Rearranging Chairs

Rob Lamberts seriousI have been asked by patients, readers, family members, and by fellow bloggers what I think about the bill  passed by the House of Regurgitants Representatives yesterday. I resent this. I have tried hard to remain neutral as possible, finding equal cause to point and sneer at both conservatives and liberals. It’s much more fun to watch the kids fight than it is to figure out which one is to blame.

But given the enormous pressure put on me by these people, as well as threatening phone calls from Oprah and Dr. Oz, I will give my “radical moderate” view of the HC bill. My perspective is, of course, that of a primary care physician who will deal with the aftermath of this in a way very few talking heads on TV can understand. The business of HC is my business, literally. So, reluctantly, I take leave of the critic’s chair and take on the position where I will be a target for any rotten fruit thrown.

1. It’s not Armageddon.

We are all still alive and breathing, and will continue to do so after this law is passed and signed. The bill does not change things as radically as the shrill voices on the right suggest. It does not constitute a government takeover of HC, nor does it seem to extend any government programs by a whole lot. It is really not about HC at all, but instead about health insurance.

The goal of getting more people insured is a good one. Our system clearly (from my perspective) makes my services unaffordable – especially if you consider what people pay for procedures and medications I order. The lack of affordable insurance does harm people; I see it every day. The system is broken and needs fixing. Anyone who says otherwise needs to get a urine drug screen ASAP and then seek professional help.

Beware of the fear-mongers who make this out to be the “pro-death panel” legislation. It’s really not that bad.

2. It’s not Nirvana.

It’s actually more like the Foo Fighters…no wait, that’s another blog post.

There are folks on the Left who think that we are entering a golden age because of this. Some suggest this is the “Waterloo for the Republicans.” No, this bill is simply a rearrangement of how money is being spent, not a fount of blessings to those in need. Some people will benefit from this – especially those with no insurance – but most people won’t see a whole bunch of change from it.

This bill addresses the problem of the uninsured, but does not deal with the much more important issue of cost. If anything, it may worsen the problem that is actually at the core of the troubles: out of control spending. Figuring out how things are going to be paid without controlling what is being paid for is like rearranging chairs on the Titanic. The reason people cannot afford insurance is not because there are enough insurance options, it is because of the incredible amount of waste in the system. Agreeing to cover more with insurance without controlling cost will make the situation worse, not better.

3. The process was a national embarrassment.

The debate in DC did not seem to be about people getting the care they need; it seemed to be about which side would win. The lack of bipartisanship is a condemnation of both sides, an indication that power is more important to our representatives than is representation. Why didn’t the Democrats agree to tort reform (which nearly everyone supports)? Why couldn’t the Republicans concede that having people with no insurance is a problem the government should address?

We have a terrible situation in our country: a HC system that is out of control in its cost and that will bankrupt us if nothing is done. Yet what this difficulty has won us is not a national resolve to fix this problem, it is an increase in the partisan screaming and a worsened environment to effect real and beneficial change.

To me, the debate turned debacle is a very good argument for term-limits for members of congress.

4. It missed the point.

The real problem in healthcare, again, is not who is paying. The real problem is that it costs far too much. We are not in a crisis because of insurance; we are in a crisis because of what is being paid for by insurance. For legislation to have a real chance for fixing this problem, it must find a way to control spending.

The problem of health insurance is far easier than that of cost. Here’s why I think cost-control is going to be an even harder thing to tackle:

There are industries making billions of dollars off of the inefficiency and waste in HC (see my post about the Sea Creatures). Devices that don’t really help people, and specialty procedures that are unproven are paid for while primary care gets the shaft. People like shiny technology and legislators have a hard time saying “no” to it – especially with the lobbyist dollars that will protect this waste-eating industry. It’s boring to promote primary care and doesn’t play well to the constituents.

We don’t have the IT to do it. Any attempt at cost control will fail without good health IT. Doctors control a huge percentage of HC costs, yet most are operating blindly. We rely on the word of the patient for what happens in other HC settings. If you are going to expect physicians to make prudent medical decisions and eliminate waste, you must give them adequate information. Unfortunately, the current push for EMR is not about delivering information to physicians, but instead about letting doctors document more efficiently. Use IT to inform, not conform. Use IT to enable docs instead of burdening them more.

“Rationing.” Any control of cost will be about denying care. I believe that denying care that harms patients is a good thing to do, as is suggesting cheaper alternatives if they are equal in benefit. Patients are angry when they can’t get Nexium covered by the insurance company, but OTC Prilosec is just as good for them. Patients are angry when they can’t get an MRI for their back pain when it is really not appropriate for 98% of back pain sufferers. People don’t want to be denied. Americans want an all-you-can-eat buffet of medical care. Unfortunately, any change for the positive will inevitably involve some sacrifice.

