Richard Reece is the Editor-in-Chief, Physician Practice Options, and he has written a book which mostly consists of interviews with a wide variety of observers and participants from across the health care system. You can order his book Voices of health reform or see an interview with Kaiser’s George Halvorson first before you buy.  But to save me the trouble of writing a review, Richard wrote one himself, or at least interviewed himself to find out what he thought. You may notice if you are a careful THCB reader that he has shared notes with Brian Klepper at the Center for Practical Health Reform. I think you’ll enjoy his auto-review.

Question: Can we talk frankly?

Answer: There’s no other way we can talk. After all, this interview is one-on-one, mano el mano, me-on-me.

Question: Isn’t it highly unorthodox to interview yourself about your own book?

Answer: Of course. But this is a highly unorthodox book. The book consists of interviews with 40 leading health care stakeholders at work across the ideological spectrum. You won’t find this kind of book anywhere else. It calls for an unorthodox review. Anyway, this is an interview book so an interview review makes sense, doesn’t it?

Answer: I’ll ask the questions here. Who are these "leading health care stakeholders at work?"

Answer: Health care leaders who work full-time at their jobs. These leaders include hospital administrators, practicing physicians, consultants, heads of reform think tanks, author critics, single payer system advocates, consumer-driven care enthusiasts, health plan executives, academic pundits, disease management experts, physician innovators, medical directors of large multispecialty clinics, government insiders, a Chamber of Commerce leader, supply chain executives, and presidents, CEOs, or executive directors of the AMA, AAFP, MGMA, and the Blue Cross Blue Shield Association.

Question: Didn’t you bite off more than you could chew?

Answer: Perhaps. But keep in mind health care consumes one of every seven dollars in the American economy and employs one in every 11 Americans. That’s a lot to chew on, and I wanted to cut across the health care leadership landscape.

Question: Who would be interested in your book?

Answer: Leaders I interviewed, their employees, their followers, and those they serve.

Question: But that would include almost everybody in the health system.

Answer: You catch on fast, don’t you?

Question: Did these stakeholders you selected agree on anything?

Answer: Yes, the need for reform and collaboration on such overarching solutions as basic coverage for all, management platforms to monitor the performance of major players, and medical liability reform.

Question: How did you go about the interviewing process?

Answer: I did all interviews by phone, and I invited my subjects to edit the final transcript. These interviews reflect their opinions, not mine. I remained neutral in the interviewing process. In other words, I ground no ideological ax. I sought to engage in straight talk about what these leaders really thought. I waited until the end of the book before I jumped to conclusions.

Question: And what did the stakeholders conclude?

Answer:Well, in general, they thought the system was hurtling towards an economic abyss. We can’t keep spending two to six times the general inflation rate on health care. The typical premium has risen by double-digits each year over the last five years, with a total increase of 60 percent. That’s unsustainable. Health care is pricing itself out of business. Health insurance now covers less than one-half of private American employees. The erosion of private coverage is growing at 2 ½ percent a year, and the number of uninsured and uninsured is mounting. In the end, without paying health care consumers, revenues will dry up for every sector in the system. When the health care ship sinks, all participating in the system will go down with it. .

Question: You’re giving me a sinking feeling. Some stakeholders must have said you were all wet. Did everybody buy into that shipwreck scenario?

Answer: No, especially those doing well, like high tech medical specialists, health plans, the pharmaceutical industry, and supply chain companies.

Question: So who is suffering the most?

Answer: The have-nots, more and more of the middle class, hospitals, and physicians on the front lines – public hospitals, family physicians, general internists, pediatricians, emergency room physicians. Even the seniors are suffering. They’re paying more out of pocket (21 percent), than before Medicare was introduced (19 percent). Safety net hospitals are the canaries in the coal mine. In July, for example, the St. Vincent’s Health System in New York, one of that state’s largest health systems, filed for bankruptcy. And over 65 emergency rooms in the last 10 years in California have closed their doors.

Question: What are prospects for single-payer?

Answer: Everybody, no matter what their political persuasion or their desire for such a solution. says single-payer isn’t in the immediate cards. Much of the reason is political. The Democrats are still gun-shy after the Clinton fiasco of 1994, and the Republicans are betting the farm on consumer-driven market reform. Some of the wishful thinking "progressives" foresee a collapse of the system between 2008 and 2012, after Bush leaves office.

