Firms Feel Pain From Health Law

Big employers faced with incorporating the first round of health-care changes next month are grappling with how to comply with the long list of new rules.

Many companies are hiring consultants to help sort though the mountain of new mandates, which include extending dependent coverage to children up to age 26, and may eventually result in covering more employees. Some are also considering changes to their plans—including pushing costs to workers.

There is also some concern about how to digest the sheer volume of paperwork.

"There's administrative burden just to try and understand the 2,400 pages of the document," says Jenn Mann, vice president of human resources at software maker SAS Institute Inc.

As a result of the reform, SAS is doubling its legal and consultant expenses for 2011, says Ms. Mann. She declined to provide a dollar amount, and SAS wouldn't say what it currently spends on health-care overall.

SAS is also taking steps now to prepare for changes that take effect in future years. In 2018, a tax kicks in on employers with plans whose costs exceed certain levels. If SAS doesn't adjust its health plans, it estimates the tax will cost it approximately $20 million a year, says Ms. Mann.

To help get under the threshold level, in January SAS is eliminating its higher-cost indemnity plan and is also doubling co-pays to $20 from $10, she says. The company may still have to shift more costs to employees to avoid the tax, she says.

The U.S. Department of Health and Human Services says the health-care act "lowers costs for American businesses. The law provides small business tax credits, reimburses employers from some of their highest early retiree costs and cuts the hidden tax they often pay to provide care for the uninsured."

A survey conducted by Ernst & Young in August and September of 381 executives found that 31% are most concerned about the cost of compliance with the law, while 16% were most concerned about their overall readiness to comply with the law.

Borders Group Inc. has increased health-care-related consulting by around 20% to help it understand the law, says Rosalind Thompson, senior vice president of human resources.

Borders' 16,500 part-time employees in the U.S. are offered health coverage through a type of plan known as a "mini-med," which offers limited coverage.

Such plans may be more likely to run afoul of the law's requirements that insurers spend a high portion of premiums on medical care rather than administrative expenses. Those plans won a reprieve in November that loosened the requirements for 2011, but Borders says it's still waiting for guidance on how the rules will apply afterwards.

Ms. Thompson says Borders is also figuring out how to respond to the difference between how the law defines full-time and how Borders does. Borders considers employees who work 32 hours per week full-time, but under the new federal health law, employees who work 30 or more hours would be considered full-time.

Under that definition, Borders would have to cover more employees on its more expensive health-care plan.

"We'll have to do something different with part-time employees ... but until guidelines are fleshed out we don't know what," she says. The company says it's unsure whether it will reduce some employees' hours.

Borders is a member of the National Retail Federation and other groups that lobby on the company's behalf, and hopes those efforts will yield some concessions, Ms. Thompson says, though she wouldn't elaborate.

Neil Trautwein, vice president of the National Retail Federation, says the group has "a lot of concerns about the penalty mandates" and opposes "changing the definition of a full-time employee."

Furniture manufacturer Leggett & Platt Inc. is considering shifting costs to employees as it expects to have to bring more employees and dependents onto its plan.

John Moore, vice president of human resources, says that complying with the first round of changes next year will raise health-care costs by 2% for the company.

For instance, the Carthage, Mo., based company next year expects to cover more dependents after having to extend coverage to children up to 26 years of age, says Mr. Moore.

In 2014, the bill requires most people to have health insurance. Mr. Moore says he worries that will cause many of Leggett's employees who have opted out of the company's health coverage to sign up, raising Leggett's costs. Thirteen percent of Leggett's eligible employees "opt out" or elect not to have health coverage; many are young or dropped out of the plan to save money.

Mr. Moore says the company may consider increasing employee co-pays or implementing high-deductible plans in order to compensate.

Ryder System Inc. has increased its use of outside consultants by as much as 20% since March to help guide its response to the bill, says Gregory Greene, executive vice president and chief administrative officer of the truck rental company.

