment, the notion of independent nurse practitioners resulting in lower healthcare spending overall should be revisited. While mid-level providers cost less on the front end; the care they deliver may ultimately cost more when all is said and done.

Nurse Practitioners already have independent practice rights in Washington State. In my community, one independent NP has had 20 years of clinical experience working with a physician prior to going out on her own. Her knowledge is broad and she knows her limits (as should we all); she prominently displays her name and degree clearly on her website. This level of transparency, honesty, and integrity are essential requirements for working in healthcare. Below is a cautionary tale of an independent DNP elsewhere whose education, experience, and care leave much to be desired. I thank this courageous mother for coming forward with her story.

After a healthy pregnancy, a first-time mother delivered a beautiful baby girl. She was referred to “Dr. Jones,” who had owned and operated a pediatric practice focused on the “whole child” for about a year.   This infant had difficulty feeding right from the start. She had not regained her birthweight by the standard 2 weeks of age and mom observed sweating, increased respiratory rate, and fatigue with feedings. Mom instinctively felt something was wrong, and sought advice from her pediatric provider, but he was not helpful. This mother said “basically I was playing doctor,” as she searched in vain for ways to help her child gain weight and grow.

By 2 months of age, the baby was admitted to the hospital for failure to thrive. A feeding tube was placed to increase caloric intake and improve growth. I have spent many hours talking with parents of children with special needs who struggle with this agonizing decision. It is never easy. A nurse from the insurance company called to collect information about the supplies, such as formula, required for supplemental nutrition. Mom was so distressed about her daughters’ condition, she could not coherently answer her questions. As a result, the nurse mistakenly reported her to CPS for neglect and a caseworker was assigned to the family.

Once the tube was in place, the baby grew and gained weight over the next three months. At 5 months of age, mom wanted to collaborate with a tube weaning program to assist her daughter with eating normally again. A 10% weight loss was considered acceptable because oral re-training can often be quite challenging. As this infant weaned off the tube, no weight loss occurred over the next two months, though little was gained. She continued to have sweating with feeds and associated fatigue. On three separate occasions mom specifically inquired if something might be wrong with her daughters’ heart and all three times “Dr. Jones” reassured her “nothing was wrong with her heart.”

However, “Dr. Jones” grew concerned about the slowed pace of weight gain while weaning off the feeding tube. Not possessing the adequate knowledge to recognize the signs and symptoms of congestive heart failure in infants, he mistakenly contacted CPS instead. After being reported for neglect a second time, this mother felt as if she “was doing something wrong because her child could not gain weight.” This ended up being a blessing in disguise, however, because the same CPS worker was assigned and recommended seeking a second opinion from a local pediatrician.

On the first visit to the pediatrician, mom felt she was “more knowledgeable, reassuring, and did not ignore my concerns.” The physician listened to the medical history and upon examination, heard a heart murmur. A chest x-ray was ordered revealing a right-shifted cardiac silhouette, a rather unusual finding. An echocardiogram discovered two septal defects and a condition known as Total Anomalous Pulmonary Venous Return (TAPVR), where the blood vessels from the lungs are bringing oxygenated blood back to the wrong side of the heart, an abnormality in need of operative repair.

During surgery, the path of the abnormal vessels led to a definitive diagnosis of Scimitar Syndrome, which explains the abnormal growth, feeding difficulties, and failure to thrive. This particular diagnosis was a memorable test question from my rigorous 16-hour board certification exam, administered by the American Board of Pediatrics. If one is going to identify themselves as a specialist in pediatrics, they should be required to pass the same arduous test and have spent an equivalent time treating sick children as I did (15,000 hours, to be exact.)

A second take away point is to emphasize the importance of transparency. This mother was referred to a pediatric “doctor” for her newborn. His website identifies him as a “doctor” and his staff refers to him as “the doctor.” His DNP degree required three years of post-graduate education and 1,000 patient contact hours, all of which were not entirely pediatric in focus. His claim to have expertise in the treatment of ill children is disingenuous; it is absolutely dishonest to identify as a pediatrician without actually having obtained a Medical Degree.