Question: What about consumer-driven care? Is it a flash in the pan?

Answer: Hard to say. But many observers, George Halvorson, head of Kaiser, and hospital CEOs, are profoundly skeptical about the commercial viability, social desirability, and ultimate sustainability of consumer-drive care. Everybody is watching and waiting to see if consumer-drive care floats, or sinks without a trace of change… Some of the CEOs of major national health plans – McGuire of United, Hanway of Cigna, and Rowe of Aetna – say consumer-driven plans will have a bigger impact than managed care and may completely replace HMOs and PPOs. To these CEOs, consumer-driven care is the "next big thing."

Question: What about Medicare? Is it sustainable?

Answer: Not in its present form. It’s already costing $300 billion, and it will jump to $400 billion next year when the Medicare drug bill kicks in. Medicare now has 42 million beneficiaries and eats up 15 percent of the federal budget. By 2020, it will have 60 million beneficiaries and will swallow 25 percent of the budget. The consensus is that Medicare can’t keep rewarding all providers the same, whether the care is good or bad, no matter what the outcomes. Medicare’s movements towards pay-for-performance, quality measurements, and quality rewards are for real and may have a profound effect on reimbursements of hospitals and doctors. The operative word is "may." It "may" also have a Hawthorne effect, with providers adjusting to meet quality indicators, with no drop in cost levels.

Frankly, the medical establishment harbors deep skepticism about the fairness or workability of pay-for-performance. Doctors don’t believe government can separate the good doctors from the bad using quality indicators or patient satisfaction surveys alone.

Question: What about Medicare payments to doctors?

Answer: Everybody I spoke to expressed pessimism about doctors’ abilities to reverse the 26 percent to 30 percent cuts in reimbursement slated to take effect over the next five years. And most interviewees thought pay-for-performance for hospitals and doctors based on meeting quality indicators was the principle federal strategy for containing federal costs.

Question: Did your interviewees think "seamless interoperable computerization" of doctors’ offices would help save the system?

Answer: Most thought a national information infrastructure would take ten years to build. And most said it would take federal intervention and federal financial incentives to small practices to move doctors off the EMR dime and to make a national system workable.

Question: Does your book have flaws?

Answer: You bet. There are always those damnable typos. And not everybody likes reading interviews. They dismiss interviews as mere "Q&A, " mere opinion-swapping. Interviews are too subjective for some tastes. Also the book has no charts and tables and not many references. It’s just talk from an questioner biased towards physicians. This is a doctor-oriented humanistic, rather than a scientific book. But it’s balanced and presents multiple points of view. I believe reform will depend on high touch high tech innovative solutions emanating out of the private sector, not out of government. But for reform to work, government must incorporate these innovations into their programs. Also never forget some major innovations, like the Internet, started with the federal government.

Question: Did anything surprise you while doing these interviews?

Answer: A few things leap to mind.

One, I was surprised how positively and how fast employers, brokers, bankers, and other financial institutions, are viewing and moving on HSA-linked consumer driven plans. The banks see these plans as a golden opportunity to serve as HSA repositories, to use their information infrastructure to process claims, and to introduce debit and smart cards at the point of care. One health plan executive says HSA-plans will capture most of the market in two years. For physicians, the positive aspect of these developments is that doctors will be paid at the point of care with the swipe of a card. Physicians’ offices will be like ATM stations.

Two, I was surprised how big a role American culture plays in shaping our health system. Since our founding 229 years ago, Americans have believed in a relatively weak centralized federal government, in choices and freedom of action, and in equal opportunity, rather than equal results, for its citizens. Americans, for example, want choice and equal opportunities for access to the marvels of high medical technology. These cultural characteristics will dictate the direction and pace of health reform.

Three, I was taken back by the tremendous strides being made in the disease management field. This is an important development. Keep in mind chronic disease afflicts 125 million Americans. Chronic disease progresses mostly outside of physician offices and depends on patients understanding of their disease and their life style and compliance. When monitored closely and intimately in their homes and at their work and educated about their disease, patients respond intelligently and their health and outcomes improve significantly. Readmission rates to hospitals for chronic heart failure, for example, often drop to near zero.