So, what do I think about the legislation? I honestly don’t think it’s that big of a deal. I think it’s good that something is being done about those without insurance, but I worry that nobody is checking the balance on the credit card. I like the arrangement of chairs on the deck, but perhaps the hole in the boat merits a little consideration.

ROB LAMBERTS is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. His writings have been described by observers as – among other things – “strange, yet not harmful” – a description we think fits him pretty well.

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59 replies »

  1. “As free Americans most of us on the right would admire this stand Peter, I ask then why you can’t follow the logical extension to governemnt.”
    Nate, I would love to be able to direct my taxes to the departments/programs I think are doing a good job. That would include the option of not contributing to the military, but even you think that freedom on contributions be limited to so called mutually and collectively beneficial departments. By the way I have no choice how revenue on my corporate purchases is spent for political purposes as industries form their own unions (associations) to lobby collectively, even shareholders have little choice. But I view healthcare as a necessary government program as you view defense. You should also realize that many government programs do not work as well as they could because corporations want it that way and extend their influence ($) to make it so.

  2. As an example in the past few years there have been times I went without cable tv, a cell phone, or flown because I felt the product I was getting wasn’t worth what I was paying or the way I was being treated. I want this constituional freedom for my entire life. With the exception of national defence and a couple other very limited needs they have no right to my money or to tell me how to live my life.

  3. Rob can I make an appointment? I don’t rememeber the last time I waited less then an hour for a medical appointment except at miniute clinic.
    There are obviously some Drs that do better but by far the average Dr runs a terribly inefficient office. Scheduling more time between appointments then working on paper work or other task if things go as plan would be better then cram then all in the waiting room and work through them as you can.
    “I oppose being forced to buy insurance from a company that pays it’s executives millions in compensation while adding nothing of value.”
    As free Americans most of us on the right would admire this stand Peter, I ask then why you can’t follow the logical extension to governemnt. I oppose being forced to pay taxes to politicians with 2000 staff members making over $100,000, waste trillions, and add nothing of value. Your ok being ripped off 10 times worse as long as it comes from the government, those of us on the right dont want to be ripped off by anyone, corporate or government.

  4. “Not paying them a bonus for EMR will be shooting ourselves in the foot (much worse, actually).”
    Although I find Dr. Lamberts’ observations excellent by and large, I disagree with this assertion.
    There are sufficient and sufficiently good commercial and FOSS EMR/PM products on the market – despite too high prices for most commercial product, as I always note – implementation can be done efficaciously and fairly inexpensively and – as was Dr. Lamberts’ experience – the financial return can be quite high, so no financial incentive should be given to any physician.
    In addition a mandate should be issued that requires implementation of a working system within say a five year time horizon. The “working system” feature is a legal requirement on any vendor or implementer which sells or installs the system for the physician. Any vendor unable to sell and implement a working system would be liable for repayment of any funds disbursed by the customer and a reasonable approximation of the cost of disruption to the physician practice from the failed venture.
    With that mandate physicians would be happy to oblige. Vendors and implementers might be unhappy, but for every vendor unwilling to sign on, there are 10 more waiting to take the vendor’s place.

  5. ” Peter, that just isn’t logical.”
    Illogical or not, price/budget controls in other industrialized nations do it for about half the cost – with mandates.
    “It means I dont’ want the day to come when my children or grandchildren are ordered by their government to buy 4 gallons of Bordon milk every week.”
    No, they’ll be told to buy milk, who’s (if they choose to drink it) they buy will be up to them, how much they buy will be up to the milk budget, at least with single-pay.
    Lisa, I don’t have insurance, I dropped it because I got tired of playing the corrupt health insurance game. I now self insure, to a point. I don’t support mandating coverage, I do support mandating support of healthcare. I also object to being forced to buy coverage through an over priced dysfunctional system that rewards overuse, abuse, greed and waste. I oppose being forced to buy insurance from a company that pays it’s executives millions in compensation while adding nothing of value. I will probably pay the fine. However, if you wanted to wait until costs were brought down so that coverage was “affordable” we’d never get to that point. Now that costs are in your face, people will push more to bring them down.

