Return of the soccer cleat exchange

The return of our community cleat exchange signals the beginning of the youth soccer season here. My friend Ed and I have doing this for 15 years. About 200 families found a free pair of shoes during the three-hour session. As I have noted before, Ed and I get to meet the new generation of soccer stars, and there is a warm and communal feeling to the whole thing.

"I really like that chart . . ."

. . . because it says it all," noted Ellen Zane, CEO of Tufts Medical Center, in a semi-joking, semi-serious manner. Ellen and I were called back as witnesses at the end of today's hearings on health care and insurance cost trends.

Tufts Medical Center is a competitor of BIDMC, but Ellen and I share views on several topics. This is one. Even though the light orange BIDMC "bubble" appears slightly better off than the Tuft's blue "bubble" in the chart above, the larger societal issue needs to be addressed. It is hard to imagine that the Legislature and Governor really intend the citizens to be served by a health care system that rewards certain providers for their market dominance, especially with no evidence that they offer higher quality.

Ellen explained that, consistent with the findings of the Massachusetts Attorney General, "The funneling of dollars disproportionately among hospital and provider groups serves to warp the overall system balance." She mentioned that one result of this is to allow better paid systems to recruit away doctors to their networks, a result documented by the AG in the chart below.


Ellen pointed out that this result is exactly counter to sound public policy, which should rather encourage the lower cost systems to expand. She agrees with Blue Cross Blue Shield and others that a movement away from fee-for-service payments to capitated contracts will prompt greater efficiency, but she set forth a warning (one my readers have seen before):

"Global payments in and of themselves will not stop the warping behavior," she said. "Unless we deal with distortions in the market, that kind of pricing will do nothing to alleviate the system's problems."

What more do you need to know?

The State House News Service, writing about yesterday's hearings on health care and insurance cost trends, offers the following summary of one witness' comments:

Asked whether he agreed with Attorney General Martha Coakley's conclusion that costs charged by certain hospitals for the services they provide aren't linked to the quality and outcomes for patients, Partners HealthCare Chief Operating Officer Thomas Glynn said, “No.” Glynn, speaking at a state hearing on health care costs Thursday, said the most recent contracts signed between Partners and Blue Cross Blue Shield only provided for cost increases that matched medical inflation. Glynn said, “It's a little bit of a mystery to our physicians how our contract is driving up these increases.” Glynn suggested that the higher rates Partners hospitals charge to health insurers are driven, in part, by inadequate payments from the government for Medicare and Medicaid services.

It has been known for a long time that there are disparities in reimbursement rates in Masachusetts that are correlated mainly with market power. It has also been quite clear that these disparities are not related to differences in quality. Yet, the Attorney General's recent report and the testimony submitted by the state insurers under oath quantify this in manner not seen before. The kind of denial contained in the remarks reported above has no substantive support. For example, if we were to assume that all the BCBS contracts signed in the last three years had the same rate of inflation contained in the Partners' contract, the disparity between PHS and other providers would have grown simply because the base upon which that increase is applied at Partners started at a higher level. (To the extent other providers were not offered those same rates of inflation, the disparities grew even more.)

The State House News Service also said:

Andrew Dreyfus, executive vice president of health care service for Blue Cross Blue Shield of Massachusetts – the state's largest insurer – said he doesn't believe his company has the market power to eliminate disparities in the way doctors and hospitals are paid for their services.

As I note below, the Attorney General has rightly found that these disparities -- which exist in both the fee-for-service and capitated reimbursement worlds in Massachusetts -- have led to and will lead to greater market concentration by those dominant providers. As it has in the past several years and will in the future, this causes a continuing impetus for higher rates of medical cost inflation.

Several months ago, a senior executive at Blue Cross told me that the rapidly expanding utilization of services for patients in the Partners system, compounded by the higher rates being paid to that system, was "murdering" Blue Cross' bottom line. This person actually asked me what could be done about that problem. My answer was that a transparent presentation of the differential in rates was the only way I could see to create a sufficient moral imperative in the political and business environment to force a change in this pattern of behavior.

The Attorney General and the Division of Health Care Finance and Policy have now provided that moral framework. But those in the hearing yesterday made clear that a change in business practices is dependent on actions by the state government. As Andrew put it, even the dominant insurer (which has more subscribers than all other insurers combined), does not believe it has has the market power to eliminate disparities.

Thus far, though, there has not been proposed legislation or regulatory activity that addresses this problem. Who will step up in the body politic to propose and demand such change?

At the Cost Trend Hearings

I just returned from testifying at the Health Care Cost Trend Hearings. (Prepared statements are posted here.) Commissioner David Morales of the Division of Health Care Finance and Policy presided. In addition, Attorney General Martha Coakley attended, seen here with Thomas O'Brien, Assistant Attorney General of her Health Care Division.

The day started with an excellent presentation by Stephen Schoenbaum, EVP for Programs at the Commonwealth Fund. It covered a lot of topics, as you can see if you flip through his charts.

A pertinent one for the topic we have been discussing here was that a likely downside of creating Accountable Care Organizations would be an increase in market leverage of such organizations in negotiating payment levels. This will require, he suggests, some level of state action (a point I have made earlier.) "At a minimum," there would be a need for transparency of prices. Beyond that, we will "probably need" a system of all-payer prices and maybe a move to rate-setting (perhaps akin to that employed in Maryland or West Virginia.) "I don't think private payers on their own can do this," he noted, arguing for government supervision of some sort.

This theme came up later during our panel discussion when people were talking about the potential advantages of moving from a fee-for-service to a capitated reimbursement system. Jim Roosevelt, CEO of Tufts Health Plan, wisely noted, "Before going to global budgets, we need to deal with the variation in unit prices" that exists in the Massachusetts market. (See the chart above.) As noted earlier, I agree.

Health Care Cost Trend Hearings

They don't get much media coverage, but the Health Care Cost Trend Hearings being held by the state government right now offer a variety of opinions about the current health care situation in Massachusetts. The prepared statements of the witnesses are available here.

If you only have time to read one thing, look at this statement from the Attorney General. It is as thoughtful and comprehensive a view of the Massachusetts market as can be imagined. Excerpts:

Price variations are correlated to market leverage as measured by the relative market position of the hospital or provider group compared with other hospitals or provider groups within a geographic region or within a group of academic medical centers.

Variations in providers’ per member per month expenses are not correlated to the methodology used to pay for health care, with expenses sometimes higher for globally paid providers than for providers paid on a fee-for-service basis....

These findings have powerful implications for ongoing policy discussions about ways to contain health care costs, reform payment methodologies, and control health insurance premiums while maintaining or improving quality and access. The report raises concerns that existing systemic disparities in prices may, over time, create a provider marketplace dominated by very expensive “haves” as the lower and more moderately priced “have nots” are forced to close or consolidate with higher paid systems.