Until recently, the Miami-based company covered children until the age of 19 and full-time students up to 23 years of age, says Mr. Greene. Next year, it will have to cover dependents up to age 26 and remove a lifetime limit on claims.

Ryder doesn't expect big additional costs from those changes, but worries about future changes as regulators continue to flesh out some aspects of the law.

"The most concerning part is not knowing," says Mr. Greene.

From The Wall Street Journal by Dana Mattioli

Reviewed / Posted by: Scott W. Yates, MD, MBA, MS, FACP

Gates Rethinks His War on Polio

Bill Gates walked into the World Health Organization's headquarters in Geneva—for a meeting in an underground chamber where global pandemics are managed—and was greeted by bad news.  Polio was spreading across Africa, even after he gave $700 million to try to wipe out the disease.  That outbreak raged last summer, and this week a new outbreak hit Tajikistan, which hadn't seen polio for 19 years. The spread threatens one of the most ambitious health campaigns in the world, the effort to destroy the crippling disease once and for all. It also marks a setback for the Microsoft Corp. co-founder's new career as full-time philanthropist.

Next week, the organizations behind the polio fight, including WHO, Unicef, Rotary International and U.S. Centers for Disease Control and Prevention, plan to announce a major revamp of their strategy to address shortcomings exposed by the outbreaks.

Polio is a centerpiece of Mr. Gates's charitable giving. Last year the billionaire traveled to Africa, one of the main battlegrounds against the disease, to confer with doctors, aid workers and a sultan to propel the polio-eradication effort.

"There's no way to sugarcoat the last 12 months," Bruce Aylward, a WHO official, told Mr. Gates in the meeting in the underground pandemic center last June. He described how the virus was rippling through countries believed to have stopped the disease.

Mr. Gates asked: "So, what do we do next?"

That question goes to the heart of one of the most controversial debates in global health: Is humanity better served by waging wars on individual diseases, like polio? Or is it better to pursue a broader set of health goals simultaneously—improving hygiene, expanding immunizations, providing clean drinking water—that don't eliminate any one disease, but might improve the overall health of people in developing countries?

The new plan integrates both approaches. It's an acknowledgment, bred by last summer's outbreak, that disease-specific wars can succeed only if they also strengthen the overall health system in poor countries.

If successful, the recalibrated campaign could shape global health strategy for decades and boost fights against other diseases. A failure could rank the effort as one of the most expensive miscalculations in mankind's long war with disease. Already, polio has evaded a two-decadelong, $8.2 billion effort to kill it off.

Big donors have long preferred fighting individual diseases, known as a "vertical" strategy.  The goal is to repeat 1979's victory over smallpox, the only disease ever to be eradicated. By contrast, the broader, "horizontal" strategy has less well-defined goals and might not move the needle of global health statistics for years.

The polio fight is a lesson for Mr. Gates's foundation, which is funding other vaccines that could face similar setbacks. In the polio fight, his foundation backed a program that was following an outdated playbook. Polio's resurgence last year forced a major rewrite.

The shift on polio was informed by Mr. Gates's trip last year to Nigeria, a nation with a history of exporting the virus to other countries. Mr. Gates was accompanied by a Wall Street Journal reporter.

Mr. Gates has forged himself as a global-health diplomat following his 2008 retirement from Microsoft. He is using his star power and $34 billion philanthropy to try to push businesses, health groups and governments to improve health in developing countries. 

In the Nigerian city of Sokoto, the dusty center of a once vast Islamic empire, Mr. Gates drove to a palace, walked past a row of trumpeters and found himself looking up at a man on a throne wearing a flowing robe and turban—the Sultan of Sokoto, spiritual leader of Nigeria's 70 million Muslims.

Just as Mr. Gates introduced himself to the sultan, the lights flickered out.

"I want to welcome you to the real world—to the real third world," the sultan said to Mr. Gates from his gilded chair in the darkened room. 