  6. “Should I value being on time more than I value spending the extra time needed?”
    Nobody said you had to choose one or the other.
    Peter-“Sure, why don’t we get to bid on how much we’ll pay for a doc appointment.”
    Nobody suggested putting Dr. appts on Ebay. By the way if healthcare really was an industry in a capitalist country, then the market WOULD set the prices and we wouldn’t be where we are today. The customer (market) doesn’t set the prices, really they don’t even know what they are.
    If you really think having a private citizen being ordered by Uncle Sam to pay premiums to an insurance company to pay for all services, for all people, from immunizations to IVF, from cradle-to-grave, is going to LOWER the cost of care for everybody, Peter, that just isn’t logical.
    I think a majority of citizens agree on the need for HC reform, but I think everybody has a different definition of just what reform is. I intensly dislike the very idea of my government ORDERING me to purchase insurance from a for-profit industry, to pay for your vasectomy, Peter. It makes me really angry. That doesn’t mean I “don’t care about poor people” as Maggie would label me, and it doesn’t mean I’m scared of or hate reform. It means I dont’ want the day to come when my children or grandchildren are ordered by their government to buy 4 gallons of Bordon milk every week.

  7. “and therefore are not decreasing costs.”
    Margalit, but Trinity says they are decreasing costs? There is always an upfront cost to implementation that is factored into the future expectation of lower costs.

  8. “Why don’t patients with higher paying insurance get preferential teeatment? Treating your best customers better is business 101.”
    Sure, why don’t we get to bid on how much we’ll pay for a doc appointment. Appointments then would be handled in order (and time) from highest bidder to lowest bidder. Careful Nate, you might just be one of the lower bidders.

  9. I just spent 20 extra minutes counseling a woman who was depressed and potentially suicidal. Should I value being on time more than I value spending the extra time needed? Office visits are unpredictable. I make it a point to get people out within an hour of their scheduled appointment, and generally run 20-30 min late if I get behind. I work-in visits during the day so people can be seen, and our office is open 7:30 AM-7 PM M-F and 9-12 on Sat.
    PCP’s don’t need more patients, patients need more PCP’s. The US has a 70/30 Specialist to PCP ratio because of the neglect of Primary care with the payment system. Most believe this is one of the main sources of cost. You are cutting your nose off to spite your face when you hurt the PCP. A PCP’s success is measured by people staying well and healthy. A specialist’s success depends on sickness and procedures, as does the hospital. So do you want to improve the lot of the docs whose job it is to save the system money, or do you want to drive them to money-consuming professions.
    By the way, I drive a used Honda with 120K on it. I do, however, probably earn more than you do. I am sorry if you think that’s a bad thing.

  10. Amen. Do you realize if just one doctor in one community, anywhere in America, right now launched an ad campaign “Guaranteed on-time appt time or the visit is free” they’d have market share. They’d have appointments booked months in advance. Can you imagine your local MRI imaging center running ads like this? Where do you think everyone would go for their MRI’s? Things like this are obvious to folks with common sense like Nate and myself. But these things don’t happen because we don’t have a “patient-centered” healthcare system. The business model doesn’t operate to serve its customers. Nate you can’t “pay more” for an “on time” appointment because you just “don’t understand” that it cannot be done. You can’t understand how “chaotic and hectic and unpredicatable” a doctor’s office is. These are examples of the types of responses you would likely get. Baffling.

  11. is it maybe time for PCP to get more efficient? for example distribution of capital cost. Office buildings and equipement only make money when they are being used. Most of your Dr offices are only open M-F 9-5 or 6. ERs and Urgent Care show there is demand for evening and weekend hours, why aren’t they bringing in partners or employing docs to work their off hours?
    Why don’t patients with higher paying insurance get preferential teeatment? Treating your best customers better is business 101. Personally I wont go to the doctor becuase it takes all darn day and the waiting room sucks. If you want me to wait 2 hours for your service better give me some TV to watch and a hot receptionist.
    Why can’t I schedule an exact appointment? I would gladly pay $20 more for a 11 am appoinment where I could show up at 11:50.

  12. All the PCPs I grew up with make more then I do, drive nicer cars, live in bigger houses, and have young hot wives. I was forced to upgrade my software to accept EDI at my own expense, I think its why I am single today, they can pony up the money.
    I’m not a fan of rude goldberg solutions. If reimbursement is to low thn raise reimbursement don’t “make up for it” by giving them freebies and subsidies.

  13. Nate: it is the primary care offices that are getting the money, and they need it. The margins for primary care are such that it has stood in the way of spending the money on EMR. Most docs are not like me in that they don’t really believe in EMR. They don’t know how to do it. They will find any reason not to do it. Plus, they won’t be profitable on them without a lot of help. There are far more stories of failure than there are of success. PCP’s are quitting in droves and they are one of the keys to real HC reform. Not paying them a bonus for EMR will be shooting ourselves in the foot (much worse, actually).

  14. Funny how we all pay for EMRs and HIPPA EDI requirements but docs yet they get to pocket most of the change.
    We need to stop babying doctors they aren’t broke and can well afford to spend 20K to buy their own EMR and make it back in savings.

