A Vote For Trumpcare

The world is not going to end.  We witnessed a revolution earlier this week.  The people have spoken and they chose the anti-establishment, street smart, government shrinking candidate who bucks the status quo.  We find ourselves in uncharted territory, with an unpredictable President-elect, who has unclear plans for healthcare.  Here is what we do know.  Mr. Trump is a successful entrepreneur.  Forbes describes the entrepreneurship pathway as having no clear story line, but a “sense of chaos, hectic decision making, and moments of great fear and doubt.” Improving our broken healthcare system will involve decision making in the face of great uncertainty.  Mr. Trump has a well-developed tolerance for this sort of ambiguity and is likely the right man for the job.  

Mr. Trump won over the white working-class individuals in small rural areas.  Sluggish economic recovery in these areas played a significant role in his unanticipated victory.  It is these disenchanted individuals watching the American Dream slip through their fingers who voted for Mr. Trump.   Those same people want the freedom to buy the insurance they need, and not what the bloated government shoves down their throats.  25% of the population lives in rural areas yet only 10% of the physicians practice in there.  Physicians are leaving the system in droves, closing their patient panels, and not keeping up with demand, thereby threatening patient access in these isolated locales. 

Independent practices have a better chance of survival than they did just a few short days ago.  Do not sit idle.  My son, who is in the second grade, was asked to write down his thoughts on this election. “If Hilary Clinton is elected, I will die.”  His teacher insisted he use facts to back up his dramatic statement.  “If Hilary Clinton becomes President, she will close my mom’s clinic, we will not have enough money for food, and I will die.”  While this is not exactly the conversation that took place over family dinner, my son did understand healthcare would change dramatically following this election.  You should have seen him on election night when the network called Pennsylvania for Trump, but that is another story for another day.  Private practice physicians must seize this opportunity to be involved in the “make things great again” conversation.  

Hillarycare was a known entity with a foregone conclusion. Trumpcare remains a bit of an unknown.  His “plan” for healthcare was revealed a little more than a week ago, ironically, at Valley Forge.  It encompasses dropping the insurance mandate and allowing purchase across state lines,  making health savings accounts accessible, price transparency, Medicaid block grants to the states (which has certainly worked well for Head Start) to encourage policy innovation, and protecting coverage for those with pre-existing conditions.  The blank canvas is full of possibilities, which is markedly better than the universal health care plan we could have been facing had the outcome of the election been different.   

Every clever “fix” for healthcare so far has had unforeseen adverse consequences.   Providing marketplaces for consumers to shop for insurance did not improve health; instead, it padded the pockets of insurance company CEO’s, lobbyists, and administrators with special interests.  The statistics on rising insurance premiums could not have been released at a better time to facilitate a Trump victory.  I am overjoyed at the possibility disingenuous CMS employees and lobbyists for the American College of Physicians could be out of jobs.  As for MACRA, I hope it goes down with the Affordable Care Act ship altogether.  Physicians want to practice at the top of their skill set, without needless oversight by administrators telling us what is “best practice.”  

The system Mr. Trump is inheriting is full of obstacles.  Patients are disgruntled about paying exorbitant premiums they can ill afford.  Even Bill Clinton chimed in, “The costs are going up, coverage is going down, it’s the craziest thing in the world.”  Maybe not the craziest thing.  I say a man getting elected to the White House without having any previous political or military experience while most of the polls were predicting his loss is fairly extraordinary.  

Admittedly, there are no easy solutions.  My best advice is for him to familiarize himself with the game, the players, the field, and the score, and then develop his own blueprint for healthcare.  Most importantly, get back to the basics.  One hundred years ago healthcare started with fundamentals:  the physician, the patient, a stethoscope, and a conversation.  People were arguably as healthy then as they are today give or take a few communicable diseases.  Additional thoughts are below:

  1. Invest and innovate, especially in primary care.  We are cost-effective and knowledgeable.
  2. Stop penalizing physicians who do not use Electronic Health Records.  Physicians are doing two hours of paperwork for every one hour of patient care and hiring ancillary staff to support this unnecessary infrastructure.   Let me care for my patients and do my job.  Give me control.
  3. Shrink or Decentralize the Centers for Medicare and Medicaid bureaucracy.  None of these people are practicing health care providers.  Why are they in charge of 18% of the GDP, when they know little of practice on the front lines?
  4. Encourage innovation and competition amongst insurance companies.  If you want a low deductible, your children covered until they are 26, and exemption from pre-existing conditions, then pay for it.  If you want only catastrophic coverage, and pay for routine maintenance as you go, then pay less and save the extra money to go on a cruise.
  5. Redefine high “quality.”  Reward physicians when they spend more time with patients, are more accessible, and able to prevent expensive hospital admissions and readmissions.  Eliminate patient satisfaction scores, immunization rate scores, and outdated HEDIS measure goals.
  6. Require Medicaid recipients to contribute to their health insurance, on a sliding income-based scale.  Require small copays for insurance plans including Medicare and Medicaid.  Even a small personal investment ($3) for a visit has been shown to increase value in the eyes of the consumer.
  7. Allow Medicare to negotiate with drug companies.  Pharmaceutical companies have been getting fat and happy while Americans have just been getting fatter and more ill. 

Our problems in health care have little to do with the patients or the physicians; rather it has to do with corruption of our administrators and nonessential healthcare players.   Beware of the snake oil salesmen touting their latest “solution” for the health care conundrum; instead, look to physicians with boots on the ground caring for real patients to provide tangible answers. 

Niran al-Agba is a physician in Washington State.

59 replies »

  1. “Give me control.”

    That was a funny line in this article.

    “Give me control, for I am a doctor, damn it.”

    That would have been a more entertaining collection of words for that moment.

    You have no say in your professional life. Talk to the Medical Assistants. They will feel your pain. While the RNs laugh.

    Pipe down and get back to work. I think I see someone from the American College of Hospital Executives coming.

  2. John, you’d better look up the definition of risk. Just as Trump thought the definition of “sacrifice” was building structures and making money.

    Scam artists risk going to jail for using other peoples money. Are they “entrepreneurs”?

  3. We should start calling these things Peterisms.

    You’re arguing Trump isn’t an entrepreneur?

    HINT: Some (not all) entrepreneurs find ways to take risks USING OTHER PEOPLES MONEY.

  4. Gregg, you write, “dis-organized medicine failed”.

    Did it really fail or was it wildly successful, so successful that we ended up curing and treating more and more patients which caused unexpected budgetary problems? If those patients had died like they did before , those budgetary problems would not exist. From my vantage point what you call dis-organized medicine initially escaped much of the bureaucracy and created all these things you talk about including the replacement of human parts, diagnostic testing that didn’t require cutting the patient open, cures for some cancers control of others, less and less invasive cardiac procedures saving and extending life, etc. None of this was expected in the earlier years. The bureaucracy built upon itself creating all sorts of nutty things including the ACA which is now imploding,

    If time permitted I would comment further on the rest of what you said, but as before I think the point has been made that you have your own point of view and that point of view may not be as good as you assume it to be.

  5. Gregg, you are correct physicians have been too passive when it came to driving change in healthcare. It is time we stand up, fight, and be the change we wish to see. Not every idea is going to work, but the larger point is clinicians actually practicing medicine with real patients should be involved since we are greatly affected.