Men like the sultan are important allies. In 2003, Islamic leaders in northern Nigeria spread rumors that polio vaccines sterilized Muslim girls. Leaders halted vaccinations, allowing the virus to spread. The WHO said the virus eventually infected 20 countries.  By the start of last year, Nigeria was home to half of the world's 1,600 polio cases. The sultan could help get the campaign back on track.

Speaking to Mr. Gates and a room of religious leaders, the sultan declared his support for the polio fight. "We want to show you our commitment," he said. "The time you have taken to come here will not be in vain."

But he, too, questioned the wisdom of targeting one disease. "Other health issues should be looked into," the sultan said, "instead of just facing one direction with polio eradication." He ticked off tuberculosis, HIV and AIDS, malaria, cholera and a parasitic infection known as "snail fever."

After the global victory over smallpox 30 years ago, a rush of energy went into similar "vertical" attacks on single diseases. The polio program followed that approach and made great gains. Led by WHO and donors such as Rotary, the campaigns by the year 2000 slashed the world's polio cases to under 1,000 from 350,000 in 1988. Polio fighters planned to eradicate the disease by 2000.

That date came and went. But polio persisted, eating up billions of dollars. 

Critics argued for a shift away from killing polio to free up money for controlling multiple diseases. In some countries, polio campaigns became an example of a functioning vaccination system even as other diseases were missed. Mr. Gates saw that himself in Nigeria.

Arriving at a Sokoto health clinic in a Toyota minivan stocked with Diet Coke, Mr. Gates stepped inside and was soon leaning on a wooden desk, flipping through children's vaccine records. "Do you know if this child had the first dose of DPT?" he asked, pointing to a record of a diphtheria vaccination of a boy who appeared to have missed a treatment. A health worker beside him didn't have an answer.

The clinic also had no hepatitis B and yellow fever vaccines, the workers said, because the government's system for supplying medicine wasn't working.

By contrast, in front of the clinic, a polio campaign was in full swing. Health workers tended coolers filled with vials of vaccine for children gathered there. 

At a meeting the next day in the capital, Abuja, Nigeria's head of primary health care, Dr. Muhammad Ali Pate, reopened the vertical-vs.-horizontal debate. Even if Nigeria lowers polio cases, he said, the gains "can't hold" without a broader health-care system, he said.

Mr. Gates listened, seated behind a name tag that read "Our Guest." Dr. Pate showed a slide of a cartoon steam-engine train with cars labeled "Education" and "Disease Control." Polio should be just one car in that train, he said.

Mr. Gates didn't disagree—certainly Nigeria needs a functioning health system, he said in interviews. But it was a matter of priorities, he said. With the world so close to killing polio, countries like Nigeria should make eradication a top priority, he said. Victory would free up millions of dollars to pay for broader health improvements.

"So the benefit of finishing is huge," he said.

On the plane, Mr. Gates strategized about what else would help win the fight, balking at one religious leader's suggestion: forced vaccinations. "Strap 'em, down, I say! Let's make it illegal" to not take the vaccine, Mr. Gates joked. Then he got serious again, citing failed attempts in the U.S. to enforce compulsory vaccinations.

In many respects, Mr. Gates remains a tech geek at heart. Aboard his plane, he expounded on an array of scientific topics: From developments in genotyping, to research showing that Bangladesh's high disease-immunity rates are due to "oral-fecal" transmission (when people build immunity by ingesting contaminated food or water).

In Nigeria, Mr. Gates scored a diplomatic triumph. He won commitments from the sultan, and Nigeria's governors, to take a more active role in polio vaccinations. "We really stand at the threshold of global health success on polio," he told the assembled governors at the close of the trip.

However, just three days later, a new front opened 2,000 miles away in Uganda. There, a woman walked into a hospital to say her son couldn't move his left leg. It was Uganda's first polio case in 12 years.  Cases also popped up in Mali, Togo and Ghana and Cote d'Ivore, which hadn't reported polio for four years. A girl in Kenya became that country's first polio case since 2006.