Four, I was surprised how powerful an overall influence Medicare has. It sets the rules for the rest of the system, and other payers and all providers must follow its lead. One person I interviewed called the Medicare "The Sheriff "of the system, and said nobody bucks the man with the badge. Any reform, therefore, will depend on interactions between Medicare and the private sector. Medicare could, for example, could mandate it would only pay doctors with EMR systems. Here is how Andrew Grove, former chairman of the board of the Intel Corporation, explains the extraordinary power of Medicare, "What is needed to cause the industry to act is customer demand. The largest customer – approaching half of total health care spending – is the Medicare system. The entire health care industry would benefit if Medicare mandated the adoption of a Rosetta code (agreed-upon standards for all computer users) for the health care industry before institutions were granted permission to participate in Medicare business (Grove, A,S, Efficiency in the Health Care Industries: A View form the Outside, JAMA, July 27, 2005)

Question: After completing this book, are you optimistic about the future?

Answer: Not totally. Leading stakeholders in their own "health care silos" are reluctant to jump into reform unless their fellow silo dwellers crawl out of the silo and jump with them… You can take leaders to the brink of reform, but you can’t make them leap. They resist being the first lemming over the reform cliff. This attitude is particularly prevalent among health plans, hospitals, and health care associations. Physicians strike me as most eager for reform, perhaps because they see first-hand what’s happening in the clinical trenches.

On the other hand, I’m optimistic because Americans are a very entrepreneurial, innovative, and adaptable people who like solving problems. I think we’ll end up with a uniquely American public-private collaborative with lots of innovation and multiple payers.

Question: Who do you think ought to buy this book?

Answer: Health care stakeholders who want to know what their fellow stakeholders really think and who want to get a sense of what reforms are likely to occur.

Question: Thank you for your penetrating, insightful, and profound comments.

Answer: It was nothing really. The pleasure was all mime.

It’s not exactly major health reform, not universal health insurance, not even anything on the scale of the 2003 Medicare bill, but Congress is starting to put some legislation together on health reform. The new patient safety bill sets up a system for error reporting. It may be voluntary and underfunded, but at least it’s a response to something health care policy wonks know has been a problem for decades. Ditto with the forthcoming legislation on data interoperability. Love it or hate it, the Senate is clearly going to take another run at malpractice, and there’s also "reform" of the laws around state mandates for health insurance in the Associate Health Plan legislation that’s coming out of the House. In addition Nancy Johnson (R-CT) is proposing to mainstream pay for performance as the way Medicare pays physicians. None of this is too significant for the overall health system, although individual laws will have an impact on different players in the system. But the activity signals that Congress realizes that there are fundamental problems in our health care system, even though we are an election or two away from having the real stomach to do anything about it.

So this time it’s the University of Arizona Pain Clinic which is planning to close. Why? It’s main doctor has left and they can’t find anyone to replace him — I wonder why. So what does that mean?

During the past year, the UA Pain Clinic logged more than 5,800 patient procedures and outpatient visits and is estimated to treat 750 chronic-pain patients who require ongoing care, UPH records show.

So a mere 750 patients in chronic pain will be scrambling to find new doctors or face more pain….score another one for the DEA and its medical "ethics".

Those of you who get my FierceHealthcare newsletter (and if you don’t you should as it’s free!) will have read plenty from the NY Times last week about how Medicaid is a web of corruption and fraud and from the Washington Post this week about how Medicare is a maze of inefficiency that wastes one dollar in every three. OK; not exactly news to those of us in health care. In fact the very first post on THCB was about how screwed up Medicare was and why. (Hint: the answer is fee-for-service medicine)

This has now degenerated into a blogging argument between those "pro-business" DLC Democrats who think that the party should get in the vanguard of reforming those programs, and the liberal Dems who are scared (rightly) that given who’s in power (i.e. neither of them) any excuse possible will be taken by the current bunch of clowns running the country to eviscerate both programs to the detriment of those they cover.

And worse, TNR’s Jonathan Cohn who is probably quaffing his third latte before setting off to get his kids from soccer practice in his Volvo 4×4 has decided that, as his time is more valuable than mine, I should have to do remedial education for the whole party.

