Category: Medical Practice

PHYSICIANS/POLICY: Physician Shortage Looms–hold onto your wallet

Quoting a bunch of head hunters and a rural doc who can’t find anyone willing to move to Ukiah, the Los Angeles Times says this:

A looming doctor shortage threatens to create a national healthcare crisis by further limiting access to physicians, jeopardizing quality and accelerating cost increases.

And so apparently we must build more medical schools and train more doctors, even though the doubling of the number trained in the 1970s hasn’t fully worked its way through the system and won’t for another ten years.

Momentum for change is building. This month, the executive council of the Assn. of American Medical Colleges will consider calling for a 30% boost in enrollment, double the increase it called for last year.

Meanwhile the Dartmouth guys (who maintain their starring role in THCB) say something oh so slightly different:

AMC inputs were highly correlated with the number of physician FTEs per Medicare beneficiary in AMC regions. Given the apparent inefficiency of current physician practices, the supply pipeline is sufficient to meet future needs through 2020, with adoption of the workforce deployment patterns now seen among AMCs and regions dominated by large group practices.

The powers that be in health care are advocating more money to come directly from the taxpayer into the system to train more doctors, who will then cost the nation much more when they go into practice. Of course that’s a much easier answer for them than rational reorganization of the health care system by somehow or other making it all look more like Mayo.

So how do they start using language to persuade those of us suckers who are going to have to pony up for this that they’re right and the Dartmouth crew are wrong?

The AMA changed its position on the physician workforce a year ago, acknowledging that a shortage was indeed emerging. The consensus has shifted so quickly that experts who view the physician workforce as adequate — though poorly distributed, inefficient or wasteful — now are seen as contrarians.

So that’s it. Wennberg (and Goodman and Fischer and the rest of them) are now officially “contrarians”. Hmm…aren’t they the ones who make all the money on Wall Street?

CODA: The same edition of the LA Times has an article about the international outsourcing of radiology reading, which gives a clue as to how some of that “rational reorganization” might happen.


I was checking out potential book titles when I cam across this site, Health Care for Dummies. Given that I’ve spent some of the week beating up on the AMA, and spent some of yesterday touching on why the health care system looks like it does today—mostly based on Paul Starr’s book. But the real conspiracy theory is much more fun (even if I can’t exactly vouch for the truth). Read on for an amusing Friday diversion.

I’ll see ya back here on Tuesday



To those of you who’ve been paying attention, this may not exactly be news.

Apparently, health insurers don’t pay claims immediately and deny some of them. But it is news because practice management/billing company AthenaHealth has quantified the numbers across its practices and published a list by plan of who’s paying when. They’ve even sent me the spreadsheet with every plan’s numbers. And they, or rather their apparently amazing PR company (which called me at 6 am—don’t worry I’ll be making them pay my divorce lawyer’s fees) have done amazingly well to get this into Milt Freudenheim’s story in the NY Times called The Check Is Not in the Mail.


But is this news? Insurance companies make money off the float—always have. So it’s in their interest to be at the bottom of the list until either they get fined by the state (as happened to United in Arizona lately) or they get sued by medical associations (as happened to all the big guys in the late 1990s) and settle as Aetna and a bunch of others did three years ago. The numbers AthenaHealth put out seem to be a little better than they were in the 1990s, but maybe not as good as the doctors would like. If I was Humana CEO I’d call my CFO in and ask why we’re on the top of the list when the bigger more profitable plans are down the bottom!

Maybe I just love conspiracy theories too much, but given the NY Times penchant for printing up any rubbish that gets pushed to it by the current administration, perhaps Freudenheim is craving some of Judy Miller’s publicity! After all the CEO of AthenaHealth is not only named Bush but he’s a blood relative.

I’m also amused by the comments from the doc quoted:

Dr. Molly Katz, a Cincinnati gynecologist and former president of the Ohio Medical Association, said she hoped the publicity would encourage insurers to improve their payment practices. "I would much rather have my staff talking to patients than talking to insurance companies," Dr. Katz said.

Be careful what you wish for, Dr. Katz. Given that the organized medicine is getting its wish and we’re seeing more high-deductible plans, she’ll find that her staff—while they may not spend less time on the phone with insurers—will be spending much more time on the phone with their patients. Trying to get them to pay their bills!