Who is a wise man? He who learns from everyone.

In these days of cynicism about our elected representatives, I more often find reason to believe the opposite about them. One example is Congressman Michael Capuano, a Democrat representing a portion of the Boston metropolitan area. I have known Mike since his days as Mayor of Somerville, and his commitment to doing the public good has been admirable and consistent.

So, Mike now faces a tough vote on the national health care bill. I was not surprised to see an email from him to a broad group of constituents seeking their input on the matter. He asked specific and detailed questions about various provisions in the bill, and yesterday reported back to all of us.

Here are some excerpts from his note, leaving out several sections about the details of the bill. Although he gave me permission to include the whole, I wanted to focus here on his major themes.

I am so impressed with how Michael is handling this issue. Whichever way he votes, I know he will have the country's and the state's interests at heart.

Dear Friends,

Health Care reform is as important an issue as I have dealt with in my life and it is of great interest to many people.

In my last communication I shared a detailed letter expressing some concerns and seeking input. Since that time, I have received many calls, emails and letters. Most calls merely express support or opposition to the proposal. Others have more detailed points to make. I value this input and I thank you. I am still weighing my vote.

I decided long ago that this is one of the few issues I will decide without regard for political impact - it is too important. I will cast my vote on the basis of what I think is in the best interest of our country, state and district; if there is a political price to pay for that vote, so be it.

So, as of this writing, here is the status of the issues I raised:

1. Pundit views to the contrary - I have NOT decided how to vote. I want to vote YES, but I am still not certain that this SPECIFIC bill deserves my support.

2. One reason for this hesitancy is that we still do NOT have a final draft of the reconciliation bill. No one can or should make a final decision before they read, consider and discuss the final product. We are so far beyond generalities and rhetoric that decisions made before the actual language of the bill is available are irresponsible.

...

8. Process - Some opponents of the underlying proposal are focusing on the process for passage. While I don't like the convoluted process we will be following, it will not deter me from a thorough analysis of the proposal. I would ask if anyone remembers the process that was used for Medicare, Civil Rights or any other important legislation. Furthermore, I can assure you that convoluted processes have been used many times by Republicans and Democrats. In fact, process is only a means to an end - the real issue is the product. If the product is good, I will vote yes - if it is bad, I will vote no. Following the process may be an interesting sidelight, but the important factors are decided in the substance of the bill.

Like others, I wait anxiously for the text of the reconciliation bill. When it is public, I will ask again for comment from informed observers.

I realize that many people are tired of this debate - so am I. But it is important and complicated. It took years to enact Medicare, Medicaid and Social Security - and I argue that it was worth the time and trouble.

I realize that some just want us to vote yes or no based on a few talking points. I will not succumb to that suggestion. Health care is a serious and complicated matter. I do not believe that the vast majority of people really want me to vote on the basis of rhetoric.

I also realize that some see this as a political tug-of-war between the right and the left or between Democrats and Republicans. I do not see it that way at all. I see it as the implementation of basic values:
First - Do you believe that every American should have health care coverage? I do.
Second - If you do not, the answer is easy, vote no. But then you should also think we should repeal Medicare and Medicaid.
Third - If you agree with me that the goal is to expand coverage, the next questions are whether THIS actual proposal gets us closer to that goal, does it do it in a fiscally responsible manner, and does it harm the programs we already have in place? The answers are never as clean and neat as the first two questions and this is what I am trying to decide now.

For those who have contacted me, I appreciate your input. For those who wish to do so, we are happy to hear from you.

Congressman Mike Capuano
8th District, Massachusetts

---
P.S. The title for this blog comes from the Pirkei Avot, or Chapters of the Fathers, a group of Talmudic commentaries on the Old Testament, dealing with moral and ethical principles.

Price controls do not work

If there is anything about economics that has been proven over and over, it is that price controls do not work. The unintended consequences are usually worse than the problem that led to the solution in the first place.

Massachusetts legislators, feeling the frustration of higher insurance premiums, are now considering a bill to limit doctor and hospital reimbursement payments to 110% of Medicare rates, or perhaps some other percentage of Medicare rates. The problem with this is that Medicare rates are not fully compensatory to doctors and hospitals and have contributed to the increase in private insurance company rates. This was one of the conclusions reached by the Attorney General in her extensive investigation of these matters.

An unreported fact in Massachusetts is that Tufts Health Plan, at the request of the Group Insurance Commission (the agency that manages the state employees' health plan), recently sent out a request for proposals for a new insurance contract for the tens of thousands government employees covered by the GIC. The main provision was that the doctors and hospitals would have to agree to rates set at 110% of Medicare.

The result: It was a bust. Hospitals and doctors did not express interest in the contract because they knew that they could not cover their costs with it -- even though they could have been included in a limited network and have an effective monopoly to serve this large group of customers.

If today legislators adopt price controls over hospital and doctors' rates, tomorrow they will have to deal with layoffs and closures in the Commonwealth's strongest economic sector. These organizations are not for-profit enterprises with shareholders who can absorb losses.

It is interesting to me that a state in which many people decry the idea of rate-setting would consider the idea of picking a certain price target by fiat for the medical sector. If we are going to move towards government supervision of reimbursement levels, please instead set up a regulatory body to determine the appropriate level of rates based on best medical practices and true underlying costs of hospitals. An evidentiary hearing in which all those factors are considered by qualified administrative law judges would do more to provide a sound basis for determining rates than the price control approaches being raised.

A Day in the Life of a Poison Center

Blogging buddy Tony Chen (formerly of Hospital Impact) sent me this link and the following note:

I just wanted to send along a cool/important link that you might be interested in. The Illinois Poison Center did a unique "behind the scenes" look into the type of calls they get on a daily basis, culminating in this post "A Day in the Life of a Poison Center." There are lots of crazy/interesting/important/funny things in here (what DOES one do when a 2yo accidentally takes his grandfather's viagra?!)

Anyway, just thought I'd pass it along. So many of the calls these guys get (about half of their 100,000 calls per year, actually) are from clinicians working in hospitals leaning on their expertise. It's amazing to think about how many ER visits are avoided because of the poison hotline.

Status-Quo Anxiety

Marybeth, a Women's Health Nurse Practitioner here, sent me this link to a James Surowiecki New Yorker article from August. I think it is really well done.

Would you buy anything from this company?

Another in a series of unsolicited email solicitations, many with undue informality. A marketing company, at that.

Is grammar dead? Punctuation? Correct capitalization?

Subject: Re:Thank you for your time on the call - Paul (Of course, there was no call, and this was not a return of an email.)