  15. Peter, you are correct in assuming that any efficiency gains EMRs are currently providing are not passed down to the patient, or insurer, and therefore are not decreasing costs. Even Dr. Lamberts mentions that the EMR allowed his docs “to raise our income to the top 10% of all primary care docs”, and the same is probably true for Trinity. [AR means Accounts Receivables]
    All that said, all the loses from implementing an EMR, as Contrarian describes, are not passed down either.
    The operational efficiencies brought about by EMRs and good billing systems are not going to reduce costs of care. The interoperability and availability of complete records, coupled with decision support and evidence at the point of care, should eventually reduce costs by eliminating wasteful procedures and tests, and hopefully errors.
    At least that’s the vision…..

  16. “Prior to Medicare and SS and other worthless promises from Washington that we don’t need to save we were. If THe goernment taxes you and in exchange promises you don’t need to save, is it a wonder people beleived them?
    What do I need to save for Medicare will cover my medical cost and SS my living expenses. The Democrats promised me.”
    Nate you are honestly making the assertion that the primary reason that private household saving has declined over the past 30 years is because of SSI and Medicare? You should get a show on Fox and ramble on with half-truths and emotional ranting in place of actual analysis & facts.

  17. “If THe goernment taxes you and in exchange promises you don’t need to save, is it a wonder people beleived them?”
    So would that mean in countries with more social programs their citizens would save less that U.S.?

  18. Tom,
    The benefits of the elimination of sin manefest in 20-30 years, the bills that funding sorce paid manefest today.
    “cigarette ads are banned completely,”
    ? uh what? I’m reading a Joe Camel add right now.
    “I do agree that fixing the uninsured problem was the first thing to do. I see it as the low-hanging fruit and the easier and probably wiser.”
    Disagree 100%. If you fix cost you would fix the uninsured problem. If you fix the uninsured problem you worsen the cost problem. How is this productive?

  19. “Trinity is not an insurance company so it does not sell policies or set premiums.”
    Yes, my point exactly, but patients pay for medical care through premiums, co-pays and deductibles. You can offer that reduced time spent in AR (please explain acronym) would reduce co-pays, but in relation to premiums and deductibles it may be a small part to the patient. For instance does your system mean that specialists can/will charge less? This is what’s wrong with the system, your “savings” don’t necessarily transfer to the patient/premium payer but could simply go to investor returns – which does not solve our overall cost problem.

  20. “We need to become a country of savers not spenders”
    Prior to Medicare and SS and other worthless promises from Washington that we don’t need to save we were. If THe goernment taxes you and in exchange promises you don’t need to save, is it a wonder people beleived them?
    What do I need to save for Medicare will cover my medical cost and SS my living expenses. The Democrats promised me.

  21. OK Contrarian, I see your point. But I have a practice in which we have successfully implemented an EMR. We did this when we had 2 physicians and are now up to 4 docs and 2 midlevels. We have maintained profitability throughout this and our EMR has allowed us to raise our income to the top 10% of all primary care docs (through efficiency, mainly). It is not impossible, it is just hard.

  22. It appears that several of our members don’t understand the business burdens of a small medical practice.
    Suppose you couldn’t raise prices, you couldn’t control expenses, and you were morally obligated to meet the needs of customers who are eager to sue if anything goes wrong.
    On top of this, you have to fight a third party for your payment, you have to document every service that you provide, you may have to be available 24 hours a day. You have to complete pages and pages of various redundant applications every year, you must prove that your education is up to date … the list goes on and on with items not found in other businesses.
    And now you expect physicians to take on the added burden of an EMR. Except for the early adopters who have some sort of interest in computers, the industry has not positioned themselves to tackle the approximately 75 percent of physician practices with fewer than nine physicians (small practices). These doctors do not have the time or interest in learning how to set up an EMR. (Many have not even developed office manuals) Vendors provide “software trainers” to practices, but they do not provide implementation specialists. These practices need someone who knows the workflow of a particular specialty of medicine with the background to problem solve software and hardware issues. They need someone who can customize the program for the end user and return in 3 – 6 months to customize some more. You could have the greatest, easiest software in the world (NextGen or Adobe), but you have to face the fact that there is a steep learning curve to all EMRs (networking, office layout, security issues, simple trouble shooting, workflow issues, hardware issues) that most physicians are not willing to go through for unproven benefits as well as the loss of income in the first 3 – 6 months due to decreased productivity when transitioning to an EMR.
    Vendors could provide the necessary implementation specialists, at double the cost of installing an EMR. ($60,000 or more of a solo doctor) But the time investment of due diligence on top of the other burdens of these small practices virtually eliminates any level of significant adoption. Every practice’s time needs are different which is why a program that works for one practice will not work in another seemingly similar practice.