The practice of pediatrics can be deceptive as the majority of children are healthy, yet this field is far from easy. Pediatricians are responsible for the care of not only the child we see before us, but also the adult they endeavor to become. Our clinical decision making affects our young patients for a lifetime; therefore it is our responsibility to have the best possible clinical training and knowledge base. Acquiring the aptitude to identify congenital cardiac abnormalities is essential for pediatricians, as delays in diagnosis may result in long-term sequelae such as pulmonary hypertension which carry with it a shortened life expectancy.

Nurse practitioners have definite value in many clinical settings. However, they should be required to demonstrate clinical proficiency in their field of choice before being granted independent practice rights, whether through years of experience or formal testing. In addition, the educational background of the individual treating your sick child should be more transparent.

Raising our children is the most extraordinary undertaking of our entire lives. Parting advice from this resolute mother is to “trust your gut instinct, and no matter what, keep fighting for your child.” Choosing a pediatrician is one of the most significant decisions a parent will make. This child faced more obstacles than necessary as a result of the limited knowledge base of her mid-level provider. A newly practicing pediatrician has 15 times more hours of clinical experience treating children than a newly minted DNP.   When something goes wrong, that stark contrast in knowledge, experience, and training really matters. There should be no ambiguity when identifying oneself as a “doctor” in a clinical setting; it could be the difference between life or death.

When it comes to the practice of medicine, the knowledge and experience required are so vast that even the very best in their field continue learning for a lifetime.

Some graduating nurse practitioners believe they are equally as prepared as newly trained physicians to care for their patients. The numbers, however, in hours of hands-on training and experience, simply do not back up that assertion. Physicians have at least 11 years of education after high school. By the time we set off to practice independently, we have had a minimum of 20,000 supervised patient contact hours. Depending on the type of training and school attended, a nurse practitioner has had a minimum of 500-1,000 supervised patient contact hours.

Niran Al-Agba (@silverdalepeds) is a third-generation primary care physician in solo practice in an underserved area in Washington State

“I just want you to know, I won’t have a colonoscopy”, my new patient said with some amount of fervor in his voice. “And I don’t want to take a lot of medications.”

I looked him straight in the eyes and said “This is America, you don’t have to do anything, and I work for you. My job is to help you know your options.”

He seemed to relax. I reflected on the words I had just uttered, yet another time – it is the way I often try to set the tone as a non-authoritarian, patient focused physician.

“You don’t have to do anything”, of course, only applies to the patient.

The doctor has to do a lot of things, like document a treatment or follow-up plan for Medicare patients with a BMI over 30, or provide computer generated patient education to a minimum percentage of patients, and achieve a certain percentage of e-prescriptions. And right about now, we are starting to see financial consequences if too many of our patients, like the man I had just met, don’t want to take the medications that can bring their blood pressures or blood sugars below certain targets.

My new patient illustrated plainly how impossible it is to be practicing both “evidence based” and “patient centered” medicine in a climate where doctors are held responsible for “outcomes” that are the result of patients exercising their free will.

Later, at home, I was reading The New England Journal of Medicine and came across a series of online posts about transforming healthcare. In one, Dr. Amy Compton-Phillips illustrates the way she feels healthcare has started to and must continue to evolve. She seems to think this nation will move “up, out” from “standardized, evidence based care” to “care driven by patient goals” very soon:

I wonder how likely it is that payers like Medicare and for profit health insurers will loosen their grip on doctors’ day to day adherence to practices that are proven or at least strongly believed to save them money and benefit the greatest number of people, and instead allow the premiums they collect to satisfy individual, idiosyncratic patient preferences. That would reduce them to conduits for money, and strip them of their powers as arbiters and enforcers of “best practices”.

In fact, I seem to remember that’s what insurance companies were like when I was a resident more than thirty years ago. That was when doctors were supposedly authoritarian and paternalistic. In Family Medicine, that was certainly not the case – we were trained to put our patients’ values and preferences first. And back then, we didn’t get “dinged” by authoritarian, paternalistic insurance companies if our patients exercised their rights and declined to follow our advice.