Hi Paul,

This is Jessica from an Online Marketing Solutions Company called Futuristic Inc.,

We are a Global database company providing customized & complete marketing solutions based on your needs across the globe. Business Expansion, Lead Generation, & Brand awareness are what we are best at. We partner you in increasing your clientele and reach globally.

Our Expertise includes List Acquisition, Email Appending and Email Marketing across all industries, worldwide. There is always an advantage in keeping an updated database of your target market as it helps you to retain your clients and also enables you to get new business opportunities.

To know more on how we can help you in your marketing initiatives, kindly let me know a convenient time when we can have a quick call to discuss or respond to this email with your Target audience and Industry and I would revert accordingly.

Looking forward to your response.

Regards,

Jessica [last name removed]

Marketing Manager

Futuristic inc.,

"But our patients are sicker"

Liz Kowalczyk at the Boston Globe provides a story and the detailed analysis of the rates paid by Harvard Pilgrim Health Care to hospitals and physicians in Massachusetts. Similar charts have now also been filed by Blue Cross Blue Shield and Tufts Health Plan. All this demonstrates again that the health care reimbursement system is broken.

How not to regulate rates

I wrote last month about a proposal by our Governor to limit insurance rate increases for the individual and small business market in Massachusetts. While he has filed legislation on this front, he also has taken administrative action through his Division of Insurance (summary of both here). New DOI emergency regulations could be used to turn down any rate increase that exceeds 4.8%.

On February 14, DOI issued "filing guidance" to the insurance companies to carry out these regulations. Here's the disapproval section, requiring the previous year's rates to stay in effect if the new rates are not approved:

Health Plans may immediately re-file if a filing is disapproved, but the filing will be subject to at least another 30 days for review. Health Plans may not increase a rate from the prior year if the filing is disapproved. For example, if a group policy is renewing on April 1st, and the March 1st filing for April rates is disapproved, the prior April's rates must stay in effect until such time, if any, that the Health Plan's filing is deemed not disapproved. Health Plans must notify the affected policyholder if a filing is disapproved by the Division.

While I have made clear my predisposition for a wholesale state review of insurance payments to providers, the Administration's rulemaking is another matter altogether. This kind of piecemeal approach to regulation is ill-advised. You simply can't just look at one set of premiums and rule on their reasonableness by administrative fiat.

To the extent the proposed rates are reflective of the demographics and actuarial characters of the group's members, any attempt to use a predetermined price index as a threshold is, on its face, arbitrary. Beyond removing the proper price signal of the underlying cost of medical care and the risk characteristics of the population, turning down a proposed rate increase on these grounds introduces a level of turmoil into the market that will be difficult to unravel.

For those from out of state, please recall that the preponderance of these policies in Massachusetts are written by non-profit insurance companies, so there are no shareholders to bear the shortfall. Instead, the insurers will have to reduce capital reserves, modify plan designs, or cross-subsidize these policies with revenues from other policies. Where reimbursement rates are currently under negotiation, the insurers might attempt to put downward pressure on providers to sell services for this customer segment below cost to make things balance. If agreed to, this would lead to further cost-shifting to other subscribers; but it might be that providers choose not to sign up with insurers that request this. That would leave consumers with policies that do not include certain doctor and hospital networks.

In my days of regulating utilities, the appellate court would have found this kind of ratemaking to be arbitrary and capricious. Requiring investor owned utilities to sell certain services below cost might also have been found to be confiscatory. I don't know what legal standard would apply here, but I am guessing we might soon find out.

Fortunately, indications are that the proposed legislation is unlikely to make progress, but this administrative regulatory approach will move forward unless it is stopped. It should be.

What does it take? (revisited)

I beg your indulgence to read this old post of mine, but more importantly, to read the comments that it stimulated from some of the world's experts in process improvement, but also from some "regular people."

All things considered, are we in the health care professions moving fast enough to transform the delivery of care? And whatever you think about today's problems and this generation of caregivers, how about trying harder for the next? An excerpt:

The Lucian Leape Institute at the National Patient Safety Foundation released today a report that finds that U.S. “medical schools are not doing an adequate job of facilitating student understanding of basic knowledge and the development of skills required for the provision of safe patient care.” The report comes approximately 10 years after the Institute of Medicine’s landmark 1999 report “To Err Is Human,” which found that 98,000 Americans die unnecessarily from preventable medical errors. “Despite concerted efforts by many conscientious health care organizations and health professionals to improve and implement safer practices, health care remains fundamentally unsafe,” said Lucian L. Leape, MD, Chair of the Institute and a widely renowned leader in patient safety. “The result is that patient safety still remains one of the nation’s most solvable public health challenges.”

A major reason why progress has been so slow is that medical schools and teaching hospitals have not trained physicians to follow safe practices, analyze bad outcomes, and work collaboratively in teams to redesign care processes to make them safer. These education and training activities, the report states, need to begin on Day 1 of medical school and continue throughout the four years of medical education and subsequent residency training.

“The medical education system is producing square pegs for the delivery system’s round holes,” said Dennis S. O’Leary, MD, President Emeritus of The Joint Commission, a member of the Institute, and leader of the initiative. “Educational strategies need to be redesigned to emphasize development of the skills, attitudes, and behaviors that are foundational to the provision of safe care.”

Questions for medical students and residents out there. Have you received training in process improvement or the science of care delivery? If so, tell us about it. If not, is it something that you would fine useful? Would it influence how attractive you found potential training programs when planning your career?

Crowd sourcing comes through again

I have written below about the incredible power of crowd sourcing, using the reach and scope of social networking on the Internet to solve a complex problem. Here's a play-by-play about a difficult question. It demonstrates how the asynchronous participation of many participants inevitably converges on the right answer in less than 24 hours. You just have to be patient and let the truth emerge.

I posted the following problem on Facebook:

Query -- what makes some Facebook status updates stay put on the top of your page until cleared, while others appear as one-time updates? (Yesterday at 12:22pm.)

Luba:

I think it's an algorithm that has to do with how often you comment on other people's posts. Facebook tries to be smart about which people you actually care about seeing. I often find it wrong and look at both top stores and most recent to get a full picture of what is going on.

Me:
No, I mean that it stays at the top of your profile page -- sometimes.

Kim:

I think if you go to your home page and write on your wall (as opposed to the "feed" page), it stays up as your status until you change it.

Me:

Nope, it only persists when I post it from the profile page, but then not always. It is inconsistent.

Beverly:
My daughter's answer to these kinds of questions was always, "That's just FB being weird." Evidently they have their quirks.

Eileen:

Do the updates have links (i.e., to other web sites)? Those show up in the news feed but won't get posted like a FB status update on your profile page. Your previous status will remain if a newer post has any kind of link attached to it.