  6. Sorry! No intent to offend. I’ve been in direct delivery of care, though not as a clinician since the mid 70s after graduating from UCLA School of Public Health with and MPH in behavioral sciences and community health – which the rest of the country is just now catching up with in 2016 due to the triple aim and population health narrative.

    I wholly agree the ‘healthcare conundrum’ we’ve ‘co-created’, and yes I mean all of us from the AMA to ABMS, the litany of member specialty societies, state medical boards and the economic turf carved out via the credentialing process and enforced by hospital medical staff privileging practices, the entire hospital administration profession, and so-called managed care to the copy cat equivalents on the allied or ancillary health side. We created an excessively hierarchical ecosystem which is imploding of its own internal weight and complexity.

    I was a pioneer in the PRA (Physician’s Recognition Award) Category I CME program world, and a certified California Medical Association surveyor (under the mentorship of Stanley Skillicorn, MD) well before its adoption by state medical boards as a condition of re-licensure. Back then, it was truly about focused education after ‘medical audits’ (peer generated criteria for quality care by specialty) determined ‘gaps’ in what should happen vs. what was actually evidenced in the medical record. We assumed the light touch of voluntary CME to be both reasonable and appropriate ‘intervention’ to less than optimal or evidenced based care.

    As I see it, dis-organized medicine failed due in part towards its tendancy to ‘circle the wagons and shoot in’ via an apparent addiction to the internecine warfare of cognitives v proceduralists and other geo-political credentialling practices. It failed to ‘own’ the organization and dispersion of mission critical healthcare assets from hospitals, to ambulatory surgical centers and the litany of diagnostic imaging and therapeutic centers (lithotripsy, radiotherapy, etc.) which migrated away from and competed with traditionally controlled hospital operations. The exit was compelling from efficiency, access, governance and investment thesis perspectives. Yet, in the fee-for-service world, expanding access often meant bench-marking price to inpatient equivalents and generally adding to the nation’s healthcare tab. The efficiencies did not return a benefit to the community though it typically enriched the physician partners. Any hospital volume declines by the emergence of this usually un-welcomed (unless it was a JV) competition were offset by hospital charge master price increases which added the double wammie of induced excess capacity and aggregate total cost increases.

    The independent practice association (IPA) introduced as a means for ‘mainstream’ medicine to participate in and ‘craft’ the emerging prominence of the Health Maintenance Organization (HMO) model and their lighter footprint PPOs as the took over as the predominant financing and delivery model of ‘U.S. Healthcare Inc’. The theory was as more untethered practices were drawn together by an increasing volume of shared patients, it would drive the need for practice integration, greater care coordination collegiality, the requires healthIT spine, core management services support (MSO), group purchasing including supplies and professional liability insurance, etc. In other words, ‘cowboy medicine’ would give rise to ‘pit crews’ in the words of Atul Gawande. The ‘integration’ (clinical, financial and legal) would be incremental, scalable and driven by the gravity of mission and culture essential for an emerging group practice, ergo the term ‘GPWW’ (group practice without walls) emerged for a while. This all went south beginning with the aggressive ‘roll-up’ strategy that converted sleepy community based HMOs to for-profit operators that lost sight of their community benefit (DNA) obligations and shifted to an ‘EPS’ (earnings per share) culture which was all about profit growth.

    This collapsed as we all know. Some may remember the meteoric rise of Maxicare and its national expansion via HealthAmerica (a house of cards) which drove what was a promising model of engaging private practices in California into Chapter 11 Bankruptcy.

    In my view docs have a super duty to take control of the healthcareborg they have been culpable in co-creating. We have a house of cards that is imploding as we speak. Yet this sense of ‘learned helplessness’ must start with them. I have said repeatedly the ‘exits’ from this mess into direct practice and even concierge medicine is a rational response to an irrational system.

    So if we have any discourse here, it need be with what works and not just for the low hanging fruit rather easy to pick off, but what leads to a sustainable healthcare financing and delivery ecosystem. I’d say the first step in that direction is for hospitals to be seen as ‘cost centers’ (as in the Kaiser Permanente – including Group Health – California models) and NOT the ‘revenue centers’ model fueled by fee-for-services that has produced the armies of clipboards hounding you and your peers, let alone their multi-million dollar salaries even at so-called ‘non-profit’ 501c3 health systems.

    Again, thanks for piece!

  7. Peter we can both say whatever we want, but the proof is provided by those that are willing to continue to invest in projects Donald Trump is involved with. They don’t invest when they think they will lose money.

    Do you think most businesses are self funded? That is what it sounds like. Businesses fail all the time and investors recognize that though those inexperienced in business don’t.

    If I remember correctly McDonalds original secretary accepted stock in that hamburger company rather than full payment for services. She owned one of the mega mansions in Palm Beach Florida. You probably would think of her as smart. But, had McDonald’s failed you probably would call McDonald a theif and a liar because his secretary would never have been paid.

    We need people like you to provide your services, but one would never invest in a person that could not understand risk and reward.

  8. “‘Mr. Trump is a successful entrepreneur.’ Really? I suppose if serial bankruptcies…”

    Bankruptcy laws have changed through the years, but I think it worthwhile to state that Abraham Lincoln could have gone bankrupt if he lived under today’s laws. He kept paying his debts off and to my understanding never fully pain them.

    But I need not point to an almost bankrupt President when I can point to several others.


    Not only Presidents were surrounded by debt , industrialists were as well.

    Henry Ford’s early company went bankrupt.

    Then again for those of you still members of the Mickey Mouse Club, yes, Walt Disney went bankrupt.

    One doesn’t create a great company without the risk of failure. That is capitalism. The bad companies disappear and the good companies survive. In fact many of our richest and most productive citizens have failed once or more before their genius created companies that we recognize as huge successes. Some who are afraid of failure have to remember that unless one faces failure one can almost never face that fantastic success.

    In Israel where the population is only a bit more than 8 million we see a large number of start up companies that fail. However, failure in Israel doesn’t have the negative impact it has elsewhere. If the logic is good people will loan to those failures again and again because those are the ones moving the world forward. That is why in the world Israel, having a population of only 8,000,000, is number three in patents while most of the rest of the world of 7.4 billion is far behind.

    Gregg, maybe later I will deal with some of your other points, but I think you get the idea that these quick responses appealing to emotion don’t lend themselves to an accurate portrayal of an individual even if personally satisfying.

  9. Steve- I am still working on who the WE is exactly. Insurance companies and drug companies should do it because the government should follow the pathway of other countries and negotiate, negotiate, negotiate. There is no incentive to negotiate right now. Pfizer knows Medicare will pay full price for their drugs right now. What if that was in jeopardy ie if your price does not come down, then we will not cover your drug at all. Neither party understands the inside issues of practicing medicine. This is where the WE comes in and we put together individuals from all backgrounds with an interest in healthcare and formulate plans.
    Listen, if I could make the same amount of money seeing 15 instead of 20+ patients per day, I will jump at the chance. You are right some will try to keep doing what they are doing, but patients will see the difference and likely vote with their feet. If life is more manageable for physicians, there will be more of us instead of so many running like their hair is on fire.