I hope Dr. Compton-Phillips is right, and that healthcare in this country finds its way up and out of this oxymoronic situation that certifies clinics as “Patient Centered Medical Homes”, yet punishes them when they respect their patients’ wishes.

Today, an intensive care unit patient room contains anywhere from 50 to 100 pieces of medical equipment made by dozens of manufacturers, and these products rarely, if ever, talk to one another. This means that clinicians must painstakingly review and piece together information from individual devices—for instance, to make a diagnosis of sepsis or to recognize that a patient’s condition is plummeting. Such a system leaves too much room for error and requires clinicians to be heroes, rising above the flawed environment that they work in. We need a heath care system that partners with patients, their families and others to eliminate all harms, optimize patient outcomes and experience and reduce waste. Technology must enable clinicians to help achieve those goals. Technology could do so much more if it focused on achieving these goals and worked backwards from there.

This week marks a step that holds tremendous promise for patients and clinicians. On Monday the Masimo Foundation hosted the Patient Safety Science & Technology Summit in Laguna Niguel, California, an inaugural event to convene hospital administrators, medical technology companies, patient advocates and clinicians to identify solutions to some of today’s most pressing patient safety issues. In response to a call made by keynote speaker former President Bill Clinton, the leaders of nine leading medical device companies pledged to open their systems and share their data.

Lack of interoperability between medical devices plays no small role in the 200,000 American deaths caused by preventable patient harm each year, such as in the case of 11-year-old Leah Coufal. After undergoing elective surgery, Leah received narcotics intended to ease her pain.

When Leah received too much medication, it suppressed her breathing, eventually causing it to stop altogether. Had she been monitored, a device could have alerted clinicians when Leah’s breathing slowed to a dangerous level.

But as we know, clinicians are busy and unfortunately don’t always respond to alarms from bedside machines. If a machine measuring her breathing had been linked with the device delivering her medication, it could have automatically stopped the drugs from infusing into her blue, oxygen-deprived veins.

All of this is possible today; technology is not a barrier. Until now, the only thing that’s stood in the way is a lack of leadership and a lack of willingness for device manufacturers to cooperate.

Through collaboration between health care providers and the private sector, health care can move from a system that relies on the heroism of individual clinicians to one that utilizes safe design.

Additional links:
· See my video interview about the summit
· Read an article with the pledge

Director of the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Peter Pronovost, MD, PhD is a practicing anesthesiologist and critical care physician who is dedicated to making hospitals and health care safer for patients. Pronovost has chronicled his work in his book, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out. His posts appear occasionally on THCB and on his own blog, Points from Pronovost.

Massachusetts has a long track record of making headlines in the area of health care reform, whether or not Mitt Romney likes to talk about it.

In 2008, Massachusetts released results of its initiative requiring virtually all of its citizens to acquire health insurance. In short order, nearly three-quarters of Massachusetts’ 600,000 formerly uninsured acquired health insurance, most of them private insurance that did not run up the tab for taxpayers. The use of hospitals and emergency rooms for primary care fell dramatically, translating into an annual savings of nearly $70 million.

But that’s pocket change in the scheme of things, so the other shoe had to drop — and now it has. Massachusetts made news recently, this time for passing legislation that aims to impose a cap on overall health care spending. That ambition implies, even if it doesn’t quite manage to say, a very provocative word: rationing.

Health care rationing is something everyone loves to hate. Images of sweet, little old ladies being shoved out the doors of ERs that have met some quota readily populate our macabre fantasies.

But laying aside such melodrama, here is the stark reality: Health care is, always was, and always will be rationed. However much people hate the idea, it’s a fact, not a choice. The only choice we have is to ration it rationally, or irrationally. At present, we ration it — and everything it affects — irrationally.

I can tell you from a doctor’s perspective exactly why this matters. Some years ago, I was volunteering as a supervisor for medical students providing outreach in a homeless shelter in New Haven, Conn. I met a woman in her early 30s who was severely limited in her activities by shortness of breath, and listened to her story.