Amy:

I think Beverley's daughter has the answer. FB is both quirky and weird.

Isabel:
Like Eileen, I thought it was links v. no links...

Cal:

There are two buttons at the top center of your News Feed page - Top News and Most Recent. Click on Most Recent and the feeds will be in chrono order.

Me:
That's not the question. Sorry if not clear. The Q is what makes a status change show up at the top of the profile page and stay there?

Beverly:

I just posted a status update with a link and it never went to the top of my profile page. I think the link people are right - link (or photo?), it doesn't go there, no link, it goes to the top and stays. Evidence-based Facebook. (:

Rob:

It has to do with how hard you strike the keys on your computer. Gentle pushes fade much quicker. (Today at 7:48am)

Phineas, we hardly knew ya

One of my favorite displays is of the actual head of Phineas Gage. If you recall, he was a railroad worker who unfortunately got in the way of a projectile -- a long, sharp iron bar that inadvertently became a missile as a result of a mistimed explosive charge.

Mr. Gage's head, and the bar that traveled through it back in 1848, and a technical explanation of the event and the aftereffects are on public display at the Countway Library at Harvard Medical School. (Contact the library at (617) 432-2170 for information.)

Not Boston

I was recently in Palm Beach and had occasion to drive my rental car to one of the local restaurants. It was "valet only" parking. As I stepped out of the car, I asked the valet for the ticket, and he said, "No need. It is the only Chevy in the lot."

After dinner, a new attendant was on duty. He asked for the ticket. I said, "It's the Chevy." He said, "I'll get it right away."

I think they were happy to have it off their lot.

New blog: Health Reform Musings

There is a new blog by Bruce Bullen. It is called Health Reform Musings.

I am hard-pressed to think of anyone in this field in Massachusetts who garners the respect that Bruce does. He was admired as a true professional when in the state government and then afterward at Harvard Pilgrim Health Care. I would keep track of what he says.

In touch or out of touch?

Here is a fascinating opinion piece in the Washington Post by Pat Caddell and Douglas Schoen, pollsters to the past two Democratic presidents, Jimmy Carter and Bill Clinton. They suggest that the Democrats are not in touch with the public regarding health care reform. "Their blind persistence in the face of reality threatens to turn this political march of folly into an electoral rout in November." See my recent notes here and here that have related themes.

More excerpts:

"The battle for public opinion has been lost. Comprehensive health care has been lost."

"Yes, most Americans believe, as we do, that real health-care reform is needed. And yes, certain proposals in the plan are supported by the public. However, a solid majority of Americans opposes the massive health-reform plan."

"Health care is no longer a debate about the merits of specific initiatives. Since the spectacle of Christmas dealmaking to ensure passage of the Senate bill, the issue, in voters' minds, has become less about health care than about the government and a political majority that will neither hear nor heed the will of the people."

"For Democrats to begin turning around their political fortunes there has to be a frank acknowledgement that the comprehensive health-care initiative is a failure, regardless of whether it passes. There are enough Republican and Democratic proposals -- such as purchasing insurance across state lines, malpractice reform, incrementally increasing coverage, initiatives to hold down costs, covering preexisting conditions and ensuring portability -- that can win bipartisan support. It is not a question of starting over but of taking the best of both parties and presenting that as representative of what we need to do to achieve meaningful reform."

Moore helps get more done

I was asked to give the keynote address today at a senior leadership retreat for Sutter Health's Sacramento Sierra Region. Sutter is a community based, not for profit health system.

The Gordon and Betty Moore Foundation has teamed up with Sutter to explore means and methods to transform this multi-centered health care system to the next level of quality, safety, and patient-centeredness. Sutter has already done a lot of good work in these arenas, so the hope is to build on that and explore how to do still better and enhance the likely sustainability of the results.

Pictured here are Michael Dourgarian, a local businessperson who is Chair of the Board of this region of Sutter, and Karyn DiGiorgio, RN, MSN, Program Officer for the Moore Foundation. Not shown is Dr. John Mesic, Chief Medical Officer, who introduced me and has had a lot to do with the broader Sutter effort, and Sarah Marie Miller, who helped organize the retreat.

My job was to tell the story of BIDMC's approach to quality and safety, transparency, process improvement, and patient and family involvement. As always, this prompted lots of good questions and interaction, as people considered what might be drawn from our experience and applied to their own, and as I did so in reverse from their comments.

New blog: Gastrically Changed

There is a new blog on the scene, entitled Gastrically Changed, by Kristen, a labor and delivery nurse who decided to have gastric bypass surgery. It is poignant and thoughtful and well written. (I like the play on words: It is hard not to read it as gastrically challenged!)

After I wrote her a note praising the blog, Kristen replied:

From the beginning of this entire process, I knew I was going to be very open about it. I think if you try to be secretive, people think you are ashamed or embarrassed about what you are doing...because THEY think YOU think you are doing something wrong. That makes everyone uncomfortable. I knew that I would lose a lot of weight...fast...and people would figure it out either way. So if people would know, even if I didn't tell them, why not be open about it and remove all the uncomfortableness? This surgery was going to change my life for the better and I wanted to share that excitement with people! I was aware that, by being this open, people would ask questions and be curious. So if being open about my experience can help educate them, maybe I can do my small part to make this more accepted all around.

Please take a look and enjoy and learn from this patient's perspective.

In memoriam: Ray Tye

I just got word that Ray Tye, one of the most generous people I have ever met, has died. He was generous in the way Maimonides would have liked: He gave without fanfare and with no wish for recognition.

Every now and then, he would hear of a patient, either local or international, who needed some sort of expensive medical treatment that was unaffordable for that person. Ray and his Medical Aid Foundation would provide funds for travel, treatment, and follow-up care -- from conjoined twins to an Iraqi woman with a heart condition.

In spite of his not wanting attention, people wanted to recognize Ray. Here, for example, Catholic Charities gave him their Justice and Compassion Award, the first time Catholic Charities presented that award to a member of the Jewish community.

At the personal level, Ray was warm and thoughtful and engaging. He would call me from time to time with an idea or to offer support, and he was always polite and modest, never wanting to interfere or be an inconvenience.

He was beloved in our community and will be missed in so many ways.

Mini Mobile Billboard

Adventures in the airports continue: Upon boarding my flight, I came upon a fellow passenger with this new type of mobile billboard. It is a changing electronic message worn on the body. The person was advertising Isagenix, a kind of food supplement called nutritional cleansing.

(I am not offering an endorsement nor otherwise commenting on the efficacy of this product, so please don't submit comments about that. This post is about the medium, not the message.)