  10. “Nope. They don’t want to compete. ”

    Of course they don’t want to compete and neither does any large company with market share. That is one of the problems with Obama and the ACA. He and the ACA like to deal with large corporations. The ACA reduces competition in all areas including hospitals, insurers and physicians. The left likes to set prices and micro manage. That generally leads to less competition. Under the present rules and regulations it is very hard for new entrants into the ACA’s health insurance realm.

    If you think that the interference of the ACA is minimal where health insurers are concerned then you better reread the bill. New entrants face too many obstacles. Therefore, when one says they are going to increase competition that means ridding ourselves from some of the rules and regulations of the ACA.

    As before I am not going to comment on some of your other ideas because your glibness continues even though it appears the naiveté you claim to exist in others seems tightly held by you. “Nope” with your follow up explanation clearly demonstrates how you miss the point.

  11. Nope. They don’t want to compete. Most of our states have been dominated by one, two or three insurers for years. Now, states are eliminating any regulatory barriers that exist, and insurers still aren’t coming. Alternatively, if insurers wanted to compete, they could simply start up in a new state. Hasn’t been happening. The costs involved in starting up are stopping them, not regulations.(Doctors should inherently know this. Most of us give volume discounts to larger insurers. Actually, they just pay us less and we accept it. When a new carrier comes along and they have very few patients we don’t accept lower payments from them. IOW, insurers can offer whatever kind of lower premiums they want, but they can only do that if they can get providers to participate. We aren’t going to participate with a new provider until they have a proven track record of being able to pay on time.)

    Perhaps the best example of this is Medicare Advantage. Insurers with MA operate under the same rules. What we still see with MA is that insurers avoid working in the same markets. Granted, in the markets where they do overlap costs tend to be a bit lower.

    What people on the right should also acknowledge is that in the exchanges insurers can, if they want, compete. It has been a pretty mixed bag so far. I would say there is not good evidence that we know how to get insurance companies to compete, and when placed in positions where they can do so, the results have been mixed. Just glibly saying you are going to “encourage” competition is meaningless. Really, I am pretty well grounded in economics and math, but I think you need to read more and understand how markets are currently (and historically) shaped.

    Niran- Who is this we that will do all of this negotiating? Why would insurance companies do that? Drug companies? Why aren’t hospitals and insurance companies already negotiating for the lowest prices they can get? (The one area where we could do this easily is with Medicare, but that is a special interest issue. Neither party is interested in changing it. Either party could have done so years ago if they wanted.) Sorry, this all comes of as wishful thinking unless you actually have some plan, some means to accomplish it.

    As to your other ideas, I think they have merit. Of course, what will really happen when you pay more per patient is that many people will keep saying the same number of people to increase income. Not sure how you guard against that or maybe we don’t want to do so. My preferred idea, would be to have a freeze on payments to specialists while shifting increases to PCPs.

  12. Yes, but you do not work in a private clinic, which has vastly different challenges than either of those you face. Encouraging competition in insurance does have a basis in reality. Whether or not those pieces are put into play, depends on what this administration does.
    As to how we invest in primary care and where the money is going to come from… we negotiate savings in other areas ie insurance companies, government bureaucrats, and negotiation with drug companies to start. There are likely numerous other places to find significant savings. The money saved from a variety of interventions creates a pool of money to “invest” in primary care clinicians. Listen, I am not asking for more money. I am asking for more money per patient to see fewer patients and in turn do a better job with them. As the quality of care improves, the need for specialty care decreases. Also, charging a premium on access to specialists that is “unnecessary” as well as “unnecessary” ER visits are things that should be disincentivized in a variety of ways. Solutions are going to take “thinking outside the box.” My thoughts may not be revolutionary, but what do we have to lose by changing course? Things are clearly worse than they were before Obamacare and as of Jan 1, MACRA is going to kick off Dr-exit, the consequences from which will take years to recover from.

  13. Yep. Bankruptcies do not disqualify one from being a successful entrepreneur. His tolerance for ambiguity is one of his best assets, no matter which side of the aisle you are on. The risk does NOT require everyone buys in and participates. We have survived for many generations without that. You have clearly swallowed that idea of the left, hook, line and sinker. You had me interested until you went the Adelade route. Mostashari has no idea what those of us on the front lines are doing.
    Look, my bias is that I am the owner of a private practice in existence for 46 years. I have been voted one the top physicians in the county for seven years running. I know healthcare for children and I am good at it. These are my opinions based on my experience and direct observations over the last 16 years. More than 7 physicians are retiring in this county at the end of the year, they are young, far younger than retirement age. There is a looming crisis on the horizon, no one is talking about. There will be NO physicians at the rate we are going except in large cities, which will be catastrophic.
    Those suffering in small rural areas are the ones who overwhelmingly spoke for change.
    Now, you are a tech person. It appears you are an entrepreneur yourself. You believe in your heart of hearts, it makes health care better. I am afraid it does not, especially as things stand now. Not where I practice and not for what I do in primary care.
    You can insult my opinion, but these are my thoughts based on my experience practicing medicine. I do not cherry pick patients and accept every patient with significant congenital defects and chromosomal disorders sent my way. These children can become very sick at times and we can handle 95% of what comes our way. That takes time, effort, and fortitude as well as a “tolerance for ambiguity.”
    Money should be spent on allowing us to actually do our job; which means spending enough time with patients to save lives. Technology may have a place in hospitals or large institutions, it is NOT required or even preferable for me to do my job. When someone in the tech world actually understands what I really do every day in my office with patients, then they will GET it. But so far, it helps bureaucrats collect data and that is of no consequence to me.

  14. Oh my! Where to start on the TrumpCare ‘faith based’ hologram which you seem to have swallowed in whole?

    ‘Mr. Trump is a successful entrepreneur.’

    Really? I suppose if serial bankruptcies and forced bailouts including a record near billion dollar annual operating loss constitutes ‘success’. Had he not ‘owned’ the banks, his failing roll of the dice real estate house of cards would have erased his entire net worth. Gulp! Some successful entrepreneur, and that’s before TrumpU, AirTrump and a line of failed extensions of his brand. Who knows what other stories might be revealed by his allegedly ‘under audit’ tax returns?

    ‘Mr. Trump has a well-developed tolerance for this sort of ambiguity and is likely the right man for the job. ‘

    Nowhere in evidence is this man’s ‘tolerance for ambiguity’ evident. What we do know is quite to the contrary, i.e., how thin skinned and undisciplined he is and how quick he is to draw and fire his wrath at others with little to no self awareness nor concern with the disproportionate power advantage he possesses especially when attacking women, other minorities and those with considerable less standing than he. Hardly a skill set for a competent CEO.

    On TrumpCare:

    ‘It encompasses dropping the insurance mandate and allowing purchase across state lines, making health savings accounts accessible, price transparency, Medicaid block grants to the states (which has certainly worked well for Head Start) to encourage policy innovation, and protecting coverage for those with pre-existing conditions.’

    The socialization of risk REQUIRES everyone to be in the pool less adverse selection drives an underwriting death spiral. Eliminating the American Enterprise Institute recommended and market driven policy of the individual mandate is both naive and foolish – though institutional amnesia as to its origins seems to have set in.