Months earlier, she had a brief illness and spent a few days in bed. When she got better and back on her feet, she noticed she had a pain in her left calf. She thought about seeing a doctor, but had no insurance and couldn’t afford to go. So she just hoped the pain would go away.

It didn’t; it got worse. But she didn’t seek medical attention because of cost; it simply didn’t hurt enough to justify spending money she needed for food.

Until suddenly, late one night, she found herself gasping for breath with stabbing chest pain. Naturally, she wound up in the emergency room via ambulance, and then the intensive care unit. She was diagnosed with a pulmonary embolism, a blood clot in the lungs. This condition can be fatal, and in her case, nearly was.

The source of a pulmonary embolism is usually a blood clot in the leg. In this case, that’s just where it came from — a blood clot causing pain in the left calf. When a clot in the leg is detected and treated early, a life-threatening pulmonary embolism is entirely preventable at fairly low cost.

This woman, a mother back then of a 3-year-old daughter, would never fully recover. Her health care costs ran to hundreds of thousands of dollars, a bill for the hospital, and by extension, the taxpayers — namely us — to pay. She had no means to pay it — and didn’t ask for the care in the first place. The shelter called the ambulance.

By denying this woman access to care she needed, or public insurance that would have paid the nominal costs of early care, our system resulted in both ruined health and a much bigger bill.

Unfortunately, I can tell this tale from a personal perspective as well. Some time back, a family member — a healthy man of 32 — noticed a discoloration on his skin, and saw a doctor. The doctor recommended that he go to a dermatologist. But just then, this man was leaving one job and looking for another. Naturally, that meant he was temporarily uninsured. So he decided to wait for his new job and his new insurance.

Some months later, with a new job, new insurance, and newly married, the man went to the dermatologist. He was diagnosed with malignant melanoma. It had grown since his first doctor visit, and try as they might, the surgeons could not get all of it. Following cycles of chemotherapy, the man died at age 34. Tragically irrational rationing.

In cases like this, people are paying with their lives for the gaps in our insurance system, something the health care reform of the Obama Administration at least partly addresses. There are costs to fix those gaps, yes — but there are higher costs in not doing so. A skin biopsy is a minor expense. Extensive surgery and cycles of chemotherapy are enormously expensive, to say nothing of the economic toll of a working, productive young adult becoming a debilitated and dying patient.

In a system of universal, or nearly universal health insurance such as in Massachusetts, decisions about what benefits to include for whom are decisions about the equitable distribution of a limited resource. If that is rationing, then we need to overcome our fear of the word so we can do it rationally. By design or happenstance, every limited resource is rationed. Design is better.

In the U.S. health care system, some can afford to get any procedure at any hospital, others need to take what they can get. Some doctors provide concierge service, and charge a premium for it. Any “you can have it if you can afford it” system imposes rationing, with socioeconomic status the filter. It is the inevitable, default filter in a capitalist society where you tend to get what you pay for.

That works pretty well for most commodities, but not so well for health care. As noted, failure to spend money you don’t have on early and preventive care may mean later expenditures that are both much larger, and no longer optional — and someone else winds up paying. If you can’t afford a car, you don’t get one; if you can’t afford care for a bullet wound — if you can’t afford CPR — you get it anyway, and worries about who pays the bill come later.

But those costs, and worries, do come later — and somewhere in the system, we pay for them.

By favoring acute care — which can’t be denied — our current system of rationing dries up the resources that might otherwise be used for both clinical preventive services and true health promotion. Fully 80 percent of all chronic disease could be eliminated if our society really rallied around effective strategies for tobacco avoidance, healthful eating, and routine physical activity for all. But when health care spending on the diseases that have already happened is running up the national debt, where are those investments to come from? The answer is, they tend not to come at all. And that’s rationing: not spending on one thing, because you have spent on another.