Polio, which spreads through water contaminated by human feces, paralyzes just one person for every 200 infected. Discovering just a few cases could mean that thousands have been infected. 

That demands massive vaccination campaigns.

On Feb. 28, 2009, Mr. Aylward, the WHO official, was grocery shopping in Geneva with his wife and son when he got an urgent email about the Uganda case. For 30 minutes, Mr. Aylward stood next to a spinach display, working his phone and setting in motion a plan that 10 days later vaccinated 48,000 children in Uganda.

Costly emergency responses like this became increasingly common last year. The Gates foundation had set $47 million aside for emergencies, Mr. Aylward said. By early June, the money was running down.  That month, Mr. Gates flew to Geneva for the meeting in the WHO's underground room.  Mr. Aylward came with good news to offset the bad news about polio's resurgence, he recalled later.

After describing the outbreaks, he shifted to Nigeria's progress against polio and described positive results from a trial of a new vaccine. 

But those positives didn't offset the risks of polio's revival, say several attendees of a follow-up meeting. "It was becoming evident that the virus almost knew no bounds," said Dr. Steve Cochi, senior adviser at Centers for Disease Control. "It kind of confirmed some of our worst fears."

A month later in Seattle, Gates Foundation officials paused at a PowerPoint presentation showing the foundation's polio grants were approaching $1 billion. It was a staggering amount for a program that appeared to be stalling. "We can't go to Tachi and Bill and ask for more money," without reviewing the program, one person said, referring to Mr. Gates and Tachi Yamada, a top foundation official, according to an attendee.

In August, experts commissioned by the WHO landed in Angola, Pakistan, Afghanistan, India and Nigeria to evaluate the polio program. In Africa, a team found that once polio had been ended in some countries, weak health-care systems let it return. In northern India, bad sanitation, malnutrition and other intestinal issues are believed to hurt the oral polio vaccine's effectiveness.

These findings echoed the message to Mr. Gates in Nigeria, and marked a turning point among the Gates Foundation and other backers of the polio fight in the debate over whether the strictly "vertical" polio strategy could succeed.

In October, the Gates Foundation summoned backers of the program, including Unicef, CDC and Rotary, to its Seattle headquarters for a major rethink. Two weeks later it called in independent experts for help. The outcome of those meetings will be reflected in the revamped plan coming next week. Polio backers say they are buoyed by reports of just 71 polio cases worldwide this year, vs. 328 in the year-earlier period. 

If approved in May by member nations of the WHO, the new strategy will set ambitious goals for getting close to eradicating polio by the end of 2012. The plan bolsters the core "vertical" approach of polio program but also adds a "horizontal" strategy, including training for health workers on topics such as hygiene and sanitation.

Nigeria will be a key testing ground. The country has made strong progress against the disease since Mr. Gates's visit. But stopping polio there, and in at least one of the three other countries where it's deeply rooted, will be the main challenge in the next three years, Mr. Aylward says.

Failure to achieve that goal will raise questions over whether the program continues, he says.

A big hurdle is money. The polio program is $1.4 billion short of the $2.6 billion it needs over next three years. The Gates Foundation will continue its polio grants, but says it can't make up the shortfall.

But funding is just one worry for Mr. Gates in his new career. He built his foundation on the promise of life-saving vaccines, reflecting his penchant toward finding technological solutions to problems. As polio shows, technology can be hampered by political, religious and societal obstacles in the countries where he's spending his money. He's still learning how to navigate through those forces.

In Nigeria last year, Mr. Gates sat on the lawn behind his hotel reflecting on that. Science can simplify the job, he said, but "the human piece is the ultimate test." 