For your convenience . . . almost

A couple of years ago, I wrote admiringly about ubiquitous cell phone charging stations in Iceland, where you could automatically pay a small charging fee and securely leave your phone behind to be charged while you did something else. So you can imagine my pleasure at seeing this complimentary charging station, sponsored by CNBC, at a Florida airport (after my check-in below).

But I guess you can't always expect to get something for nothing. Many of the connector cables were out of service, rendering the charging station useless -- and not a great reflection on the sponsor.

Positive ID

Working in a hospital, I have become very sensitized to the issue of proper identification of patients. Like other places, we require affirmative redundant identification by the patient before histories are taken, procedures are undertaken, and drugs are administered. For example: "What is your name?" "What is your birthday?" Not: "Are you Mary Smith, born on April 15, 1945?"

All this has made me more alert in other venues. This morning, I approached the American Airlines counter to check a piece of luggage. It is early on a quiet day, and there are no other people waiting in line. No pressure. I hand the agent my pre-printed boarding passes and my driver's license.

"That will be $20 for the luggage," she says.
"I thought I was exempt because I am an Aadvantage Gold member," I reply (while silently noting that the sign on the counter says $25, and not $20.)
"Well, I'll just waive it," she says.

She hands me a new boarding pass, with "Steven Levy" on it and my luggage receipt, which says "ORD" instead of "SFO."

"But I am going to San Francisco, not Chicago. And this boarding pass does not have my name on it."

"What is your name?" she says with a bit of annoyance, although she still has not returned my license. I tell her.

She reissues the boarding pass and luggage receipt.

I review both very carefully. And I wait until I see the luggage tag securely fastened to my suitcase.

Passion, accuracy, and politics

I admire the President and really hope a health care bill is passed by Congress, but I wonder if his overstatement of what the bill does might ultimately cause him to fail. Here's the latest, as reported in today's New York Times:

Boiling down his proposal to a few sentences, Mr. Obama asked, “How many people would like a proposal that holds insurance companies more accountable? How many people would like to give Americans the same insurance choices that members of Congress get? And how many would like a proposal that brings down costs for everyone? That’s our proposal.”

Is that really the proposal?

As for holding insurance companies more accountable, a number of state insurance commissioners have their doubts, at least with regard to federal regulation of premium rate levels.

Will we have the same insurance choices as members of Congress? Well, maybe to the extent that they can choose from a number of plans, but that is not the full set of benefits to which they are entitled.

And, as for bringing down costs, every person in the industry knows that is just not true. David Brooks explains why in his op-ed today.

From the beginning, I pointed out that Mr. Obama was over-promising when he was offering (1) a reduction in health care costs; (2) an increase in access for people currently uninsured or under-insured; and (3) maintaining choice for people in their selection of doctors and hospitals.

Opposition to Mr. Obama's plan is often characterized as a politically motivated attack from the Republicans. Certainly, some of that is true. But some portion of the opposition also arises from this kind of overstatement, which in turn generates mistrust or at least concern among educated members of the public.

Mr. Obama is betting, though, that his energy and passion will carry the day in motivating members of Congress in his own party to muster enough votes.

Crystal clear compassion

Kevin Cullen sensitively writes this column in today's Boston Globe about Crystal Sannella and her colleagues from BIDMC who recently went on a medical mission to Haiti.

I've had the privilege of getting to know some of these folks, and I am struck by their generosity of spirit. You can see this, too, in the post-mission emails among them and to those of us in hospital administration. Here are some excerpts from three:

Now that we are all back from Haiti, I just wanted to take a minute to say again what an honor it was to work beside all of you this last week. Despite conditions that really defy description, you each worked tirelessly to provide the absolute best quality of care possible given the circumstances of the situation, and I - and the patients and families we cared for - appreciate that. Surrounded by such devastation and tragedy, it would have been easy to despair; yet each of you managed in different and unique ways to create something positive in an otherwise bleak reality, always acting professionally and with compassion.

The experiences we have had will all make us better in our own roles and appreciate the resources we do have to provide great clinical care at BIDMC. I have no doubt that there are many more people alive this week who would not have been had we not been there. There were unfortunately a lot of deaths as well, but having reviewed every case, I can honestly say that nothing more could have been done in the clinical situations you were all in. You have touched the lives of many and they were grateful for it -- evidenced by the fact they did not want us to leave.

[This trip] was shocking, tragic, exciting, challenging, inspiring, and memorable -- sometimes discouraging, but ultimately immensely gratifying. We were all frustrated and saddened by the limits of what we could do, but despite those limits I think we were able to do some very good work. I'm also especially grateful that as a very junior member of the department I was given the opportunity to help. It was a profound experience for me, and I hope very much that I can make international work a significant part of my practice in the future.

Fast followers

With thanks to somebody at Krū Research, a global think tank focused on empowered patients, I repeat the following idea:

We talk much, encourage and glorify “leaders” in any space. But the real power is in “fast followers.” It’s a business strategy concept well known to entrepreneurs and venture capitalists, but not a familiar concept to others.

Here's a video that demonstrates the concept. If you cannot see the video, click here.

What happens next in MA?

What happens next in Massachusetts with insurance reimbursement rates now that many of the facts and figures have been made public?

Here's what I see. The dominant parties in the state on whose watch the disparities in the marketplace have taken place -- Blue Cross Blue Shield and Partners Healthcare System -- face financial and political problems, respectively. The PHS rates that are so much higher than others' cause a major financial drain for BCBS. They do so in the short run just by the degree of current utilization. The effect is compounded over the long run, though, as PHS has a competitive advantage vis-à-vis other systems in recruiting community-based doctors and thereby brings more and more referrals into its hospitals. That these differentials have now been made public by the state creates a political embarrassment for PHS, which has often asserted that its creation brought about substantial economies of scale through integration of care.

I suspect that these factors will lead to a negotiated agreement between BCBS and PHS, where PHS takes a bit of a haircut in its current reimbursement contracts. Not so much that it dramatically affects the PHS bottom line, but enough so that both parties can say that they have cooperatively acted to slow down the rate of health care spending in the state. Will the new rates be anywhere near the statewide average? No way. Will they do anything to offset the competitive advantage that PHS has had or will continue to have? No.

Then, BCBS will come to the rest of us (including BIDMC and our physician group) whose rates are next in line and ask for a "comparable" rate reduction. Citing the PHS deal, we will be publicly and privately pressured to make similar concessions for the good of the Commonwealth. Of course, any such rate reduction would then serve to maintain PHS' market dominance.