Nor is this limited to health care. The higher the national expenditure on health-related costs, the fewer dollars there are for other priorities, from defense, to education, to the maintenance of infrastructure. If cutting back on defense calls the patriotism of Congress into question, then classrooms get crowded and kids are left to crumble. Apparently, it is no threat to patriotism to threaten the educational status of America’s future. Whatever…

The resources we ration may be laundered in such a way as to make the rationing invisible. Those little old ladies never actually do get shoved out the ER door — or if ever that does happen, it’s both illegal and a scandal that makes headlines. But our kids may well wind up in overcrowded classrooms with outdated textbooks, because the money ran out. That, too, is rationing.

Massachusetts has thus embraced nothing other than the inevitable in proposing that health care costs be capped. Colleagues and I went further in a program we called EMBRACE, published in the Annals of Internal Medicine in 2009. We actually suggested a rational approach… to rationing. For any hope of ever moving in that direction, we have to “embrace” the reality of limited resources and stop wincing every time we hear the word. All finite resources run out, and all resources are finite. We have to stop running away from this fundamental reality, and deal with it. No little old ladies waiting in the ER need be harmed in the process.

The more we spend on acute care, the less we spend on prevention. But also, the less we spend on other things that matter — like books for our kids in school. The less we spend on books, and teachers, the lower the literacy rate. The less our literacy, the less our society is able to read the writing on the wall.

Right there, in bold lettering for those who can read it, is the time-honored message that rationing is inevitable. Whether rational, or irrational, however, remains a choice we can make. Here’s hoping the experiment in Massachusetts may help show us how to make it wisely and well. Minimally, here’s hoping it helps us stop running from the only reality we’ve got.

David Katz, MD, MPH, FACPM, FACP, is the founding (1998) director of Yale University’s Prevention Research Center. This piece first appeared at The Huffington Post.

The U.S. Supreme Court ruled on Jun 28^th by a 5-4 vote to let the individual mandate portion of the Affordable Care Act (Obamacare) stand. Immediately following, a CEO of one of the nation’s largest insurance companies was asked if people can expect their premiums to go up as this law is implemented. The answer was yes.  So what can employers do to protect themselves from the inevitable?

One strategy for driving market incentives back into the healthcare system and driving down costs is called consumer-driven health insurance, and it is growing in popularity. Historically, the consumer or patient has had very little monetary skin in the game when it comes to the cost of healthcare. We go to the doctor and pay our copay, and never have to worry about what it really costs for health care.

Many employers are now trying to incentivize their employees to be as prudent a purchaser of health care as they are of any other product or service. And they’re doing this by offering high-deductible health insurance policies combined with health savings accounts, or HSAs.

For the 50 percent of patients who collectively spend only 3.5 percent of all healthcare dollars, it’s a fantastic alternative. Instead of paying the high premiums for a lower-deductible plan to the insurance company for care you don’t use — that’s money that goes out the window unnecessarily — you can store the money away, accumulating it every year until a health event occurs when you really need it.

To be sure, a big drawback to these high-deductible insurance plans is the negative impact they can have on the five percent of patients who spend 50 percent of all healthcare dollars. Many worry that high-deductible plans will increase the total cost of healthcare because those with chronic healthcare problems won’t get the help they need until their condition gets so bad that they are forced to seek help — when obviously the cost will be much greater. They have a very valid point.

One solution to this problem is a new type of primary care called “Direct Primary Care.” Under this arrangement, patients struggling to manage multiple chronic health conditions pay their physician a flat monthly fee, usually $100 to $150 a month, for all their primary care needs. This pays for all office visits and office procedures, and the insurance company only gets billed when a specialist is involved or when the patient goes to the hospital for surgery and other more serious procedures.

Direct Primary Care seems to work well for both patients and physicians because it gives the doctor a financial incentive to do everything he or she can to keep that patient as healthy as possible. Instead of the usual 10 minutes per patient, the doctor will often spend an hour or more with the patient, especially initially, to really understand his or her problems. Initial assessments can often last several hours, during which the doctor does a detailed patient history and assesses the complex social and emotional factors affecting the patient’s health. No time is spent billing the insurance company.

Remember, under our current bill-for-procedures health care system, most primary care physicians have thousands of patients in their practices and must see each one as quickly as possible in order to bill enough office visits and procedures to earn even half the money earned by a specialist like a cardiologist. In contrast, a Direct Primary Care physician needs only about 500 patients in his or her practice to make a good living, and because of the lower case load, these patients now have much greater access to the physician.