So why did I get so grumpy with the secretary of the AMA and his talk at TEPR. I actually stood up and asked a long question which he interrupted to tell a bunch of lies about Canada, ignoring that there are lots of other countries with universal health care that do it differently and better. When I finally got to ask about why when ePrescribing was originally mandated for Part B in the house version of the 2003 MMA eRx legislation and ask as to why it mysteriously was left out of the final bill, and what was the AMA’s role in that — well as Neil Versel said to me afterwards “no one dodges the question like the AMA.”

Things he featured prominently………………The uninsurance crisis and how tough that is for doctorsThings he didn’t mention……………………The AMA’s long, long history of opposing universal health insurance including 1994

Things he featured prominently………………The AMA’s proposal for tax credits for the uninsuredThings he didn’t mention……………………That those proposals do almost nothing to reduce uninsurance

Things he featured prominently……………….How Pay for Performance was unfair on doctorsThings he didn’t mention……………………The AMA’s long, long history of opposing quality improvement

Things he featured prominently……………….How Medicare pay rates have fallen by half over timeThings he didn’t mention……………………The vast real increase in physician incomes since 1965

Things he featured prominently……………….How physicians will drop Medicare patients if fees go downThings he didn’t mention……………………The research that shows that this is untrue and an empty threat

Things he featured prominently……………….How other countries government’s paid for doctors’ ITThings he didn’t mention……………………How other countries doctors earn much less than him and his colleagues

Things he featured prominently……………….How the government should pay for physician IT but not mandate its useThings he didn’t mention……………………Every other business has been force to get IT to better serve its customers

Things he featured prominently……………….How Canada has rationing and is going to allow some private medicineThings he didn’t mention……………………That low–middle income Canadians don’t go bankrupt from the cost of health care

Yup, apparently it is just everyone else’s fault and physicians have no need to change anything.

I am on record as wanting doctors to run our health care system. I want physician organizations to get the money and decide its rational allocation . But apparently organized medicine’s response is to bury its head in the sand and demand that the rest of us hand them a blank check, and let’s all pretend it’s 1972 again.

Please please someone tell me that this guy is an anachronism and that he really doesn’t represent physician opinion….or else I will get even more depressed…

PHYSICIANS/TECH: The intransigence of the AMA knows no bounds

Here’s what I wrote for FierceHealthcare today.

Attendees at the 22nd annual TEPR meeting could be forgiven for being a little anxious about the future. Conference organizer and Medical Records Institute Peter Waegemann put out a call for action, noting that at the first conference some speakers thought electronic medical records would be here within three years, then ten, and now more than twenty years later we’re still arguing about different standards. The keynote from AMA secretary Joseph Heyman showed where the problems lie. Although Heyman is a solo practitioner who runs a paperless office and has been using EMRs since 2001, he trumpeted his organization’s party line—No cuts in Medicare, or risk that doctors will stop taking patients. Great suspicion of pay for performance. Opposition to mandates to use technology. Demands for straight payment to acquire and use technology. Apparently the medical world has gone to hell and it’s anyone but the AMA’s fault, so apparently we shouldn’t expect doctors to save the health care system by using IT, unless it comes at no cost and inconvenince to them.

I’ll be back with a little more, and some much harsher words later.

PHYSICIANS/BLOGS: Disheartened? Maybe

I love people commenting on THCB, and 99% of the comments are very, very thoughtful. But I am a little dismayed that while only one person wants to comment on my long piece on the individual insurance market, one other on VC in health care (and that someone I wrote about clarifying a point she made) and none on my experience at the consumerism conference—28 people have something to say about a malpractice study I just point to!

People, malpractice is one percent of the dollars, and it’s about 17th on the list of major health care problems and issues we face in this country! It’s the abortion issue of health care—polarizing way way beyond it’s importance.  <sigh>

PHARMA/PHYSICIANS: Attacking the Rx data stream

So perhaps this is getting serious. Doctors Object to Gathering of Drug Data

If the A.M.A effort succeeds, "legislators will turn their attention elsewhere, and the industry can hang on to one of its most valuable data sources," according to an article this week in the industry trade magazine Pharmaceutical Executive, which was co-written by an A.M.A. official and an executive with the leading vendor of prescription data. Even many critics concede that patients’ privacy is apparently not an issue, because the tracking systems identify only the prescribing doctors, not patients. But many doctors find the use of the data by sales representatives an intrusion into the way they practice medicine."These doctors were outraged that people came into their office and talked to them about how many times they prescribed a particular drug," said Dr. John C. Lewin, the chief executive of the state medical association in California, one of the states where complaints about the current system arose.  The California group is beginning its own program under which doctors who do not opt out under the A.M.A. system will get comparisons of their prescribing patterns in 17 classes of drugs from the data companies, said Dr. Lewin, who added that the program was being started as a pilot effort that he hoped would be extended statewide.