By:  Robert A. Guth, The Wall Street Journal

Reviewed / Posted by: Scott W. Yates, MD, MBA, MS, FACP

What Thomas Jefferson Said

What Thomas Jefferson Said:

"The democracy will cease to exist when you take away from those who are willing to work and give to those who would not."
-- Thomas Jefferson


"It is incumbent on every generation to pay its own debts as it goes.
A principle which if acted on would save one-half the wars of the world."
-- Thomas Jefferson


"I predict future happiness for Americans if they can prevent the government from wasting the labors of the people under the pretense of taking care of them."
-- Thomas Jefferson


"To compel a man to subsidize with his taxes the propagation of ideas which he disbelieves and abhors is sinful and tyrannical."
-- Thomas Jefferson

Sorting Fact From Fiction on Health Care

In recent town-hall meetings, President Barack Obama has called for a national debate on health-care reform based on facts. It is fact that more than 40 million Americans lack coverage and spiraling costs are a burden on individuals, families and our economy. There is broad consensus that these problems must be addressed. But the public is skeptical that their current clinical care is substandard and that no government bureaucrat will come between them and their doctor. Americans have good reason for their doubts—key assertions about gaps in care are flawed and reform proposals to oversee care could sharply shift decisions away from patients and their physicians.

Consider these myths and mantras of the current debate:

• Americans only receive 55% of recommended care. This would be a frightening statistic, if it were true. It is not. Yet it was presented as fact to the Senate Health and Finance Committees, which are writing reform bills, in March 2009 by the Agency for Healthcare Research and Quality (the federal body that sets priorities to improve the nation's health care).

The statistic comes from a flawed study published in 2003 by the Rand Corporation. That study was supposed to be based on telephone interviews with 13,000 Americans in 12 metropolitan areas followed up by a review of each person's medical records and then matched against 439 indicators of quality health practices. But two-thirds of the people contacted declined to participate, making the study biased, by Rand's own admission. To make matters worse, Rand had incomplete medical records on many of those who participated and could not accurately document the care that these patients received.

For example, Rand found that only 15% of the patients had received a flu vaccine based on available medical records. But when asked directly, 85% of the patients said that they had been vaccinated. Most importantly, there were no data that indicated whether following the best practices defined by Rand's experts made any difference in the health of the patients.

In March 2007, a team of Harvard researchers published a study in the New England Journal of Medicine that looked at nearly 10,000 patients at community health centers and assessed whether implementing similar quality measures would improve the health of patients with three costly disorders: diabetes, asthma and hypertension. It found that there was no improvement in any of these three maladies.

Dr. Rodney Hayward, a respected health-services professor at the University of Michigan, wrote about this negative result, "It sounds terrible when we hear that 50 percent of recommended care is not received, but much of the care recommended by subspecialty groups is of a modest or unproven value, and mandating adherence to these recommendations is not necessarily in the best interest of patients or society."

• The World Health Organization ranks the U.S. 37th In the world in quality. This is another frightening statistic. It is also not accurate. Yet the head of the National Committee for Quality Assurance, a powerful organization influencing both the government and private insurers in defining quality of care, has stated this as fact.

The World Health Organization ranks the U.S. No. 1 among all countries in "responsiveness." Responsiveness has two components: respect for persons (including dignity, confidentiality and autonomy of individuals and families to make decisions about their own care), and client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider). This is what Americans rightly understand as quality care and worry will be lost in the upheaval of reform. Our country's composite score fell to 37 primarily because we lack universal coverage and care is a financial burden for many citizens.

• We need to implement "best practices." Mr. Obama and his advisers believe in implementing "best practices" that physicians and hospitals should follow. A federal commission would identify these practices.

On June 24, 2009, the president appeared on "Good Morning America" with Diane Sawyer. When Ms. Sawyer asked whether "best practices" would be implemented by "encouragement" or "by law," the president did not answer directly. He said that he was confident doctors "want to engage in best practices" and "patients are going to insist on it." The president also said there should be financial incentives to "allow doctors to do the right thing."