Face-to-face appointments last as long as is needed, and the doctor is completely familiar with the patient’s needs and life challenges. The physician now has the time to educate, to motivate, and to focus on helping the patient make the behavioral changes that are oftentimes so crucial to his or her well-being — stopping smoking, for example, or losing weight and eating better.

When a referral to a specialist is needed, the Direct Primary Care doctor calls the specialist ahead of time to discuss the patient’s situation and then spends time discussing the patient’s follow-up needs with the specialist after the visit. Truth be told, this is the kind of healthcare that most physicians want to practice — it’s the reason most of them went into medicine in the first place.

In the new book, The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You, author Stephen C. Schimpff, MD, tells the story of one chronically ill patient who went from needing 23 different prescriptions from four different doctors, to needing just seven prescriptions  — all because one Direct Primary Care doctor took the time to examine the patient’s needs closely and coordinate his care. The patient’s health and quality of life improved dramatically as a result.

I know of a Direct Primary Care physician in my own Salt Lake City area who spent many years as a traditional physician. Frustrated by having to see patients for only minutes while having to spend hours fighting with their insurance companies, he took a sabbatical. After seeing a television story about Direct Primary Care, he realized that’s the kind of medicine he’d always wanted to practice, so he set up his own Direct Primary Care office.

Each month, this doctor invites his patients to join him for a healthy free lunch, where he teaches them about this marvelous miracle called the body and how to take care of it. Who says there’s no free lunch? This doctor makes great use of them to incentivize his patients to learn how to stay healthy.

There is a lot that employers can do to curb the inevitable cost increases projected as a result of the implementation of the Affordable Care Act. Employers are in a pivotal position to drive market incentives back into healthcare in an effort to slow down future increases. Consumer driven health insurance is just one of many strategies employers can use.

Darrell Moon is CEO of Orriant, a wellness-program provider serving companies nationwide.

Us and Them
And after all we’re only ordinary men

The wanna-be congressman appeared with his neat hair and pressed suit, a competent yet compassionate expression on his face.  ”The first thing I am going to do when I get to congress is to work to repeal Obamacare,” he said, expression growing subtly angry.  ”I will do everything I can to give you back the care you need from those who think big government is the solution to every problem.”

My wife grabbed my arm, restraining me from throwing the nearest object at the television.  I cursed under my breath.

No, it’s not my liberal ideology that made me react this way; I’ve had a similar reaction to ads by democrats who demonize republicans as uncaring religious zealots who want corporations to run society.  I am a “flaming moderate,” which means that I get to sneer at the lunacy on both sides of the political aisle. I grew up surrounded by conservative ideas, and probably still lean a bit more that direction than to the left, but my direction has been away from there to a comfortable place in the middle.

It’s not the ideology that bugs me, it’s the use of the “us and them” approach to problem solving.  If only we could get rid of the bad people, we could make everything work.  If only those people weren’t oppressing us.  If only those people weren’t so lazy.  It’s the radical religious people who are the problem.  It’s the liberal atheists.  It’s the corporations.  It’s the government.  All of this makes the problem into something that isn’t the fault of the person making the accusation, conveniently taking the heat off of them for coming up with solutions to the problems.

Taken to its logical end, the “us and them” mentality leads to concentration camps, the Spanish inquisition, the gulag, or McCarthyism.  The problems this state of mind creates are much bigger than the ones it is trying to avoid in the first place.  Hate crimes are committed against people who aren’t like us, while others are demonized for voicing an opinion that go against the “right” way of thinking.  Both of these reactions are extreme, and both of them push us further from the solutions to any problem.