This latest dose of outrage is almost hysterical. In both senses of the word.

There are some doctors who are vehement in their opposition to drug companies. They won’t take the free lunch. There are some who take advantage. For most, they have a fairly neutral opinion of drug reps. But the concept of not allowing anyone to know their prescribing patterns doesn’t exactly smack of the transparency that we’ve heard so much about. And frankly if the drug companies don’t know how to detail docs as efficiently as possible (and for that they do need the data) it’s likely that their marketing efforts will get more unfocused and more onerous on the system as a whole. And in general I’m of the belief that useful targeted marketing & sales is better than blanket non-targeted efforts. So unless we are going to ban ALL pharma marketing (which will mean tossing a great deal of useful babies out with the bath-water) and fundamentally change how information about drugs is communicated to physicians, then getting rid of the IMS type data is not helpful.

POLICY/PHARMA/TECH/PHYSICIANS: The Industry Veteran thinks Uwe and McLellan are missing the point

It’s been a while since we heard from The Industry Veteran, but the dialogue between Mark McClellan and Uwe Reinhardt I reported on at WHCC last week did raise his hackles. I love Uwe’s analysis and think McLellan is very sensible (though suffering from obvious political restraints). But the Veteran didn’t exactly see it that way. Here’s his sense of what ‘s wrong with health care and how to fix it.

The dialogue you reported between Mark McClellan and Uwe Reinhardt was hugely disappointing as both appeared more intent on glad-handing each other than identifying culprits in the health care system. I offer the following as a useful rule of thumb for THCB readers: whenever someone says more IT represents a principal solution to a better health care system, the red light should flash on one’s shit detector.As uncle Marcus Aurelius advised, let’s return to first principles. Assuming THCB wishes to address the big issues and not turn into a blog for techie nerds, the problems of health care cost, quality and access in the U.S. result from some basic factors. The first of these is that there are too many middle men extracting too much profit (or, in Marshallian terms, too much economic rent) from the system. Among these, third-party payers are both pernicious and dispensable. Most analysts euphemistically classify payers and the efforts of other sectors to deal with them as “administrative costs.” It seems I’ve been seeing these administrative costs pegged at 25-30% of the health care bill for the past twenty years. Since Bush’s millenarian-oil junta has been running the country, I would guess that figure to be substantially higher because payments to providers have been tapering while premiums keep escalating. Given that the administrative costs for Medicare are approximately 2%, it appears self-evident that the current system, based on employers and insurance companies, should appeal only to Reagan-Bush types who consider the proper role of government to be one of handmaiden to business.Within the provider segment, specialist physicians are another extortionist bunch. There is simply no defensible reason for every mother’s doctor-son to expect an annual income between a quarter-million dollars and $650,000. Do I hear in the background, diminuendo, the arachnid voices of techie wonks crying for tactical proposals in lieu of venting and ideology? Sink your incisors into these. (1) Use relative value reimbursement scales to promote a systematic de-skilling. (2) Increase the labor supply in the medical specialties with U.S. citizens who graduate from foreign medical schools. (3) Feminize the medical profession by elevating nurse practitioners and using staff-model and other arrangements that permit 9-to-5 shift work.Manufacturers, particularly in pharmaceuticals, are due their reproach as parasitic middle men. The European countries routinely use reference pricing to help keep them in line and health care’s Iron Triangle of cost-access-quality does not appear worse there than here. In fact the WHO rates U.S. health care as thirty-something in world while France receives the number one spot.Now you’re probably correct, Matthew, in pointing out that the public opinion polls on health care have to show a larger percentage of people expressing a vehement discontent with the system over a sustained period before substantive change can occur. To foster that attitude, I humbly advise interested parties to hammer away at the big issues instead of creating diversions and wasting time with minor tributaries such as IT. I believe there is sufficient greed to expose, enough contradictions to raise and tragedies to highlight, all of which can help prepare the public mood. The drama that can affect public attention, however, seldom resides in the IT department


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