There are domains of medicine where a patient has no control and depends on the physician and the hospital to provide best practices. Strict protocols have been developed to prevent infections during procedures and to reduce the risk of surgical mishaps. There are also emergency situations like a patient arriving in the midst of a heart attack where standardized advanced treatments save many lives.

But once we leave safety measures and emergency therapies where patients have scant say, what is "the right thing"? Data from clinical studies provide averages from populations and may not apply to individual patients. Clinical studies routinely exclude patients with more than one medical condition and often the elderly or people on multiple medications. Conclusions about what works and what doesn't work change much too quickly for policy makers to dictate clinical practice.

An analysis from the Ottawa Health Research Institute published in the Annals of Internal Medicine in 2007 reveals how long it takes for conclusions derived from clinical studies about drugs, devices and procedures to become outdated. Within one year, 15 of 100 recommendations based on the "best evidence" had to be significantly reversed; within two years, 23 were reversed, and at 5 1/2 years, half were contradicted. Americans have witnessed these reversals firsthand as firm "expert" recommendations about the benefits of estrogen replacement therapy for postmenopausal women, low fat diets for obesity, and tight control of blood sugar were overturned.

Even when experts examine the same data, they can come to different conclusions. For example, millions of Americans have elevated cholesterol levels and no heart disease. Guidelines developed in the U.S. about whom to treat with cholesterol-lowering drugs are much more aggressive than guidelines in the European Union or the United Kingdom, even though experts here and abroad are extrapolating from the same scientific studies. An illuminating publication from researchers in Munich, Germany, published in March 2003 in the Journal of General Internal Medicine showed that of 100 consecutive patients seen in their clinic with high cholesterol, 52% would be treated with a statin drug in the U.S. based on our guidelines while only 26% would be prescribed statins in Germany and 35% in the U.K. So, different experts define "best practice" differently. Many prominent American cardiologists and specialists in preventive medicine believe the U.S. guidelines lead to overtreatment and the Europeans are more sensible. After hearing of this controversy, some patients will still want to take the drug and some will not.

This is how doctors and patients make shared decisions—by considering expert guidelines, weighing why other experts may disagree with the guidelines, and then customizing the therapy to the individual. With respect to "best practices," prudent doctors think, not just follow, and informed patients consider and then choose, not just comply.

• No government bureaucrat will come between you and your doctor. The president has repeatedly stated this in town-hall meetings. But his proposal to provide financial incentives to "allow doctors to do the right thing" could undermine this promise. If doctors and hospitals are rewarded for complying with government mandated treatment measures or penalized if they do not comply, clearly federal bureaucrats are directing health decisions.

Further, at the AMA convention in June 2009, the president proposed linking protection for physicians from malpractice lawsuits if they strictly adhered to government-sponsored treatment guidelines. We need tort reform, but this is misconceived and again clearly inserts the bureaucrat directly into clinical decision making. If doctors are legally protected when they follow government mandates, the converse is that doctors risk lawsuits if they deviate from federal guidelines—even if they believe the government mandate is not in the patient's best interest. With this kind of legislation, physicians might well pressure the patient to comply with treatments even if the therapy clashes with the individual's values and preferences.

The devil is in the regulations. Federal legislation is written with general principles and imperatives. The current House bill H.R. 3200 in title IV, part D has very broad language about identifying and implementing best practices in the delivery of health care. It rightly sets initial priorities around measures to protect patient safety. But the bill does not set limits on what "best practices" federal officials can implement. If it becomes law, bureaucrats could well write regulations mandating treatment measures that violate patient autonomy.

Private insurers are already doing this, and both physicians and patients are chafing at their arbitrary intervention. As Congress works to extend coverage and contain costs, any legislation must clearly codify the promise to preserve for Americans the principle of control over their health-care decisions.

By Drs. Jerome Groopman and Pamela Hartzband for the Wall Street Journal. Dr. Groopman, a staff writer for the New Yorker, and Dr. Hartzband are on the staff of Beth Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical School.