Us and them-ism is also a prominent feature in medicine.  Drug companies are evil, Medicaid patients are scum, doctors are too busy counting their money to care, and patients don’t listen to what their caring doctors say.  My conservative patients come in to the office assuming that all of the problems in health care are obviously caused by Obama, just as the liberals blamed it all on Bush four years ago.  They worry about me leaving medicine because of the passage of the ACA, not really knowing what kind of impact it actually has on primary care physicians.  Ironically, the one thing both conservatives and liberals agree on is term limits for congress members, as we all see that the “bad” special interest groups are controlling congress.  Maybe that’s more of the us and them-ism, but I can get anyone to laugh at a joke with a congressman at the butt.

“When you don’t have blood going to your head,” I explain, “you pass out so the blood can get to your brain easier.  Getting blood to your brain (and your heart) is pretty much essential…unless you are a member of congress, where having a brain or a heart seems to be a liability.”  I’ve gotten laughs from the right and the left on that one.

We unfortunately are soon to experience the pinnacle of us and them-ism: a presidential election.  Those who govern us leave governance and embrace pure politics. If Obamacare was the best possible law, the republicans would demonize it anyway to avoid giving the president the political upper hand.  The same would happen if there was a republican president; this is bipartisan power lust with no apology.

Yet the problem in my exam rooms remains: care is too expensive, there is more red-tape and less good care, more patients have no insurance than ever before, and doctors are getting really, really tired of dealing with this mess.  Patients die due to poor access to care (far more than most people realize), and many grow rich off of a system which pays more attention to shareholders of device manufacturers than to the patients with the devices in their bodies.

The intersection between health care and politics is the place where I lose my temper.  Politicians playing the power game with the lives of my patients are my arch nemesis.  This is insane.  This has to change.

When I was a medical student I did a cardiology rotation.  I had a patient who had a heart attack and was sent to the floor, seemingly stable.  I met her and her family, getting to know the situation as well as could be understood by a student.  I heard the overhead page for the code on the ward she was in, so I ran to see if it was her who had suddenly crashed.  My heart sank when I came to her room and saw a flurry of activity around her doorway, with her family somberly standing outside while people hurried in and out of the room.  Her husband’s eyes were tearful as I came up to the doorway.

“It’s Maria,” he said to me, “She just stopped breathing.”

I gave a weak smile to try to comfort him. “I’ll go and find out how she’s doing.”

She wasn’t doing well.  Her heart rhythm was nothing I had ever seen before and her face was ashen.  The respiratory therapist was assisting her breathing using a bag-mask and the nurses were attending to her IV.  The cardiology fellows I was working with on the rotation were in a corner, far away from the woman, arguing with each other.

“I think it’s a junctional rhythm with PVC’s,” said one with passion.

“No, it’s clearly a left bundle with a-fib,” argued another, with derision in his voice.

As the argument went on between the doctors, the woman grew more pale.  She was obviously dying.  I thought about her husband, not able to be with his wife as she lay dying in bed, away from him, instead being the subject of an academic debate about heart rhythms.

I felt sick.

The rhetoric on health care seems eerily similar.  The patient is laying on the bed dying while the politicians are vying for the upper hand in the debate.  The patients are ignored, though, serving as a tool with which to smear the other side.  Just like I felt when I was a medical student, I feel powerless to do anything while a tragedy unfolds before my eyes.

With, without
And who’ll deny that’s what the fightings all about
Get out of the way, it’s a busy day
And I’ve got things on my mind
For want of the price of tea and a slice
The old man died

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind) where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

As health reform evolves,  I’ve been watching multihospital systems grow in size and power and speculating what their gigantic size means.

Here, as of 2008, were the 10 largest systems in revenue size

1. Veterans Administration Hospitals,   $40.7 billion
2. Hospital Corporation of America,  $28.4 billion
3. Ascension Health, $12.7 billion
4. Community Health,  $10.8 billion
5. New York Presbyterian, $8.4 billion
6. Tenet Health, $8.3 billion
7. Catholic Health Initiatives,  $7.8 billon
8. Catholic Health West,  $7.6 billion
9. Sutter Health, $6.9 billion
10. Mayo, $6.1 billion

What strikes me about this list are that such giant systems like Kaiser, the Cleveland Clinic,  Johns Hopkins,  Duke, and Health Partners in Boston don’t even appear, and the large  number of Catholic multisystem chains.  The revenues of multihospital systems has undoubtedly grown since 2008.   In 2011, hospital  mergers and acquisitions hit an all time high.

