President Obama was right last week to pivot to two things in the wake of the Supreme Court’s Affordable Care Act (ACA) decision: (a) a plea to Republicans (yet again) to please, pretty please drop their opposition to the law and join him in tweaking it and fixing what remains broken in healthcare, and (b) Medicaid expansion.  

It’s probably too much to hope Republicans will drop their fierce attempts to trash, dismember or repeal the law—as the political season leading to the Nov. 2016 elections gets underway in earnest.  But Medicaid expansion could prove a fruitful path to concrete results.    

As a reminder, the 2012 Supreme Court decision on the ACA nullified the law’s provision compelling states to expand Medicaid.  Instead, it made such expansion voluntary. 


GundermanAs kids growing up in the Midwestern United States, my friends and I loved baseball.  We spent many hours each summer day playing the game, and when we weren’t out on the sandlot, we were reciting the stats of top players, arguing the merits of our favorite teams, and trading baseball cards.  Baseball is more than America’s pastime.  It is a sport on which millions of Americans have cut their athletic teeth, laying a lifelong foundation of physical fitness and instilling important lessons about competition and character.

Imagine my distress, then, in beholding the state of major league baseball in 2015.  Stalwart players such as Carlos Gonzalez of the Rockies and Robinson Cano of the Mariners have been posting career-worst numbers, and even a venerable team such as the Boston Red Sox, which boasts the fourth-highest payroll in all of baseball, is stuck in last place in its division.  And this problem of poor performance is not a fleeting phenomenon.  Consider the Chicago Cubs, who have the worst home field record of any team over the last 50 years, and haven’t won a World Series since 1908.

Clearly, the best interests of our youth, the American public, and baseball fans everywhere are not being well served by our current largely unregulated approach to baseball quality.  Poorly performing players are appearing in game after game, and losing teams keep showing up on opening day season after season.  This isn’t just a matter of pride.  The economic implications of Major League Baseball are huge – the Los Angeles Dodgers have a payroll of nearly $300 million, and the New York Yankees franchise has an estimated worth of over $3 billion.  Something has to change.


Screen Shot 2015-07-05 at 9.34.36 AMIf flying an airplane without cockpit instruments is equivalent to having no data about healthcare delivery, then flying an airplane with an overwhelmingly complex cockpit data environment is probably just as dangerous.

In this compelling webinar (Online, Tues July 7th, 2-3 PM) you’ll learn strategies that will let you visually present data in the most powerful, attention-getting ways possible – giving you the tools to reach patients, clients and colleagues.

Learn the common mistakes that can confuse users, detract from your presentation and ultimately put quality care and patients at risk.


This weekend is not only independence day in the US, it’s the culmination of a patient-led uprising to demand that providers hand over their medical data. To that end I & THCB are supporting Health Data Independence Day. Sign the petition at and please use and encourage others to use the free tool from the associated Vocatus Project to request your data from your doctors and hospitals. I’ll be taking up the cudgels in the continuing story of my son’s “Search for Intr-Aero-Bili-Ty” but for now we’re thrilled to publish this amazing piece from Health IT expert and very recent cardiac patient, Brian Ahier–Matthew Holt
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Data Liberación is our battle cry…

Six years ago I wrote a blog on Independence Day. In 1776 the 56 citizens of the 13 British colonies signed their names to a document declaring that the King was abusing the colonies and violating the basic principles of human decency bestowed by God. So they declared independence from Great Britain and birthed the United States of America.

Abraham Lincoln said in a speech during his Senate race against Stephen A. Douglas of the Declaration of Independence, “This was their majestic interpretation of the economy of the Universe. This was their lofty, and wise, and noble understanding of the justice of the Creator to His creatures.”

We are blessed to live in the greatest country in the world. We have had many struggles and challenges and have had to to overcome the sins of the past, but the Founders wisely put in place a constitutional framework that allows for transformation changes to occur, generally without bloodshed. The Republic is alive and well and actually improves every generation. I wish all of you a peaceful, safe, and joyous Fourth of July celebrating with family, friends, and neighbors. I also hope that you will participate in the first Data Independence Day.


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In a 6:3 decision, SCOTUS rescued Obamacare once again. Obamacare, untouched by Donald Trump and the Anti-Death Panelists, was almost brought to its knees by a single word; a lowly, miserable, reclusive preposition – “by”.

A brief summary.

Obamacare helps low income families buy health insurance through subsidies doled out by the Internal Revenue Service (IRS). Health insurance is sold at online marketplaces called exchanges. The online exchanges have been created by the state or the federal government. The statutes say that subsidies are available for insurance bought “through an exchange established by the state.”