    New wine in the same old bottle:

    Health savings accounts (HSAs) and thus voucher equivaents including block grants to the states are not point of purchase empowerment plays driving a consumer directed care revolution that will tame the rapacious appetite of an over-engineered, physicians ‘purchase order driven’ zeigeist that equates to a ‘do more to earn more’ incentives disproportionately fueling specialty or niche market waste, fraud and abuse. Your exempting physicians from the problem seems a little ‘tone deaf’, and make no mistake we ‘patients’ do play a variably modest to material role in the healthcare conundrum as well.

    Selling across state lines is upside mythology. Lets assume the law of large numbers prevails in terms of best pricing practices. An out of state plan is more often than not nowhere near critical mass in a specific and ‘adjacent’ marketplace to argue for or extract ‘most favored nations’ rate’ (best price). These are tired and now recycled Republican talking points under the guide of choice, freedom and independence. What this really means is I have the right to buy ‘junk insurance’ – so-called mini-meds which look attractive from a premium standpoint but provide little to no coverage in the event I need serious attention. The wrap around catastrophic solution is mythical too as well.

    The empowerment of primary care physicians is also a solution but perhaps not in the generic manner you suggest: ‘Invest and innovate, especially in primary care. We are cost-effective and knowledgeable.’ Direct practices, retainer medicine or membership based models like Qliance in your state have real promise but ONLY if the assume additional risk for downstream exposure a la IoraHealth or more recently PCP empowerment via Aledade ACO business models.

    I have developed many provider networks including a 250,000 member equivalent Primary Care IPA with a global (hospital, physician and ancillary) risk (including drugs) percent of premium download @85% from both commercial carriers and Medicare Advantage contractors. We capped and empowered the PCPs as prudent resource managers and traffickers into the specialty and sub-specialty domain via office training, detailed and current provider directories and immersive PCP engagement into the critical role they play via referrals and hospitalization. We even capitated via sub-capitation higher cost specialty services (orthopedics, oncology, cardiology, urology, general surgery, etc). Bottom-line, we failed and went BK. Primaries sandbagged to protect their total income returns and more often than not shifted the liability to buckets of their specialty partners. There were many issues underlying this tendency and ultimate demise, but holding out primary care physicians as an on the come innovative solution calls the question via what business model? I suspect you line up on the dis-intermediation side of concierge medicine – a cherry picking practice at best.

    I completely agree with you on empowering Medicare to negotiate direct and on behalf of some 54 million beneficiaries vs. deleveraging their aggregate market power via a series of PDPs under Part D. I wrote about this advocating on behalf of Proposition 61 in California (which unfortunately couldn’t spend like the drunken sailors at PhRMA: and this failed): https://yesonprop61.wordpress.com/2016/10/17/yes-on-proposition-61-the-california-drug-price-relief-act/ and the deconstruction of the ‘NO’ narrative: https://yesonprop61.wordpress.com/no-on-prop-61/

    The most informed claim you make is: ‘Admittedly, there are no easy solutions.’ Agree, but lets get honest about what works and then develop the political chops to get it done.

    Gregg Masters

  15. Your comment saying insurers“ don’t want to compete, they want to make money” suggested that Niran was a naive child. I recognize and believe Niran does as well that competition has been reduced by those on the left so I straightened out your thinking process and told you how competition works. One doesn’t get much competition when government sets too many parameters like was done by the ACA.

    You now agree with the basics of competition something you didn’t understand before or aternativley you worded your statement on competition in a very poor fashion that demonstrates one who doesn’t have a firm handle on economic principles and how they have been discarded by the ACA legislation.

    “Glib?” Not maybe, but absolute. Before complaining about being tired of talking points learn what they are. The ACA along with other regulations place all sorts of restrictions on insurers that discourage new entrants into the marketplace. New entrants would increase competition.

  16. “In a competitive environment ”

    Sure. Hope you know the old economist joke that ends with “assume a can opener”. You have just assumed one. Most health care markets are dominated by relatively few insurance companies. IF, and that is a big if, we actually had a competitive environment, what you said would be true. In fact, we don’t. In some ideal economic model, you are correct. In reality, not the case. As I noted, states have already tried to encourage insurance companies to enter their state to compete. Has not worked. Glib? Maybe, but mostly I am tired of talking points that have no basis in reality.

    Invest in primary care. I agree with this, but again, how is this going to happen? You just put the GOP in charge. Where is the money going to come from? This is not about accepting the election and moving on. This is about having been in health care for 45 years in some form or another and paying attention. You can’t just glibly assert that we will invest in primary care without considering where that capital will come from.

    BTW, I work at both a CAH AND a level one trauma center. I have to deal with the issues facing both.

  17. “Trumpland: Where hate and ignorance is popular again.”

    Peter most of the hate I have been hearing seems to come from you.

  18. Pesto maybe you could tell us how you paid for health coverage before the ACA and after the ACA and what you would prefer without it?

  19. Uh, no doctor got any subsidy from Ocare. Govt had 8 years to correct the financial meltdown sequalae and craft a healthcare bill. Instead we got a health insurance bill/monstrosity forced down our throats filled with goodies for pharm, insurance companies, etc and when the money ran out they all bailed. Face it, Obama has been a failure top to bottom, and the nation has repudiated his legacy.

    We the peasants changed the face of the republic. We were sliding towards destruction. Us po’ white trash (I’m really Hispanic and Irish) don’t know nuffin and should go die.

    You spew the hate that you accuse us of having. You are the delusional one.

  20. Anyone working for critical access hospital (costs of which are paid by the government) is going to like big government. It literally sustains you. Your bias is exactly opposite to mine. Investing in primary care IS the answer because it avoids other higher expenses in the long run. Allan already handled the market competition issue below quite well. I’m not sure age is an issue, but I am likely younger than you are. I agree with Allan that you sound angry and glib in your comments; the election is over. Accept it and move on. No one is going to run around closing CAH’s, those are necessary to healthcare infrastructure in this country.

  21. “Encourage competition among insurance companies? How old are you? Do you have any idea how naive this is? They don’t want to compete, they want to make money.”

    I’m sure Niran can answer this herself better than I, but when I read this I wondered how much you understood about the marketplace.

    In a competitive environment if insurers aren’t competitive they don’t make money. If cost is an issue then insurers competing with one another will attempt to underprice one another. It may not be their choice to compete, but in a competitive market they either compete or die. Competition causes prices to fall towards their marginal levels.

    I would make a few other comments, but based upon the time and your glib statements I don’t think it is worth it. This example should be sufficient enought to note the errors in your logic and understanding..

  22. Sorry. You have Trump. You don’t get to have anything you put on your list. What you will get is some effort to allow sales of insurance across state lines. This is already allowed. In the 6 states that have passed laws encouraging sales across state lines, no insurance companies have come to participate. If you are really a doctor, and if you have ever really run a practice, you should understand why. Next, you will get block grants for Medicaid, which will really just be cuts in Medicaid money, then giving it to the state. You will also get HSAs, great for people who make lots of money. Not os great for those who don’t.