Posted by: Scott W. Yates, MD, MBA, MS, FACP

Selling out doctors to pay off lawyers

Civil justice reform, which is sometimes referred to as “tort reform,” is not addressed in any health reform bill now being considered by Congress. As a matter of fact, civil justice reform is rarely being discussed even though it should be a critical component of every discussion and in every legitimate health reform bill.

Physicians understand its importance. And so do the American people. Many are beginning to wonder why it’s not in any bill.

Howard Dean, former chairman of the Democratic National Committee, at a town hall meeting in Virginia last week said, “Tort reform is not in the bill because the people who wrote it did not want to take on the trial lawyers. And, that is the plain and simple truth.”

Unfortunately, the “plain and simple truth” is that Democratic leaders in Congress and President Obama are selling out the doctors to pay off the trial lawyers.

In a recent poll, 90 percent of physicians agreed that health reform will not succeed in bringing about substantive reform without addressing tort reform. Sermo, an online community of over 100,000 physicians, reports that while reasonable people might disagree on the specifics of tort reform, the fundamental principle remains that defensive medicine is a byproduct of the current tort system.

The “plain and simple truth” is that leaving the tort system “as is” ignores more than $200 billion in potential savings annually in health care. If the fundamental driving force behind any national health reform proposal is improving care and reducing costs, tort reform should be contained in every rational approach to health reform.

Defensive medicine is one of the largest contributors to wasteful spending, and it can manifest in many forms: unnecessary CT scans, x-rays, MRIs, cardiac testing and inappropriate hospital admissions. A 2005 survey in the Journal of the American Medical Association found that 93 percent of doctors reported practicing defensive medicine. These unnecessary and expensive tests and procedures are not ordered to advance the care and treatment of a patient or help the physician diagnose a medical problem. These tests and procedures are ordered exclusively to protect a physician from a potential and likely frivolous lawsuit.

In a recent speech before the American Medical Association, even President Obama said that doctors shouldn’t “feel like they are constantly looking over their shoulder for fear of lawsuits.” The president recognized that defensive medicine is “a real issue” but there is nothing in the bill to protect physicians from frivolous lawsuits. And, there is nothing in the bill to help stop defensive medicine.

While the White House and the Democratic leaders in Congress don’t want “to take on the trial lawyers,” they are apparently willing to fight with the doctors, the hospitals, the drug companies, the health insurance industry and even the American people on health reform. But they feel compelled to placate to the trial lawyers? Protecting trial lawyers at the expense of physicians is not in the best way to address health reform and it is not in the best interest of the American people.

At the Center for Health Transformation, we have developed several solutions which would advance patient safety and provide for fair and effective compensation for individuals who have legitimate claims. Our solutions establish accountability and encourage the disclosure of adverse medical events so future medical errors can be avoided.

For example, we believe that physicians should be shielded from liability if they demonstrate the use of clinical best practices in the care and treatment of patients. Shielding physicians from liability when they use best practices would reduce defensive medicine and minimize the loss of competent health professionals driven out by the high cost of litigation insurance.

We also support the creation of specialized health courts to address medical malpractice cases as a rational civil justice reform. Even some Democrats have rallied around the health court solution. Former Sen. Bill Bradley (D-N.J.), in a recent New York Times column, said “Malpractice tort reform can be something as commonsensical as the establishment of medical courts – similar to bankruptcy or admiralty courts – with special judges to make determinations in cases brought by parties claiming injury.”

We believe it’s time to stop selling out the doctors to pay off the trial lawyers. The president must include civil justice reform in any successful health reform proposal.

Former House Speaker Newt Gingrich is the founder of the Center for Health Transformation. Wayne Oliver is director of the Center’s civil justice reform project.