Here's my proposal instead. Let us, in the presence of the state's Attorney General, so there are no concerns about antitrust violations, all agree to rate schedules equal to the current statewide average reimbursement rates for hospitals and doctors.* Let's create two major categories -- one for academic medical centers and their doctors to reflect the societally important teaching role -- and one for community hospitals and community-based physicians.**

In other words, let us recognize that the health care reimbursement system in Massachusetts is broken. It is time to get rid of the idea that rates should reflect market power. Have them instead reflect the health status of the population, with appropriate adders for medical education or other specific programs of societal value as directed by the state. Further, if the state and federal government insist on underpaying for Medicaid and Medicare patients, let us acknowledge that amount explicitly in the approved rates for the private insurers.

I know I don't fully understand the insurance business, but I cannot figure out why BCBS and the other insurers in the state would object to this approach. I can't see why it is to their advantage to conduct numerous negotiations for reimbursement rates or to have different rates in place for exactly the same services.

What about quality, you might ask? Well, it would certainly be great to adjust reimbursement rates for meaningful measurements of quality of care. But let's start first by equalizing the base rates, and then we can work on quality metrics in the next step.

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*Or if would make more sense, perhaps a different average would be employed for the Eastern and Western parts of the state, or urban versus rural areas, to reflect regional differences in the cost of living.
** While I make this point with regard to fee-for-service payments, it is certainly a prerequisite for a move towards the kind of global, or capitated payment recommended by the state's Massachusetts Special Commission on the Health Care Payment System. As I have noted in an earlier post: If a capitated rate were established for PHS providers today based on this differential, it would perpetually reward this health care system for its market dominance.

Senator Kerry informs and learns

US Senator John Kerry joined a BIDMC event last night in Florida to provide an update to members of our community on recent events in Washington regarding the progress of a national health care bill. We were impressed with the extent of the Senator's knowledge on the subject and his commitment to thoughtful legislation, and we were grateful for the time he spent with us.

There was also time for John to meet several of our supporters and doctors. Here, he is briefed by Maine businessman Bobby Monks and BIDMC doctor Dr. Steven Freedman,who have been working together to develop a new patient empowerment and involvement model called "Trust".

Humorous note: Dr. Mark Zeidel, our chief of medicine, jokingly describes Trust as a template for patient-doctor interactions that would enable a husband to offer his wife a full, complete, and detailed summary of his visit with a doctor -- as opposed to the stereotypical summation:

She, "What happened and what did he say?"
He, "It was fine."

Railing against the tide

Several months ago, I wrote about the futility of banning social media in a hospital. I argued that it was counterproductive and a waste of resources. This point of view has been supported in other forums.

Now, I learn that the University of Iowa Hospitals and Clinics organization is banning Facebook and other such applications as "inappropriate for the health care workplace."

I shared this article with e-Patient Dave, who replied, "The instant killer question on this issue, from the people I talk to, is 'So, what do they do about people doing it on their phones?'"

Indeed.

May I have the envelope, please?

In a post below, I listed several of the questions posed by the MA Division of Health Care Finance & Policy in preparation for the first of annual public hearings concerning health care provider and insurer costs trends. There were also others posed by the Attorney General. The answers to these questions have now been submitted by various parties. The answers are publicly available. You can open the envelope and see them here.

I haven't had time to review all the submissions yet, but the point I made a couple of weeks ago about federal and state underpayment for Medicare and Medicaid services, and the resulting impact this has on commercial insurance rates, is well documented in several of these filings. If I have a chance in the next few days, I'll pull out pertinent excerpts on this and other topics so you don't have to dig through dozens of pages.

Magnets help pancreatitis pain

Please watch this fascinating story on YouTube about a patient with chronic pancreatitis, who found relief in a procedure developed by BIDMC doctors Steven Freedman and Alvaro Pascual-Leone. I wrote about this earlier here, but watching this patient talk about it provides another dimension to the story.

If you can't see the video, click here.

Me, here and there

I really enjoy sharing what we have learned about enhancing quality and safety, transparency, and process improvement with health care providers and insurers around the country. But sometimes you just can't arrange to be there in person.

Today, I was invited to talk with board members and senior staff at HealthSpring, a large Medicare Advantage organization serving several states in the South and Midwest. I couldn't get there, so I joined by phone. Here's a picture of "me" presenting to the group.

Pioneer speaks about MA health reform

The Pioneer Institute is a public policy research center in Massachusetts. On the political spectrum, most people would call it conservative, or a least free-market oriented. In my opinion, regardless of your particular position along that spectrum, the institute's work is worth reading.

Last month, it issued a paper about the Massachusetts health care reform experiment that serves as a report card on a number of factors, with particular focus on the question of the equity and sustainability of the financing of the health care insurance access system put in place by Chapter 58 of the Acts of 2006.

For those interested in the possible applicability of the Massachusetts model to the national scene, authors Amy M. Lischko and Kristin Manzolillo say:

It is undeniably premature to enact a reasoned national-level solution based on Massachusetts’ or other state experiments. . . .

[We give Massachusetts'] health care reform financing an overall grade of “C” based on the following findings:

Metric 1: Is the funding for healthcare distributed equitably across various funding sources? The data indicate good performance in this area in the early phases of reform; however, without more recent data available, there is only a moderate level of certainty that this has been sustained. Grade: B.

Metric 2: How have per capita health care expenditures changed for the newly insured and the health safety net? Reform’s sustainability relies upon a continuing decrease in the use of the Health Safety Net Trust Fund (HSNTF) as more individuals gain access to insurance. With funding going towards both the HSNTF and Commonwealth Care, along with increased per capita spending on the newly insured, it remains unclear if this model is sustainable. Grade: C

Metric 3: Has the reform altered relative health care cost trends?There is no evidence to suggest that the reform has changed the general health care cost growth trend that was estimated based on 2004 data; however, it is inappropriate to rely on older data for evaluation of this metric. Grade: Incomplete.

Metric 4: Are premiums going up and if so for whom? The reform has to date succeeded at reducing the rate of increase for people purchasing in the nongroup market, but costs in Massachusetts still exceed national averages. Furthermore, the recent cost increases experienced by small groups need to be understood and quickly addressed if the reform is to be sustainable. Grade: C

Metric 5: Are residents able to afford coverage, or do they seek exemptions to the individual mandate? Based on the available data, the initial number of individuals deemed unable to afford coverage is minimal. However, with rising health care costs, the sustainability of this area of reform is questionable. Grade: B

Metric 6: How do Massachusetts’ medical bankruptcy rates compare to those in other states? While Massachusetts residents reported a decrease in the difficulty of paying medical bills since 2006, one in five adults indicated that they were paying off medical bills over time in 2008. When looking at adults earning more than 300% of the federal poverty level, over one in four are still carrying medical debt. Grade: C

AHCJ to JC: Please be less obscure

The Association of Health Care Journalists offers advice to the Joint Commission about transparency and clarity.