    As to your list, a few ideas are good. Invest in primary care? Who is going to do that? Not the insurance companies. Again, if you really are a doctor you know that already. Guess that leaves the government, but then you don’t seem to want govt involvement. How is this going to work?

    Encourage competition among insurance companies? How old are you? Do you have any idea how naive this is? They don’t want to compete, they want to make money.

    #2 is fine. However, at some point someone is going to ask you to prove that what you are doing actually works. Better figure out how to measure what you do. If I were in charge I would drop requirements that you use EHRs, just require that you show what you are doing is effective and leave it up to you to figure out how to do that.

    #5 Good. Also, please show us that this results in better outcomes for your patients.

    #6. True, especially when buying non-health care related goods. When it comes to health care, this has been shown to stop people from getting drugs they should take and screening they should have. Read up on Value based insurance. We should probably be making some stuff free, some stuff really cheap and other stuff expensive.

    #7-Good idea.

    #3- Not sure where you are going here. I assume you know that Medicare administration costs less than that for private insurance. (Dont bother bringing up the Avik Roy nonsense. Anyone smart enough to get an MD can figure out why he is wrong.) If you are saying Medicare has too much say in what we do, I guess I get this, but need to be more specific.

    BTW, I work at a 25 bed critical access hospital in the hinterlands as well as a level one trauma center. What is your plan to pay for healthcare for those poor in rural areas, especially since poverty is mor common in rural areas?

  23. There are so many rules and regulations out there that I will bet all or almost all have done something that could be cosidered criminal in their lifetimes. I don’t know of many promotors and builders that havensn’t been investigated. They too frequently have to deal with government officials frequently Democratic so one should expect to be investigated hanging out with those types. Trump actually hung out with Hillary and that scares me because she is the quintessential crook along with being a treasoness liar.

    By the way I read some of your 560 and I am sure there are a few that might have been true, but I saw a whole bunch of mistatements from the trash you seem to indulge in. We can throw mud at each of the candidates, but at the end of the day the candidate most likely needing pardoning and likely will be pardoned is Hillary Clinton. If she is pardoned I expect a lot of others to be pardoned as well leaving all the lower level Clintonites available for prosecution. If this is done as I predict ask yourself why so many had to be pardoned.

  24. Bobby- while I was born during the time Nixon was being pardoned, (so not all that knowledgeable) I wholeheartedly agree with the rest of your post after that. In this case, we do not have consequences yet, only perceived ones. Let’s relax and see what happens.

  25. Who’s, the exchanges? How much did subsidies go up to compensate?

    I find it puzzling (but not really) that those speaking the loudest against Obamacare are the ones who don’t have it, need it, and don’t buy through it. This fight is not about what coverage we all need and can afford, but what ideology of failure the right wants.

    They went up, 1. because premiums were set too low ( optimistic blunder) to reflect that the buy-in enforcement for young/healthy’s would actually work.

    2. Because the Obamacare risk group was a group by itself with nothing to blunt the never-could-afford-insurance-before sick group who needed it and still do – I’m betting a lot in those remote, underserved rural regions you say you care so much about.

  26. How is this any different than 2000? I lived with the disappointment my guy lost when “really” he won. Maybe you would prefer “not enough people spoke outside of California and New York for her.” Any way you slice it, this is the result. The electoral college allowed Penn, MI, Ohio, and WI decide this election. Insurance premiums went up by 30% in Penn, maybe that had something to do with his victory? It would be very interesting to superimpose the map of insurance premium increases, over the surprising states that turned red after years of blue. I haven’t seen that yet, but would find it fascinating. Regardless, it is time to move forward looking at the glass half full. That is how life works.

  27. The primary care system was arguably less broken than before MU and EHR mandates. We CAN go back to the paper system and fee for service, but maybe that is not where the country is headed. Paper is cheap, efficient, and very effective. Getting a 10 page note for an ear infection seen elsewhere with a bunch of junk on it is not as helpful as my 20 line dictation diagnosing the same thing. In 10 seconds or less, I can glance and see what the exam findings were and what medication was used. That is real efficiency. Fee for service is like anything else, a specific payment for a service rendered. The reason it became uncontrollable is due to third party payers “paying” for everything. Why are massages, acupuncture, and other non life-saving treatments covered by third party payers now? When a consumer is not paying directly for that service, it encourages wasteful spending. Why be careful when “it is covered” anyway? I will try to go point by point.
    1) you do not need EHR for population health. You WANT it for this purpose. People get flu shots the same way they have for the last 25 years. In addition, the insurance companies call my patients directly and remind them. Third party payers have databases and should use them plus hire the extra staff to do the legwork.
    2) The system is “wasteful” because we do not have enough care continuity. This is one of the largest issues we have. When patients only see me for a decade, very few tests are duplicated. Also, once you have trained your patient or parent, they utilize fewer services because they know its ok to stay home on Sunday night when their child has a fever. It is a partnership between me and my patient. Receiving one on one care from ONE person with an occasional specialist thrown in here or there empowers consumers to be comfortable making these decisions. CONTINUITY will decrease spending considerably.
    3) When one has Continuity, the physician already knows the patients meds, allergies, conditions at the point of care. In the elderly, the physicians involved could coordinate like they always did, fax a dictation on 1 page and it gets added to the chart. Better yet, give the patient a memory stick and have them print it out and hand it to their primary care doc directly. Now maybe some physicians actually love their EMR systems. Fine, they can keep them. Eliminate the mandate for EMR’s for all of us. Add documentation flexibility.
    4) As far as access, this could be handled many ways. Yes, someone can print out your note and had it to you. It could be put on your “device” within a few days after being seen. When I send a patient to a specialist, I have them take a picture of the dictation note that is most important for that appointment. Recently, we could not get digital xrays transferred to the ortho appointment. I had the mother take a picture on her cell phone of both views. While it is a bit rudimentary, it was effective and helpful for the specialist.

    Although I have written some rebuttal to your points, we really want the same things. We just look at the solution differently. I do not know one physician who really enjoys working with electronic records. It is a pain in the neck. Physicians are supposed to look and talk to patients, not be typing on a computer. It goes against everything we were trained to do and believe. For some reason, physicians keep going along with the changes as if we have no choice. My soapbox is that we do have a choice. While you might not agree how important continuity is, mull over it for a while. It is the way to solve many of our care quality and cost problems.

    I am asking for ‘flexibility’ in the documentation methods for physicians and dropping the mandate. Larger conglomerate institutions can afford expensive technology. I cannot. Why close my small clinic down, when it provides a significant contribution to the community by keeping children safe and healthy?

  28. As far as “the people have spoken”, (which seems to bother you)

    Only because it’s BS. ~25% of voters “have spoken” for Trump. Moreover, Clinton’s popular vote plurality continues to grow, and is now reported at about 1.8 million more aggregate votes than The Donald’s. So, it seems that of those who bothered to “speak” at the ballot box, Trump was not their first choice. That he was nonetheless elected owes to structural Constitutional mechanics more than national popular will.

  29. The only mandate I mentioned was the misguided EHR requirement. I do not think there has been a mandate for the Republicans since 1984 when I was 10. I remember the entire country was almost completely red. In my mind, a true mandate would be considerably different than the results we saw Tuesday night. As far as “the people have spoken”, (which seems to bother you), those people who showed up and voted have chosen a new leader in accordance with the representative democracy in which we live. Neither you or I can do very much about that. We need to embrace change and move forward.