  23. very good points- although–
    “This bill addresses the problem of the uninsured, but does not deal with the much more important issue of cost.”
    How can we, as doctors, say anything is “much more” important than sick people without insurance !!– I am sure overstated your feelings here.
    You are exactly right when you write–“We have a terrible situation in our country: a HC system that is out of control in its cost and that will bankrupt us if nothing is done”
    We need to start thinking like this-We need to think of ourselves as a country heading into bankruptcy– not as a rich country-
    As a country facing bankruptcy we need start saving money in ALL areas- in every piece of legislation- not just health care
    We need to become a country of savers not spenders

  24. Andrew writes:
    > It’s a little silly to fund something with a source
    > you hope will disappear
    It depends of course on what you’re funding whether it is silly. If you’re funding say primary education, then I’d say it is silly. If you’re funding increased medical expenditures roughly attributable to the effects of smoking, it seems to me reasonable to associate a declining revenue stream with a hoped-for declining need.
    Oh, and since we’re abolished sin, there are no sin taxes. Only disinctentives to negative externalities.

  25. Peter –
    Trinity is not an insurance company so it does not sell policies or set premiums.
    Its hospitals on their IT platform do realize decreased days in AR due to full integration from registration/scheduling to care and billing/financial management.
    The point being technology enables things, but humans and how they work together, with common goals and principles, improve the delivery of health services; increasing quality and decreasing cost. High adoption is the norm because Trinity focuses on organizational culture and the role culture plays in changing how a network of physicians and hospitals deliver care. That is the heart of delivery system reform for the US going forward.

  26. Good discussion on HIT. I especially agree with Dan’s “For those that lament the limitations of EMR, I’d offer that those limitations are failures of vision, not potential.”
    The reason IT is important is the nature of our payment system. European nations are much more apt to accept the government dictating things and are more likely to accept denial of care. They may not like it, but Americans are innately anti-government (from our “taxation without representation” roots). So control cannot be with a big club or we will see all hell break loose.
    Again, the use of IT for documentation of office visits is the center of attention when it should be the least important. Doctors look at labs, x-rays, and meds from other docs far more than they read the office notes (bloated by E/M requirements, they are 95% filler, 5% substance). If EMR becomes a device to generate “filler” easier, it will decrease efficiency. If, however, it is used to gather information and inform medical decision-making, it is extremely powerful in reducing waste.

  27. Dan, are insurance premiums significantly less (if at all) for those who use Trinity Health System of Novi, Michigan?

  28. The commentary above on the use of information technology for handling of clinical data could not be more accurate. Complaints from physicians about adoption of EMR systems have next-to-no basis. No basis in fact to be more accurate, but the cost of most commercial systems is much too high and the lack of forthrightness from vendors on system weaknesses do provide some slight basis for complaint.
    The beneficial side effects from universal digitization are huge, including the ones cited above.
    Even with universal digitization it will take many years for the positive effects to be seen in a lowering of cost of medical services – an increase in quality of service will be seen immediately and continually – but the reduction will eventually occur to the benefit of providers and patients alike. Fortunately to the detriment of vested interests which now benefit from the massive waste of resources.

  29. For those that lament the limitations of EMR, I’d offer that those limitations are failures of vision, not potential. Do a little research on the platform Trinity Health System of Novi, Michigan has deployed in 25+ of its hospitals. CPOE rates dance around the 70% number. 400 evidence based protocols guide behavior, resulting in documented improvements in outcomes, readmission rates, vent acquired pneumonia, ADE’s, etc. and 8% increase in time the nurse spends at the bedside.
    The magic is not the technology but the significant, deliberate investment Trinity makes in readiness, spending typically 12-18 months with culture change management before installing a sliver of technology.
    It’s a model from which many providers could learn.

  30. Healthcare is for sale in this country to the highest bidder. Surely none of you expect there to ever be a real “fix” do you? Squeeze the water-filled balloon of greed in one place to get it under control and it will simply bulge out in another.
    The whole “pie” only looks pretty until you slice it, guys.