These are the good old days

Interesting point of view from our CIO, John Halamka, in this Business Week article.

Quietly in service

Mark Krivopal, Medical Director of one of our hospitalist groups, sent me this note:

Dr. Kwan Kew Lai is one of our hospitalists and has been with us for a few years. Besides being an excellent physician with a previous training in infectious disease, she is also an avid marathon runner and, more importantly, constantly does philanthropic work. She's been all over Africa helping people with AIDS. She's been to New Orleans after Katrina. Now she is back from Haiti.

In your blog you talk about some other members of the BIDMC and Boston medical community providing relief in Haiti. I wanted you to be aware of Kwan Kew as well. She does these things without the fanfare or really even telling anyone. I feel incredibly privileged to know and work with her.

Here's her blog.

Argentina candy invasion

As my loyal readers know, I am an infrastructure junkie. But I also take some pleasure in noting the country of origin of products I see in grocery stores, but especially in public places like restaurants and hotels. For example, how does New Zealand butter make it to the tables of fancy restaurants in London, when the UK has a powerful dairy sector?

Several months ago, I expressed wonder at the fact that a hotel in Boston could find it commercially reasonable to import bottles of water from the other side of the globe to serve to people attending conferences. As a trained economist, I marveled at this application of the theory of comparative advantage.

Yesterday, another example emerged at another hotel. Sitting in front of me on a conference table were these sucking candies. Look closely and you will see that they are from Córdoba, Argentina, a distance of over 5000 miles. How can this be financially sensible with a surfeit of hard candy manufacturers in the United States?

Now, I know that the peso has been falling in value relative to the dollar, making exports to the US more attractive. But this is a broader story than commerce with the US. From this article, we see that this company exports its candy to 110 countries. From humble origins -- an Italian immigrant in 1924 engaging his children in making caramel at the family bakery -- the company has become a world presence.

The capitalist system has its inequities and demands regulation in many respects, but the "invisible hand" of Adam Smith is truly a wonder to behold. These kind of examples explain why it is impossible for economies with centralized control to replicate the scope, scale, and diversity of the product and service offerings that emerge from free economic systems.

A doctor's visit

This note came from a doctor newly arrived in Boston. As you know, MDs can be the harshest critics of care, so it was heartening to receive this.

This letter is to convey my deep appreciation for the outstanding care I received at BIDMC several days ago when I was emergently taken to the Emergency Department for acute abdominal pain, then to the Intensive Care Unit. In a quick series of roller-coaster like events, I developed a bacteremic shock and a liver dysfunction which were very promptly managed, and I was discharged feeling much better in less than a week.

Several remarkable individuals- doctors, nurses and other health care staff were involved in my care. I have never been in a hospital for anything other than minor things; this was my first time at the receiving end of serious care, a valuable lesson that made me reflect what it is that they do that makes a difference between a frightening experience and one that I can look back and learn from, as a physician myself.

First, they explained and reassured. I think the doctors and nurses deserve a lot of credit for keeping me and my family informed regularly of what was going on, in a transparent and objective, yet reassuring manner. This allowed me to be a participant witness of the rapidly unfolding events without panicking. For a frightened patient, uncertainty about the illness is often worse than the illness itself. Reassuring words from a confident physician can make a huge difference, and instill that essential ingredient of recovery, namely hope.

Second, they were empathic and respectful. All those involved in my care evinced the four key elements of empathy (engage, educate, empathize and empower); examples were the nurse who empowered me to titrate my own oxygen use based on my looking at the O2 saturations (but of course without letting down her own guard), and my physicians who listened to my own interpretations of the illness before stating his or her own, backed by good evidence, of course. And the use of good humor made this patient feel special (as one nurse put it, “I was the best patient in ICU because I talked, sat up and provided ample urine output!”)

Third, they provided effective and efficient care which was proactive, and not reactive. My journey from walking into the ED to receiving expert assessments was within minutes. Not a single procedure was delayed, and not a single intervention left out in efforts to make the illness more comfortable to bear. I would especially commend the nurses who, as the key coordinators of care (the “quarterbacks” of the care team as one of my colleagues puts it) were always on top of what was happening and communicated effectively with me and the family all the way through.

We don't spend more

Many in the United States bemoan the fact that we spend such a large share of our GDP on health care. We argue that we could do it better and for less, and we point to other industrialized countries as proof. But we overlook the fact that those countries spend more on improving the social determinants of public health. It appears that the combined total of these two categories may be relatively constant across countries.

The Blue Ridge Academic Health Group has published a report entitled, The Role of Academic Health Centers in Addressing the Social Determinants of Health. (Go to this site and look for Report 14.) It contains a startling set of statistics.

Country -- % of GDP on Social Programs/% of GDP on Sick Care/Total % GDP
United States -- 2.3%/16%/18.3%
Canada -- 5.8%/10%/15.8%
Netherlands -- 9.6%/9%/19.6%
Sweden -- 11.6%/9%/20.6%

The report summarizes the situation as follow:

Our current health care system is costly and ineffective to an increasing degree each year because it has too limited a focus – sick care delivery – and pays inadequate attention to health promotion. Moreover, the health promotion programs that are in place rarely focus on social determinants of health such as jobs, housing, education, etc. Instead, the focus largely remains on the health problems and concerns of individuals, rather than on the problems endemic to a population.... That’s why the Blue Ridge Group believes that the U.S. health care delivery system, as currently constructed and funded, is the not the optimal foundation – even with more direct financial investment and dramatic changes in incentives and regulations – to improve the health status of Americans and thereby achieve greater societal happiness and progress. Similarly, we are concerned that current health reform activities are focused too narrowly on insurance reform without setting in play genuine reforms that also reflect the factors relating to social determinants of health.

Thanks to my friend and colleague Dr. Fred Sanfilippo, Executive Vice President for Health Affairs at Emory University, and Chairman of Emory Healthcare, for leading me to this report.

Moore's code

Although Massachusetts is a relatively small state, it has the sixth largest (by acreage) state park system in the country. One example is Moore State Park in Paxton. Here are two details from a winter walk.

It is up to us, not the US

A conversation with a reporter yesterday helped me clarify my thoughts about federal health care legislation. In my view, the most effective role of the federal government would be to provide national standards by which the health insurance companies operate (e.g., with regard to pre-existing conditions, rescission, and lifetime limits), require the existence of insurance exchanges, and establish the conditions under which universal access to insurance is made possible. Other items I would suggest for federal legislation are summarized below.