  30. Allan, yes early on I thought I might be in trouble for writing this article, but figured I would ride it out and stick to the central point, which is the world is not going to end. Moving to Canada does not solve the American Healthcare problem. It is time to roll up our sleeves, get to work, and innovate. I suspect there will be some “outside the box” ideas coming down the pipeline.

  31. You know, both of those are intriguing ideas. Tricare Standard works that way with indemnity method if the provider is out of network. Patients just bring in the check and sign it over. It is effective and the consumer understands what “they are spending” so to speak. Anything that encourages ownership of individual health and wellness is a good thing for healthcare overall. Medi-buck type vouchers also helps quantify things more accurately for the consumer. Right now, some Medicaid families tend to over utilize because it is no cost to them. ie, they can email me at night, I will tell them to walk in the next morning at 9am and they still go to the ER for a simple immunization reaction. Patients paying out of pocket are less likely to do these sorts of things. Thank you for reading.

  32. Thanks, Niran, for your thoughtful piece.
    I keep thinking that the root cause of all our problems is third party payors.
    These cause all of us to believe we are dealing with Santa.
    As far as I can see the only ways to get around this problem is to have either have indemnity-type insurance* or to subsidize with Medi-Buck type vouchers.

    *Claims money is paid to the patient first and he/she reimburses the provider.

  33. I’m just pointing out some facts. And I know full well that we don’t have a direct popular vote democracy. If we had that, only 9 states would matter (51% of population). But, this “mandate” and “the people have spoken” talk is simplistic.

  34. Niran, I see early on you were faced with a lot of flak by those who believe bureaucracies provide healthcare and think government bureaucrats are smarter and know more about the needs of the people than the people themselves. How to respond to them while working seems to be a job in itself.

    I especially like your comment:

    “ Mr. Trump has a well-developed tolerance for this sort of ambiguity and is likely the right man for the job.”

    Great comment for those that are so scared they are considering moving to Canada. It also recognizes that the ability to negotiate, compromise and deal with people is a talent that can go unrecognized by those so faithful to EHR’s and the strictest guidelines.

  35. Maybe the donors have learned that their massive donation might yield little reward. I guess the Saudi’s asking Hillary for a refund won’t work and will do more to reduce this type of influence than anything else recently tried. Placing her in jail where she should be might encourage honesty in our politicians. Apparently we have only seen the tip of the iceberg where Hillary is concerned.

  36. Exactly my point Anish. There is hope for a different conversation and that is exciting as we go forward.

  37. Niran, Nice post. it certainly feels like there’s a measure of hope where there wasn’t any before. The change in conversation when it comes to health care is remarkable. Its good to finally hear health-savings-accounts/ direct primary care being discussed openly on the national stage.

  38. You are talking about 2 different things. First you talk about govt rates for different episodes of care. These costs are set by CMS and there is a lot of jawboning back and forth about what these rates should be. In general primary care doctors get shafted and specialists do great; mostly based on the strength of their lobbying efforts from what I can tell. I have yet to see a specialist in private practice that does not make a boatload of money.

    The other costs you mention are the costs of running a practice, which include certain administrative/compliance costs. Certainly any and all regulations that are not necessary should be gotten rid of and/or streamlined. But we have to have some regulations in place, otherwise there would effectively be medical anarchy, which no one would want. So the question is, what is the right amount of regulation? Personally I just have to think that malpractice insurance is out of control because you have all these ambulance chasing lawyers advertising on TV all the time. They make a boatload of money as well.

    Certainly the overall cost of healthcare is predicated somewhat on the underlying costs of delivering goods and services. But that is not the major reason for our high cost system.

  39. EHRs are important for several reasons:

    Remember that before Meaningful Use, you did not have an EHR, and the system was still broken. Costs were rising incessantly. We cannot go back to that old system of paper records and fee for service — we just cannot afford it.

    Why is an EHR important?

    1) you need it for population health. Example: you want certain patients in your panel to receive a flu shot every year. How could you do that without a database? How would you remind them. Are you going to pull 3,000 charts or would you rather just run a computer program that gives you the answer in 1 minute? Some people might go to CVS to get the shot — wouldn’t it be good if you could just download that information into your system? So the point is how do we get the right amount of data that you need in order to run your practice the most efficiently, to provide the best care and to be proactive about avoiding certain bad outcomes.

    2) you need it because our fragmented system is terribly wasteful. I am sure that you know that there are many situations where tests are duplicated because you just don’t know the patient history at the point of care.

    3) you also need to know about meds, allergies, conditions at the point of care. Consider a complex case of a senior citizen under the care of a primary care doc and several specialists. How do they coordinate care efficiently without exchange of data?

    4) As a patient, I want access to my records. I want to know what my conditions are, and when I went to the doctors office. I want to make sure I am getting the right treatment. In fact today I logged into a patient portal and found out that I was overdue for a checkup. Did the doctor let me know? Nope. For all I know my condition could be worse now because I waited too long to see the doctor. I am calling on Monday to make an appointment.

    Now there is a big question as to how to get this data entered efficiently, and what data is actually needed. Physicians need to agree on this, and vendors need to develop EHRs that allow for efficient entry of data. Furthermore, physicians should offload a lot of data entry to staff as it is a waste of their time to do so.

    However, I am not a physician. I would very much like for you to rebut my points above, tell me where I am wrong and to tell me why we should go back to paper, and how that would bring costs down when it did not do that in the past. Remember, its all about the costs.

  40. All this complaining about government regs reducing patient care and doc profits.

    As I’ve said before – have some backbone and go cash only. You’ll be able to lower your prices (good for patients), reduce your overhead, and manage your own work day. No one is forcing you to work for the government or the insurance companies.

    Make America great again – go cash (or chickens)

  41. Niran,

    Thanks very much for taking the time to respond to my questions in detail. I appreciate it very much. I’ve learned a lot about the controversy around electronic records and MACRA (from a pretty low base) during the last several months. While I’m just a retiree now on Medicare who spent my career in the money management business, I’ve had a keen interest in healthcare issues for at least the last ten years or so, partly because of my broad interest in markets and efficient resource allocation and partly because of my considerable experience as a patient dating back to 1999 when I developed some significant medical issues that needed to be addressed with sophisticated interventions.

    It seems to me that attacking the medical records and MACRA issues currently plaguing doctors, especially primary care doctors, could be in the category of low hanging fruit as the Trump administration considers changes and revisions to the ACA or even replacement of it. The good news for doctors, I think, is that the changes you and other doctors would like to see would not be visible to patients, at least in the short term, whereas significant changes in the ability to acquire insurance coverage and access subsidies to help pay the premium would be. The bad news is that CBO budget scoring would not give the system much credit for budget savings because they would be extremely difficult to quantify but politicians would not have to worry about offending the most powerful interest groups like trial lawyers and drug companies. I don’t really know how the insurers feel about EHR’s and MACRA but the issues should be addressable at least in terms of providing relief to smaller practices.