  31. Dr. Lamberts,
    Good post and summary.
    One area that you didn’t touch on is good price and quality transparency information in the hands of referring doctors. Both patients and doctors need to care a lot more about costs even when insurance is paying. Transparency information, including actual insurance contract reimbursement rates to all providers, combined with tiered insurance products, could help to bring this about.
    I’ll offer just three examples. First, if there is a generic drug available, the doctor should prescribe it instead of either the equivalent brand or another brand within the same therapeutic class unless the patient can’t tolerate the generic or there is some other clear benefit to the alternative brand. If your patient legitimately needs an MRI but it can be easily scheduled a couple of weeks in advance, you should be sending him to an independent diagnostic center that is probably reimbursed half to two-thirds of what the radiology department at the local community hospital is paid. Suppose your patient needs the services of a general surgeon and you know a couple of good ones that will likely produce comparable outcomes. One practices at hospital A and one is at hospital B. Hospital A is paid 2-3 times more than Hospital B for the same work not because it’s better but because it has significant local or regional market power. You should use the surgeon at hospital B even if the other guy is your weekly golfing buddy.
    I agree with the prior comments about the need for good electronic records to both minimize duplicate testing and adverse drug interactions and to provide the analytics raw material to better learn and determine what works and what doesn’t. I also think doctors and hospitals should disclose their clinical outcomes to the extent possible and the specialty societies should apply their expertise to developing performance metrics that members of accountable care organizations can live with. Finally, regarding tort reform, I’ve long been on the doctors’ side. We need to get dispute resolution out of the hands of juries and into specialized health courts and we need robust safe harbor protection from lawsuits for doctors who follow evidence based guidelines where they exist. The bottom line here is that there is enormous opportunity to cut wasteful spending without denying patients necessary and appropriate care.
    As for patients who want all those images when they’re not indicated or the brand name drug they saw advertised on TV, I suggest PCP’s politely suggest that they might be happier with another doctor and you will provide care for them for another 30 days to give them time to find one. Finally, I’ll leave the end of life care discussion for another post.

  32. I agree mostly with Mr. Lamberts post except that cost savings require IT to fix. All countries that have costs about half ours did not do it through Health IT. I also think that subsidies to help people get insurance won’t necessarily get them healthcare, given the cost of premiums (subsidies are tied to income not premiums) and the co-pays, deductibles, cost of drugs and overtesting/treatment. I also think the profit machines are already strategizing on methods to find loopholes and work-arounds to keep the cash flowing as well as gearing up their lobby money to make changes. Also don’t discount how future Republican regimes will amend this bill. From my perspective Democrats were more for getting people healthcare while Repugs were more for getting a political win, but this (Democrate/Industry Lobby Plan) falls way short of even getting close to a fix.

  33. rc: the GA tort reform that was rejected had more to do with the nature of the law itself. Texas has tort reform already and it has not been struck down. It’s a political thing (trail lawyer lobbyists) that drives legislators to take many of their stances.
    I agree that DTC marketing of drugs is bad practice and drives up cost. There are many other things that do the same (I am going to write a post on the scam of generic meds, as an example). Controlling cost is key, but the vast majority of cost of care is wrapped up in waste and poor communication. This bill begins to address that, but it is nowhere near a solution.

  34. Hi, Rob. Thank you for taking the time to shift out of neutral into can’t win gear. That seems to be the problem with the debate — changes need to be made and noone will be happy with all of them. I’m hoping this begins the season of throwing some of the wasteful deck chairs overboard, but I’m not convinced the folks doing the throwing can tell a costly deck chair from one that saves money or lives.
    Can’t agree more on the role of health IT. Without it, we are sunk. Even in 2009, only 14% of hospitals are using CPOE (computerized provider order entry), instead relying on the centuries-old practice of deciphering handwritten hieroglyphics. And the use of computerized physician notes is even less. ( )
    We need a national movement that puts PATIENTS (that’s you and me, too) front and center in this debate. Getting them activated and involved in their own healthcare will help to steer the ship away from the iceberg (but, hopefully, not into a cliff). Allowing them easy access to ALL their health information at any time will go far to enabling this transition. Adding in a dash of social networking to the mix will get the health communications flowing.

  35. MD as HELL: I am sorry to inform you but heavily financed, wide-spread promotion of products or services that is clearly intended to mislead the public for private profit-oriented purposes – drug advertising is just that – deserves no “protection” under any interpretation of “free speech”.
    Similar to the laughable “doctrine” that because an incorporated entity is considered a “person”, i.e. the same as a real individual, for certain administrative, e.g. tax, purposes, it therefore should be considered a person for other purposes such as having the right of “free speech”.
    For those who pray by the USA Constitution, likely few or perhaps none of the Founding Fathers, revered by that group, would agree that the right of free speech included in the Bill of Rights should apply to any fictitious, not least fictitious and created solely for commercial, profit-making purposes, entity.
    I still think that MD as HELL is clearly in the wrong profession. Why continue in his current profession under the torture imposed on him by venal, supposed leftists? A career promoting “free speech” for profit-oriented corporate interests seems more fitting.