I am hoping the US government will not attempt to control the costs of health care by making legislative decisions with regard to clinical matters. Not because we should abandon cost control; but because federal efforts in this sphere are likely to be crude and not clinically appropriate. You just have to look at the process by which the USDA food pyramid is influenced by food product lobbyists to imagine how the government would attempt to regulate the design and provision of care among medical specialties, equipment and supply manufacturers, and pharmaceutical companies.

As should be evident to readers of this blog, I think it is possible for the participants in the health care system to accomplish major changes in the rate of medical cost inflation. Two articles have this theme. One is by Business Week's Catherine Arnst. The other is by Lucien Leape, Don Berwick, and others in Quality and Safety in Health Care. Both are worth reading, and they overlap in recommending several areas -- reducing infections and other preventable harm; empowering patients and families to participate in their care; and disclosing and apologizing for mistakes.

Beyond these articles, there is a remarkable consensus on these items, and yet hospitals and doctors often fail to implement them. Even hospitals that house some of the most accomplished authors in these fields often do not follow the advice of those colleagues when it comes to making improvements in the delivery of patient care.

It is not unusual for industries facing structural change to be slow to move. Why? Because the leaders of those industries were promoted based on their success in the past financial, political, and social environment. They were hired for their ability to maintain the status quo, rather than for their ability to make change. Eventually, though, societal forces make themselves felt. If an industry does not adapt, the government will step in. The medical profession has to decide whether it wants to take charge of this process or abdicate to Congress the right to act in its stead.

More on Atrius and BIDMC

Several weeks ago, I wrote about a new clinical partnership between Atrius Health and BIDMC. Today's Boston Globe has a story by Liz Kowalcyzk that provides more context for this relationship.

The article mentions the integration of our electronic medical records. John Halamka describes this in more detail on his blog:

By working with Epic and Atrius, we enabled a "Magic Button" inside Epic that automatically matches the patient and logs into BIDMC web-based viewers, so that all Atrius clinicians have one click access to the BIDMC records of Atrius patients.

No additional password required. Nothing. The entire BIDMC medical record appears. Now, computers are just tools, but it helps to have this kind of interoperability when your goal is greater coordination of care.

The infrastructure chronicles -- Volume 3

Back to our occasional series on infrastructure. For this post, I will be digging back into the telecommunications portion of my career, to a period when tin cans and string dominated the industry.* Well, maybe not quite so far back, as that, but far enough that I came up empty when I did Google searches on some of the terms below. But let's get to the point.

Have you wondered how companies can offer you free teleconferencing service? Most of us are used to paying for this service, but there are a bunch of firms that offer it for no fee, and will even create customized numbers for you and offer other add-ons. How do they do it and make any money?

The answer goes back to the monopoly days of the Bell System, when AT&T and its subsidiaries dominated. But even then, there were a number of small local telephone companies, often serving rural areas. The policy at the time was to share the revenues of the Bell System with those companies to help subsidize local telephone service in otherwise isolated communities. The mechanism for doing this was called the Separations and Settlement Process.

Once a year (think "sweeps week" on television), the traffic coming into and out of these small companies was measured and provided the basis for the number of dollars that company would receive as a gift from the overall revenues of the Bell System. It worked for everybody. Ma Bell didn't care, as it was awash in revenue anyway; and it didn't want to incur the high per subscriber costs inherent in serving rural areas. The local telco's likewise welcomed the income, which enabled them to keep down the cost of basic telephone service while providing hefty profits for the owners of those companies.

The system was often manipulated. The subscribers in Smalltown were told by the local telco when the measurement period was occurring. They were urged to make as many calls as possible during that week, knowing that doing so would pay dividends for the rest of the year.

Fast forward now to the end of the AT&T monopoly, the introduction of long distance competitors like MCI and Sprint, cellular service, cable TV, and other technological advances. Consider the Telecommunications Act of 1996, which served to open up the very switches owned by the big regional telephone companies (like Verizon) and the little ones, too, to anybody who wanted access to those computer racks.

Through this all, Congress preserved the policy goal of subsidizing local exchange service, especially for rural areas. Over time, new versions of the Settlements process emerged. It still pays for those local telco's (now called local exchange companies, or LECs) to have traffic, in that they are paid extra money from the national pool of telecommunications revenues based on minutes of use emerging from and ending in their central offices.

Now, you are starting to get the idea. A teleconference company mounts its switch on the rack of a carefully chosen LEC, maybe somewhere in the middle of Iowa. The teleconference company's very existence provides extra traffic for that LEC, generating extra Settlements revenue, part of which is shared with the teleconference company. The company does not need to charge you a fee for a teleconference, because the entire United States is already paying for it.

What is the difference between the service and technology behind the free teleconferencing service and the one you pay for? Nada.

Why would you ever want to pay for this service? Beats me. You and everyone else already are, in your regular local and long distance telephone rates.

How long will this deal last? When was the last time Congress took away a subsidy?

Now you can understand why I love health care. Having been weaned off the world of telecommunications subsidies, I craved a field in which the subsidies are even more rampant and impossible to untangle.

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* I worked as a telecommunications regulatory consultant for a while, and I was also Chairman of the MA Department of Public Utilities, which regulates common carriers in the state.

A back-handed way to make policy

One of the arcane steps in government regulation of health care is the Physician Payment Rule. This is the manner in which CMS, the Medicare agency, annually allocates payment dollars among the various specialty services. The PPR effectively makes policy.

The construct for all of this is a zero-sum game. When CMS wants to raise fees for some specialties (e.g., primary care doctors), it is required to reduce the fees for others.

The American College of Cardiology notes that the most recent version of the PPR contains such a drastic reduction in payment rates for office-based cardiology diagnostic tests that many community cardiologists are considering joining a cardiology service in a hospital.* So what's wrong with that? Well, once those MDs start providing the same services in a hospital, it means fewer services will be available close to people's homes in the community. Further, the rate the hospitals can charge for exactly those same diagnostic tests is higher than the private doctors could charge.

So the overall cost to society of health care actually goes up, notwithstanding what is supposed to be a zero-sum impact. Patients are inconvenienced, too.

As you know, I have advocated for an increase in payments to PCPs, so they can spend more time with patients and get out of their triage role. But it is short-sighted to require that, in the short-run, the sum of physician payments from Medicare not change. Perhaps the President and Congress can add this item to their health care summit discussions.

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*ACC also charges that the CMS data and methodology are flawed. I don't comment on that.

Dr. Cocchi goes to Haiti

This is a story about and by Michael N. Cocchi, MD, a fellow in Critical Care Medicine in our Department of Emergency Medicine. He joined a group of doctors and nurses recently in a medical relief mission to Haiti. It was his first time on such a mission. When I heard some of his stories, I asked if he would be willing to share them with us.

The photo of his patient Yvonne and the circumstances surrounding it are described in the video.

If you can't see the video, click here.