    Previously, as I understand it, the biggest priority for the physician lobby was dealing with the Sustainable Growth Rate (SGR) issue more commonly known as the “doc fix.” That has since been taken care of. I hope the electronic records and MACRA issues can be addressed in a substantive way soon.

  42. Barry- These are great questions. It is difficult to pick just one, but I would eliminate MACRA’s mandate for electronic health records and data collection.

    Just as “Big Data” predicted Hillary Clinton was going to be the President-elect, data is not foolproof and may not even be helpful. As part of the Transformation of care grant, the largest Medicaid provider compiled “quality measure” statistics on my practice using claims data. Numbers showed we were “above average” for ER visits. I pulled the names and evaluated the top 100 utilizers in my practice. More than 50 had NEVER been patients, yet I was judged on their activities/cost to the system. The data teaches nothing.

    Yesterday, I had a busy morning and saw 19 patients in four hours. I dictated all those cases in 20 minutes, leave, and spend the rest of the day with my children. Using electronic medical records, according to most studies, would have taken 8 hours to chart. Most pediatricians used to see 30 patients in a full day. That has become 20 with EHR documentation. Now, seeing only 20 patients does not bring enough income in to support one physician and all the staff required for added data documentation. So smaller practices have been forced to join larger conglomerate organizations to survive. Physicians try to see 25 and then stay late entering information, resulting in burn out or they hire “scribes” to the tune of 40-50K per year and having them manage data entry. The crux is none of this activity improves quality, it just costs more. The population data can actually be pulled from the electronic claims. Leave the physician out of it.

    Interoperability is a nice idea, but the needs of each different medical specialty is what makes interoperability so challenging. The best idea I have heard is allowing patients to have their own data device to carry to each provider which would help avoid duplicate testing and adverse drug interactions. It could contain the information you mentioned above.

    Now as for how MACRA affects my practice. It penalizes small practices who cannot provide the volume of data required. If it is implemented as it stands now, I will ultimately have to close my practice or start a DPC (direct primary care) practice. While some can afford it, many children on Medicaid may be excluded unfairly. It does not feel right in the area in which I live right now.

    The most unfortunate thing is a small practice actually saves money overall. In a large institution, a patient sees a different primary care provider each time they visit. My patients have been seeing me for 16 years. Imagine how well I know each and every child? I can look at them and know when they are sick, need labs, or an x-ray. Other than the cost of an office visit, I am very cheap. That is what saves money plus improves health of people. I am accountable to them and they to me. Multiple studies have shown there is an inverse relationship to physician number in a practice and hospital admission rate. Cost of care at those smaller offices is lower by as much as 30%! I have one of the lowest in the state based on “big data” compiled by the insurance company. I already knew that.

    As to the difference it would make toward reducing overall costs if we had enough time to spend with patients, reduce referrals to specialists, order fewer tests, and admit fewer patients to the hospital, THIS IS THE ANSWER TO OUR ENTIRE PROBLEM! Seriously, keeping things simple is the best way to turn healthcare around.

    As to how much primary care physicians should be paid to entice others, it is difficult for me to predict. The most I have ever made was back in 2005: $145K. Last year it was $85K. I paid almost 30K in taxes, leaving me with roughly 50K as our family income for the year. Who would really choose this as an occupation knowing that was their future?

    I would hazard a guess that guaranteed 200K would entice more people to join our ranks. Also, time spent in these small clinics while in training would definitely bring more our way, but private physicians are dropping like flies. The West Coast has some hold outs that have managed to survive, but our days are numbered. If we could have physicians hanging their shingles in small rural areas again because they can actually make a living, healthcare of the local population would improve. Costs would go down, health would be better.

    Let me know if there is something that needs clarification. Keep those questions coming. The more constructive dialogue on THCB and elsewhere, the better it is for health care of this country. Thank you for reading.

  43. Cost isn’t transparent nor available because government sets the rates and changes them every year, and private payers follow suit. The “true cost of healthcare” discussion has failed to have an open accounting to take into account malpractice insurance cost, taxes, employee staffing and training, a myriad of compliance/board certifications/CME/ biohazard rules/OSHA/regulations that cost the provider–this is never spoken of. Bending the cost curve has proven extraordinarily difficult. Bottom line, the heterogeneity of how people take care of themselves isn’t ever accounted for either. LASIK or breast augmentation costs–outside the realm of third party payment– are easily accessible and furnished upon request. What about a colonoscopy or hysterectomy? Unknown.
    Pharma is out of control but only because they were exempted from Obamacare’s fee schedule, and they were given a pass at the table due to their relentless lobby.

    I hope that Mr. Trump takes his wrecking ball against all of it. It’s rotten garbage.

  44. Thank you Pesto Sauce! I believe our voice would be better heard if practicing physicians in the trenches would unite and be more vocal. On many social media sites, they are still asking “what is MACRA?” That is a huge problem. We are too bogged down doing our job, seeing patients, documenting and saving lives instead of fighting to make sure it remains #OneDoctorOnePatient. That is better for patients, their families, and our country as a whole. Thank you for reading and commenting.

  45. A recent study–


    — for every hour of patient care, there are 2 hours of computer/EMR/EHR work that demands to be done. There are 24 hrs in one day, something has got to give. The electronic records are not interoperable and they do not connect seamlessly with one another, in fact, we were ordered to buy and invest and dream and it has destroyed lives in innumerable ways, both doctors’ and patients’. And we still have to fax the medical records to clinic in Loma Linda. They were not created to be medical documentation, but easy troves for data mining and detailed billing actions. They were not created for the physician as the consumer, but rather for health systems and hospitals in cahoots with governmental grants and rebates which were a joke.

  46. As a fellow physician in the trenches, I must congratulate you on speaking the simple unvarnished truth in this great article. Bottom line, government unfunded mandates and absurd/onerous reporting requirements have killed the soul of medicine. I hope they demolish Obamacare and MACRA! and I hope they leave us alone to put the relationship right–one doctor, one patient. I hope we get to witness he elimination of the pharmacy benefit manager, managed care and assorted bureaucrats mooching insurance premiums and dictating care. Buh Bye CMS bureaucrats, YOU’RE FIRED!!! LOL

  47. Niran,

    If you could only pick one item from your list of proposed changes to the ACA and the healthcare system what would it be?

    As a patient, I was wondering if you could speak in somewhat more detail about the electronics records issue and MACRA in terms of how it affects how you and your colleagues do your job day to day and how many patients you can see each day Specifically, how much more time do you need to spend each day complying with documentation requirements than you had to spend before these rules took effect? My own primary care doctor tells me that these new documentation requirements reduce his productivity as measured by the number of patients he can see each day by about 15%. Any information that medical researchers may be able to learn from electronic records about what works and what doesn’t at the population level may cost more than it’s worth.

    As a patient, I used to think that interoperable electronic records would be enormously helpful in avoiding duplicate testing and adverse drug interactions when there are multiple doctors involved in my care or if I find myself needing medical attention while traveling outside of my home area. I’ve since been told that the main things doctors want to know if I need to be treated in a hospital are (1) what drugs I’m taking, (2) whether or not I have any medical related allergies, (3) whether or not I have a living will or advance directive and, if so, where it’s located, (4) what current medical conditions I have such as diabetes, asthma, high blood pressure, etc., and (5) any prior surgical procedures I had and when they were done. I currently have all of that information on my iPhone and on file with Medic Alert. Any other information providers may need about past test results, etc. can presumably be faxed or e-mailed later.