More than half of all hospital admissions , 60% to be precise, occur in the 200 largest hospital systems,  hospitals now own more than half of physician practices, and large hospital systems are gobbling up rural and smaller hospitals at an accelerating rate.

Reasons behind the growth are self-evident:

·         market and monopoly power to become dominant  preferred providers in geographic regions

·         administrative flexibility  in coping with reduced federal reimbursements, trimming duplications, and creating hospital-physician bundled billing  organizations

·         Need to expand into outpatient markets by acquiring physician practices

·         More ability to negotiate higher payer prices, particularly from private insurers

·         More capacity to invest in  health reform demands for quality, safety and electronic systems

·          Enhanced abilities to direct referrals and to build high tech centers for imaging, cancer, heart and orthopedic centers

·         Anticipation of influx of 32 million more paying Medicaid recipients in 2014 and 78 million new baby boomer Medicare eligibles over the next 18 years.

Critics’  Worries

Critics  worry that consolidation:

·         will create monopolies that will drive up prices and costs for government and consumers;

·         will make hospital owners of physician practices the real economic masters of the health system,  rather than government or physicians and their organizations.

As Humpty Dumpty said in Through a Looking Glass, “ The  question is: which is to be the master, that’s all.”  The  new question is: In the physician world,  will hospital systems, now the dominant physician employer,  dictate and direct what physicians can do, rather than physician organizations?

For insight into what a reform-minded government thinks about this and other matters,  I will like to quote the words of Ezekiel Emanuel, MD,  who was one of President Obama’s principal physician advisors from his perch at the National Institutes of Health before his present physician at the University of Pennsylvania,  as cited by David Nash, MD, head of population health at Jefferson Medical College in MedPage today.

“Initiatives launched under the Patient Protection and Affordable Care Act (ACA) of 2010 are key to the solution:

• Patient-Centered Medical Homes: The Group Health Cooperative of Puget Sound model (1,800 patients per primary care physician with nurses and pharmacists doing chronic disease management and outreach) has already achieved both clinical success and cost effectiveness (a 1.5: 1 return on investment).
• Accountable Care Organizations (ACOs) focus on value-based care delivery and payment systems: Bundled payments – a veritable “prix fixe” – forces collaboration among all providers. Sacramento (CalPERS) ACO’s Acute Care Episode demonstration project (i.e., payment bundles for coronary artery bypass grafts, pacemakers, and 8 orthopedic procedures) may be the prototype for a national program.

A former Washington insider, Emanuel believes that unless the Supreme Court does something completely “wacko,” the U.S. will have universal coverage (with the exception of undocumented persons and refusals).

Costs will decrease and — with advances in interoperable electronic medical records (EMRs), comparative effectiveness research, reporting, and medical error reduction — quality will improve.

Changes in the delivery system will serve as catalysts

Within the next 10 years, Emanuel predicts that:

1.Checklists will be used routinely for intravenous therapies and surgery

2. Electronic medical records, health-related smart phone apps will become the norm

3. Remote monitoring of metrics such as weight, blood pressure, glucose levels will facilitate the management of chronic illness.

4. Health insurance as we know it will disappear

Not My Opinion

That is Emanuel’s opinion.  I believe the Supreme Court may indeed do something “wacko,” like strike down Obamacare.

Emanuel may be right on counts 2 and 3,  but not on 1 and 4.

I do not believe you can replace clinical judgments and patient desires  with checklists. .  I do not believe Accountable Care Organizations, which are essentially government-directed  consolidation of hospitals and physicians into organizations offering bundled bills, will reduce costs, nor do I believe they will replace health insurances companies. .    That is “top-down”  centralized  command and control government thinking, and  not “bottom-up” behavior in the real world.

Richard L. Reece is a retired pathologist and the author of The Health Reform Maze: A Blueprint for Physician Practices. He blogs about health reform, medical innovation, and physician practices at medinnovationblog.