The first point obviously is that in any sensible country the liberal end and the pro-business end of the Democratic party would be two different parties, and the fundamentalist loonies/mercantilist thieves that compromise the Republican party here would still be locked in the attic. But given that that’s not the case, let me try to set out the problem here as simply as possible.

The problem: Government-funded health care programs in the US (and Medicare and Medicaid are by far the two largest programs within that category) do two completely different things

First, these are benefit programs for seniors and the very poorest of the poor. Without them, the elderly would be dying in the streets (just as the uninsured actually are), just as without social security we’d be back to bread lines. That is because (and this is something the American public just cannot get its brain around) health care costs are very uneven –they are concentrated among the old, the sick and the poor far more than other groups — and if we want to help those groups we have to subsidize them. That is what social insurance is, and that’s why we pay taxes. (Or at least that’s a small part of why we pay taxes, and it’s the part that Grover Norquist et al think we shouldn’t be paying for). The good news is that overall the American public believes in that cross-subsidization, whatever Grover and his pals may think.

Now we come to the second part of the story. Medicare and to a smaller effect Medicaid are extremely complex programs that don’t give a direct benefit to their "members" but instead allow an entire industry (in fact many industries) to deliver goods and services to those people with the government picking up the tab. Yup, Medicare is closer to defense spending than anything else, and within it there’s the same level of complexity, fraud and bad behavior as in that sector (and I never mentioned Halliburton once. Dang, just did!). In fact as Medicare sets the tone for almost all health care spending, but there are hundreds of payers rather than just one big one, health care is probably more complex, fraud-ridden, and inhabited by murky characters than defense…but I digress.

More importantly the defense contractors doctors,hospitals, insurers and more recently drug companies were heavily involved in the writing of the original rules of these programs (for more read down in my Hillarycare article from last week). So they made the programs look as much like an open spigot to the US Treasury as possible, and the Federal government has been trying (and failing) to balance between the aggressive demands of those concentrated interests and those of the beleaguered taxpayer ever since. And although Medicare is very popular among its recipients (remember their alternative is dying in the streets), because costs have gone up so much, as a share of income those recipients have greater proportional out of pocket costs than they did back when the program was introduced–even though Medicare is taking care of most of their costs.

Why is this? Well essentially the cost of health care is the services delivered times the price. Those delivering services will always tell you that if you want to reduce costs you must reduce services, and will always explain why the other side of that equation must be fixed (or in fact must ratchet upwards). Of course, that’s been explained many times to be rubbish, but that won’t stop providers putting a bunch of old ladies on the street to protest Medicare cuts….and hence blurring the lines between the two parts of the story.

If they are really interested in getting this debate advanced along, both sides within the Democratic persuasion should agree on two things.

First, that the health care system as a whole will always raise prices and accept losing a few to the uninsured pool as a price effect, rather than seek a different solution because that solution is to put everyone into one pool and, gulp, limit the total dollars going into it. That’s why universal coverage (with some manner of a controlled budget) is in the end the only way to get costs under control–and it’s done that way in every other country, even if they all look very different to each other. If you don’t do that, the system will inevitably keep costing more and more, and Medicare and Medicaid will have to pay their share of it. You see we can always spend more, and would you deny care to a little old lady?

Second, that even without getting to universal coverage, you can reform Medicare and Medicaid in ways that providers may not like without financially or physically hurting patients, and that those reforms may also help reduce the waste and fraud (or at least put it on the tab of a private insurer!). How to do that is a much, much longer conversation, but the important part for this piece is that it is theoretically separable from the need to privatize the funding of the system (via means testing), which will turn Medicare from a benefit program to a welfare program — with the inevitable result of it being marginalized and all the gains of the first part of our story being eroded.

As you’d rationally expect, immigrants end up using less health care than those born here. My assumption is that it’s a factor of income and insurance status, and it seems that they do use relatively more ER care because of that. On the other hand many legal and illegal immigrants are paying taxes and not using services (especially those of working age paying Medicare tax, but planning to retire back to their country of origin), and are probably a net financial gain to the health care system.

But overall I just wonder how Don Johnson’s going to spin this.