  36. Andrew;
    Stick to your dream. And realize that Exhausted and MD as HELL are practicing at the worst possible time – during the transition of medicine from a cottage industry to a real, outcomes-accountable, systems-oriented, team-practiced delivery system. The transition has been and will continue to be, very difficult (as you see). But it will get better. Take what burnouts say with a grain of salt.

  37. Haha, if my father couldn’t chase me away from his profession, neither can you, MDHell. Thanks for thinking of me though.
    And thanks to everyone here for providing such a rich assortment of opinions and experiences. I’ve been lurking around here for about a year now and it’s been very helpful for preparing for the future, and knowing what needs to be done for it.

  38. Andrew,
    “Sin” taxes are imposed because the products are never going away. They provide a steady stream of revenue. If you are not a doctor yet, run away! It is going to get ugly.

  39. Rob, one of the best critiques I’ve read. A breath of fresh air in an otherwise stale debate. Thank you.

  40. I’m young. I’m not a doctor yet. Don’t eat me alive, please, Exhausted and MDHell.
    But Exhausted, doesn’t the tax on cigarettes serve as a legislative deterrent against smoking? It’s a vice tax – by making cigarettes more expensive, more people will quit…isn’t that the logic? It’s a little silly to fund something with a source you hope will disappear, yes, but I don’t see how it’s hypocritical if this is the intention.

  41. How is that ad regulation working out for you? Seems like a total failure if it was intended to curb useage. Why is it you want to regulate everything, anyway?

  42. Thank you for echoing the perspective that is lost by the extremist party activists here. Democrats are just showing their years of resenting being relegated to inconsequential during the Republican onslaught of the 2000s, and the Republicans are now just showing their outrage for losing their power and lust to regain it, at the alleged interest for the american people over a deeply flawed legislation.
    Wow, have you ever seen such flagrant narcissism and, in my opinion, near antisocial flairs by these politicians as a group? Such extreme partisanship is only detremental for the majority moderates who compromise the growing independent voters, like me.
    So, who will try to rationalize my ongoing question about the pure hypocrisy at hand: the federal government depends on the monies of taxing tobacco products, yet is going to take on controlling the allocation of health care simultaneously.
    Are politicians going to either tolerate the high frequency of health care needs by chronic smokers, or, will they have the equal audacity to dump them to the curb for such exorbitant expenses that often have little impact for positive change if smokers don’t stop?
    Hmmm, did any politicians who have a conscience and sincere interest in responsible change think about his one? Oxymorons, expecting politicians to have consciences and sincere interest in responsible change.
    I would pay big bucks to have a glimpse into the future of 2014 to see where this has lead the country. Oh, I forgot, we have! It was the movie “Logan’s Run”, from the late 1970’s, when the power structure just encouraged people to commit state sponsored suicide for the benefit of the masses!!!
    What will you all do WHEN the Pelosi’s, Reid’s, and Obama’s just slip into obscurity when the feces hits the fan in the next 4 years?
    Won’t remember them, will you?

  43. MD as HELL, in this USA liquor ads are regulated and cigarette ads are banned completely, even though both are perfectly legal and available in any supermarket. Other ads are regulated as well, and content on TV is also regulated. So, let’s skip the first amendment.
    I am happy to hear that you are a constructive “denier”. BTW, do you have a sense of what percentage of patients are uncooperative?

  44. I won’t comment on that last statement of brilliance.
    I do agree that fixing the uninsured problem was the first thing to do. I see it as the low-hanging fruit and the easier and probably wiser. I also do think that there are some costs that are taken care of by insurance reform (Nexium is a good example). BUT, the amount of waste in HC as well as informing decisions of clinicians is a much bigger task and has a much bigger gain.
    My point was not that this is not a reasonable first step: it is that it is only a first step.

  45. What vapid criticism. The process wasn’t bipartisan, absolute BS.
    This was a moderate Republican health-care plan adopted by moderate Democrats and passed by majorities of both the House and Senate.
    Grow the F*ck up.

  46. Welcome to post-Constituional North America, formerly occupied by the USA. margalit need not worry about the big pharma ads. They were allowed under freedom of speech in the USA. Post=Constitutional North America will eliminate it.
    As for “denying care”, I do all the time when it is not needed and when the patient is on board with the plan. I don’t have to CT every abdomenal pain for possible appendicitis if the patient is on board with the non-scan plan.
    But if the patient is adversarial or distrustful or not able to follow a conservative plan, then they start to morph into a plaintiff if I am wrong. When being “wrong” is twisted into “negligent” (insert need for tort reform, real reform, not caps which are not reform) then fire up the xrays and start spinning the gantry and let the cash flow begin.
    As for EMR, it is to track and tax, not care for anyone. It is so the government can beat me up and control me.
    The patient can keep his own record. I’ll give him any and all objective data he has purchased. I will not be his clerk.
    It is a lot like personnel issues. Somethings will never be put into writing. But when someone calls and asks if you would ever hire a person again and have you been advised not to talk to anyone about issues…well, if someone calls about a patient and asks me if I would like to see that patient again…I hope you get my drift. The EMR will be cyber-Swiss.