    Separately, how much more do you think primary care doctors need to be paid in order to induce more of the new medical school graduates to choose primary care over a more lucrative specialty and how much difference could it make in reducing overall healthcare costs over time as a result of having enough time to spend with each patient to allow you to reduce referrals to specialists, order fewer tests and admit fewer patients to the hospital?

  48. Sounds like you are frustrated with our system of representative democracy. True democracy would take popular vote numbers into account, but as I painfully learned in 2000, the country doesn’t work that way. Healthcare must move forward and those of us on the frontlines should get involved this time.

  49. It looks like we agree on most things except electronic records. I disagree the cost of technology we have today helps drive down cost of healthcare overall. The systems we currently have require more time, staff, and work to maintain than plain old paper. Why can private clinics just keep using what they have?

  50. “Billionaire donors and lobbyists already shaping Trump’s ‘drain the swamp’ administration”

    This’ll bring relief to underserved rural America. I can’t wait for my 15% tax reduction.

    Maybe a few “uneducated hillbillies” will round out his cabinet. Duck Dynasty anyone?

  51. It’s the only mandate that counts. The 47% who didn’t vote probably feel neither candidate (or Congress) would have changed their lives to any significance, or they wanted to teach the Dems a lesson for not nominating Bernie – which is like punishing the whole population for the fault of one person. That’ll teach’m.

  52. “The people have spoken”

    25.5% of them for Trump® specifically, vs 25.7% for his opponent — vs the 47% who failed to vote at all.

    Quite the “mandate.”

  53. “It is important to mention those of us in small rural areas are not uneducated hillbillies.”

    Where did I say that? By the way, what have you got against “hillbillies”? Seems a little presumptive and demeaning.

    “Trump did best among white voters without a college degree, beating Clinton by the enormous margin of 72 percent to 23 percent. Trump also won among white, non-college women 62 to 34 percent”

    Not having an education does not necessarily make you stupid, and I see ignorance in well educated people, but lack of an education does however make you less likely to earn a good living, being stuck in a homogeneous community with few options does not broaden your understanding of the wider world and also limits earning options.

    Trumpland: Where hate and ignorance is popular again.

  54. While the author makes an admirable attempt to discuss some of the issues related to healthcare today, he is missing the boat in many areas. First and foremost, just about all of the issues surrounding healthcare today relate to 1 issue: cost. It’s the cost stupid. As the author notes, healthcare consumes 18% of GNP (and rising) — way too high a number. This is unsustainable. Other industrialized countries are doing it for a lot less. Our Rube Goldberg system of healthcare just does not cut it. So any and all discussions about fixing healthcare should focus on cost.

    I can guarantee you that if healthcare was affordable, this would not be the issue it is today. But for way too many people healthcare is literally unaffordable and for most of the rest of us it just takes up too much of our spend.

    I will just comment on a few of the points above:

    1. Yes, we need more primary care. We can’t get enough of it. Primary care physicians are a big key towards driving down costs. They can keep people healthy, they can keep them out of hospitals and they can provide knowledgeable, unbiased consultation for serious health issues that the average person has a woeful lack of knowledge. We need to pay more for primary care, and we need to provide PCPs incentives for value based care. Some of this is underway already.

    2. Wrong. We need electronic records. With our fragmented system of healthcare, providers need accurate information at the point of care when treating patients. This will help keep costs down, and get patients more knowledgeable and informed about their own health. Paper charts are horrible and inefficient. Maybe easier for a physician when thinking about him or herself, but not good as a whole for patient care and keeping costs down. Now as to the point of what goes into an EHR and how much time is spent on documentation, that is certainly valid. We need to find a reasonable middle ground on this.

    4. Innovation among health insurance companies sounds good in theory but really does not work. The only way they make more money is by encouraging more utilization and keeping their 15%. There needs to be someway of controlling this. Furthermore, there has to be an individual mandate. Case in point, my son is in college and had to have an emergency appendectomy last year. If the decision was up to him, he probably would not have purchased insurance because when you are young you feel invincible. No one can say categorically that they won’t need healthcare, so everyone needs to be able to pay the bills. So we need an actuarially sound system. When people don’t purchase insurance, everyone else subsidizes them whether they realize it or not. Everyone has to get auto and homeowners insurance; what’s different about healthcare.

    5. Quality is one of those issues that is really hard to define. But we have to have some way of agreeing on value based care. And we need to have consistency on how physicians treat similar conditions. There is too much variation here.

    6. Agree. Everyone needs to pay. When somebody gets something for free, they do not value it. A big area that the American public needs reeducation on is their role. People need to understand that they have a role in keeping costs down. The attitude of “insurance will pay for it” needs to go away. And we need a lot more messaging on public health. How many unnecessary cases of diabetes do we have? Lung cancer? etc

    7. YES. It’s that simple. Pharma is out of control. Plain and simple.

    Again, it’s the cost stupid. Everyone has a role to play and everyone’s incentive must be towards reducing cost. It’s really that simple.

  55. Let’s just agree to disagree. It is important to mention those of us in small rural areas are not uneducated hillbillies. Your statement is appalling. The people living in rural areas are intelligent, hard-working, honest, and have integrity. If you do not have experience with people living in Health Professional Shortage Areas, then at least refrain from insulting them.

  56. So much wrong with this self serving piece.

    Trump was never an “entrepreneur”, as he risked “other peoples money” then declared bankruptcy several times – using the tax payer as backstop.

    “Sluggish economic recovery in these areas played a significant role in his unanticipated victory.”

    That “sluggish” economy is still a result of the, “don’t need no stinking regulations” financial collapse with the fact that rural economies are always teetering. The other fact is if rural residents want the same income as city folk they need to get an education and leave their county.

    “Those same people want the freedom to buy the insurance they need, and not what the bloated government shoves down their throats.”

    No, they want what they can afford – with the same coverage (and subsidies) as everyone else, even for pre-existing. Don’t you think those rural people with a cancer risk want cancer coverage – or do they want a buffet policy where those wanting cancer coverage pay more because the risk has been concentrated in policies that fewer people buy. Insurance is SPREADING the risk, not concentrating it.

    “25% of the population lives in rural areas yet only 10% of the physicians practice in there.”

    And that’s because most docs practice close to where they were trained – in big cities. How many docs (and their spouses) really want to live in remote, isolated. small town America. But it may take the evil government to help fix it.

    ““The costs are going up, coverage is going down,” Gee, when did you need to be told that?

    This is true for ALL insurance, not just Obamacare. At least Obamacare gave some relief with subsidies – like you may be getting doc. YOU want more money – who’s going to pay for that?

    “Require Medicaid recipients to contribute to their health insurance, on a sliding income-based scale”

    They’re already the poorest of the poor and at the bottom of the “sliding scale”. Medicaid eligibility has income limitations – care to live off those limitations and pay a sliding scale? Now that’s a way of connecting to rural America.

    It appears doc that you went to the same school for false statements as Trump.