The plaintiffs in King v. Burwell alleged that the IRS was illegally subsidizing people in over thirty states where the federal government, not the state, established the online exchanges.

The administration claimed that the subsidies applied in all states. That the language was admittedly sloppy and “by the state” also meant “by the federal government.” The country is now so polarized that even prepositions must take sides.


Bob WachterWhat’s up with the ABIM?” “I just got a note about an alternative board. Should I join it?” “Aren’t you glad to be off the Board?”

These days, I get these questions from friends and colleagues regularly. When I first joined the board of directors of the American Board of Internal Medicine (ABIM) in 2004, the organization was a well-respected pillar of American medicine. Today the organization finds itself in a fight for its life, being painted as everything from out of touch to money-hungry to, more recently, corrupt.

I just completed my decade-long service to the ABIM and, more recently, the ABIM Foundation. I’ve waited until now to write this because I wanted to be clear that I am not speaking for ABIM or its leadership. I am also well aware that there is a vocal group of critics who feel passionately about this matter, whose minds are made up, and who are approaching this fight with a take-no-prisoners zeal. By adding my voice, I am likely to become a target for their anger.

So be it. With the help of social media and a journalist who has turned this matter into a cause célèbre with an unfortunate mixture of half-truths and innuendo, the critics have managed to control the debate, and people who believe in the values of the Board have been cowed into silence. It feels vaguely McCarthyish, and there comes a time when silence is immoral. This feels like such a time.


Screen Shot 2015-06-26 at 8.33.49 AMThe Supreme Court yesterday decided that Congress meant what it said when it enacted the Affordable Care Act (ACA). The ACA requires people in all 50 states to carry health insurance and provided tax credits to help them afford it. To have offered such credits only in the dozen states that set up their own exchanges would have been cruel and unsustainable because premiums for many people would have been unaffordable.

But the law said that such credits could be paid in exchanges ‘established by a state,’ which led some to claim that the credits could not be paid to people enrolled by the federally operated exchange. In his opinion, Chief Justice Roberts euphemistically calls that wording ‘inartful.’ Six Supreme Court justices decided that, read in its entirety, the law provides tax credits in every state, whether the state manages the exchange itself or lets the federal government do it for them.

That decision is unsurprising. More surprising is that the Court agreed to hear the case. When it did so, cases on the same issue were making their ways through four federal circuits. In only one of the four circuits was there a standing decision, and it found that tax credits were available everywhere.


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Historically, placebos have been defined as a sugar pill or inert substance used as a control variable in experimental studies. Placebo effects were considered a nuisance. Researchers and clinicians have paid little attention to the fact that placebos seem to produce their own health impacts.

But in a July 2 New England Journal of Medicine Perspectives piece , Ted Kaptchuk of Harvard Medical School and Franklin G. Miller from the Department of Bioethics at the National Institutes of Health, show us that there’s more to placebos than we originally thought.

For example, in a study of patients with irritable bowel syndrome, patients experienced adequate symptom relief when given a placebo, compared to those who didn’t receive a placebo. That’s a common enough finding. But what’s most interesting is that relief was even greater when the placebo was coupled with more engaged positive interactions with a provider, such as attentive listening and thoughtful conversation. In another study, when given morphine directly by a doctor or nurse through a syringe, patients experienced more pain relief than when it was administered through an IV. Seeing it administered increased the effectiveness of the medication.

This evidence leads the authors to argue that placebo effects are not the products of dummy treatments but actually the effects of immersion in a health care environment with all its cues and signals.


NayerAs an innovator, restless entrepreneur, and national award winner for consumer engagement, I was intrigued with the stories I was reading about accessing the patient portal for data, basically the looking glass into “my data.” For those who are not familiar with health data, here’s a quick history.

As part of the Great Transformation in health care, HHS, CMS, and ONC (which is the Office of the National Coordinator for Health Information Technology), and others regularly update rules on health data, privacy, HIPAA and meaningful use. Meaningful use—otherwise known as MU—is a term that describes how the stakeholders, starting with the patient, provider (doc, hospital, etc.) and plan can and should be using the data, because it provides historical and patient-centric context. Meaningful use as a measure of quality improvement was launched to describe the kinds of health IT [HIT] improvements that would be developed over the course of several years.


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R had been my patient for over a year. She was referred to me by a colleague. She had 38 symptoms. All tests and imaging studies failed to find any demonstrable medical disease; I considered her to have “symptoms of unknown origin”.

I had little information on R’s personal and family history. I did know she was 43 years old and was 7 years into her second marriage. Her first marriage ended in divorce from a severe alcoholic husband. She had no children. She dwelled on her many symptoms and avoided all my attempts to gather more personal or social information.

Before I can share my full experience with R, I need to provide some back ground on my clinical thinking.