  47. bev,
    The pharma commercials are a big problem. If you watch enough TV in a day, you can become certain that you suffer from depression and are just about to drop dead from a heart attack.
    I don’t understand why these ads are allowed. I am certain they are contributing to cost. I wonder if there’s any research measuring the effects….

  48. Margalit;
    Your Nexium comment raises another point, and that is, pharma adverts to docs! Whenever I heard about a friend on Nexium (I’m interested b/c I am on the generic for Prilosec, omeprazole), I would always want to ask whether they asked for Nexium or the doc volunteered Nexium. I suspect it was some of both. There is no question docs get lazy about these things too, are subverted by pharm reps, or think they are doing what the patient wants. Perhaps Rob has more knowledge of this as I did not treat patients directly.

  49. bev, I of course agree with Matthew regarding which should come first, cost control or coverage, but the point which was true before the bill and is still true after the bill, is that unless physicians/patients start thinking about costs on their own, somebody else will. I just think that by education and occupation, physicians are in a much better position to make a difference.
    Not sure, but if a doctor would tell me, definitively, that Nexium is no better than Prilosec, I would get the cheaper one. Most people would. Heck, most people don’t know enough to even ask about alternatives.

  50. Rob,
    You approach of dichotomizing health care into health care financing and health care delivery certainly helps people understand the different characteristics of myriads of problems in our health care. I also agree that health care delivery lies at the heart of our problem.
    Yet, I do not agree to the notion that the two are separate and reforming health care finance won’t do much towards fixing health care delivery. The only way any force can be exerted on health care delivery is to change health care providers’ as well as people’s behavior through financial incentives. Good health IT is a must and can alleviate problems a bit but won’t solve them.
    You mentioned people preferring brand drugs to OTC drugs, but how do you change such behavior? Through education? resorting to their good morale? By denying “reimbursements”! This won’t stop them from getting cost-unjustified brand drugs, because they can pay their own money to buy those drugs. If it’s their own money, however, then people will start doing some calculation – i.e., moral hazard is somewhat mitigated.

  51. Rob. The cost issue may seem like the biggest one to you. But if you are uninsured and need care, the insurance coverage issue is MUCH bigger–and we needed to fix that issue first, for reasons that I’ve expounded on these fair electrons far too many times (it’s a price inelasticity problem)

  52. A well-considered post which I think hits all the salient points. Margalit, I don’t think Dr. Lamberts was advocating for the government to solve the problems you mentioned – it was just part of his point that they went about this process backwards – cost control incentives should have come first.
    These incentives could have been delivered in a myriad of ways short of outright governmental decisions over the practice of medicine. But that didn’t happen – so now, as you say, it is incumbent on employers, insurers, providers, and, not least, patients to make it happen. (gulp).
    ps I am SO HAPPY somebody finally said Nexium is no better than OTC Prilosec! This is what direct to patient advertising will do to people!!!!

  53. A question that has hung in my imagination is, had the Democrats not pushed relentlessly forward on reform, is it likely nothing would have been done? “Trash it and start over,” rhetoric suggested we have/had all the time in the world to do little things.
    I agree, the bill is neither Armageddon nor Nirvana, but it scares me to think that, for a large portion of our elected representatives (and some might say the American citizenry), it seems the issue was better off not addressed at all.

  54. “Doctors control a huge percentage of HC costs”
    This is very important and very true…
    “Devices that don’t really help people, and specialty procedures that are unproven are paid for”
    True, but physicians don’t have to order those. I’m sure you don’t really want the “legislators” to intervene here. Wouldn’t that be a government take over in the sense opposed by practically everybody?
    “Unfortunately, the current push for EMR is not about delivering information to physicians, but instead about letting doctors document more efficiently.”
    Unfortunately, what is one doctor’s information is a previous doctor’s documentation. There can be no information flow unless everybody creates electronic information.
    “Any control of cost will be about denying care.”
    True again, but it is the responsibility of physicians to decide what is harmful or unnecessary and subsequently deny it. Considering that nobody wants “bureaucrats” of the government type or insurance type to interfere with the doctor-patient relationship, it falls to the doctors to do all the necessary denying.
    I don’t know about the Titanic or about the chairs, but I believe it is incumbent upon physicians to practice what some have called “lean medicine”. The alternative is for the “bureaucrats” to take over and impose their version of medicine, which I suspect will not be to anybody’s liking.