By: Newt Gingrich and Wayne Oliver

Posted by: Scott W. Yates, MD, MBA, MS, FACP

Ten Questions on the Health-Care Overhaul

It is crunch time for health care. Lawmakers who are trying to fundamentally remake one-sixth of the U.S. economy say this might be the most complicated legislation they have undertaken.

Here are some basics that everyone can grasp -- and probably ought to, because the health bill, if it passes, will affect almost everyone.

1. What is the problem with health care, anyway? Is it as bad as they say?

The problem, as advocates for change see it, boils down to two big areas: high costs and lack of coverage. For some households and employers, the cost of care already is out of reach, and many more will struggle to afford it if costs keep escalating. Medicare is eating up a bigger share of government spending, and a growing number of bankruptcies and home foreclosures are linked to medical expenses.

Even though the U.S. spends $2 trillion a year for health care, some 46 million people don't have health coverage. To be sure, that oft-cited number from the Census Bureau is somewhat misleading because it includes illegal immigrants, healthy young adults who don't think they need insurance and poor people who are eligible for Medicaid.

Still, as the recession wears on, the number of uninsured appears to be rising. One study, by the left-leaning Center for American Progress Action Fund, found that as many as 14,000 people are losing their health insurance every day because of job cuts. Families who have insurance pay an additional $1,000 a year in premiums to effectively subsidize all the people who receive care but don't pay for it, according to a separate study by the liberal group Families USA and actuarial consultancy Milliman Inc.

2. Can Democrats and Republicans agree on anything?

Actually, yes. There is broad support for changing the way hospitals and doctors are paid so that they are compensated for the quality of care they provide, not the quantity of procedures they do. Democrats and Republicans also back the idea of creating online marketplaces where consumers and small businesses can comparison-shop for plans.

Both parties want to bar insurance companies from denying coverage to people who are already sick. The insurers are willing to make that concession, as long as lawmakers also require most people to carry insurance, since that would force young, healthy people into the insurance system.

It amounts to a twin mandate -- one on insurers to sell policies, and another on Americans to buy them. Although there are pockets of Republican opposition to the latter idea, both have enough bipartisan support to pass. These steps alone would represent big changes to the status quo.

3. Where are the main points of disagreement?

The sharpest divide between the two parties: Whether to create a government-run insurance plan (otherwise known as a "public plan") that would go up against private plans in online marketplaces. President Barack Obama says a public plan will keep private insurers honest. Republicans say it would give the government too much control over health care.

The other main battle, which doesn't break down as easily along party lines, is how to pay for a plan expected to cost at least $1 trillion over a decade. Many lawmakers think it makes sense to impose a tax on employer-provided health-care benefits, a perk that currently is tax-free.

Then they looked at the poll numbers. Many voters hate the idea of paying taxes on something that right now costs nothing. So Democrats have instead proposed raising taxes on the rich.
Congress also remains divided over whether to make employers (except really small ones) provide insurance. House Democrats propose that if companies don't offer insurance, they should contribute as much as 8% of their payroll spending toward helping workers buy insurance on their own. Republicans argue that companies will make up for it by cutting jobs and lowering wages.

4. What would a public plan look like?

The country already has a huge public plan -- Medicare, which covers the elderly and some other groups. It generally pays doctors and hospitals less than private insurers. Liberal Democrats would like to replicate it in the new marketplaces. They want the government directly to set premiums and services under the plan, perhaps with basic and premium options.

That isn't going to fly in this Congress, despite Democratic control of both chambers. Republicans are more opposed to having a government plan than Democrats are bent on having it. Conservatives figure the government would quickly drive private insurers out of business by undercutting them on price.

Two other scenarios have emerged as compromises. One is to hold off on creating the plan and instead impose heavy regulations on insurance companies aimed at making coverage accessible and affordable. If that doesn't work, then the government insurance plan would kick in after several years. The other idea is to create a batch of regional nonprofit insurance cooperatives to compete with private insurers. But many liberals consider that a far stretch from the original idea, since the government wouldn't run those plans.

One point that gets overlooked in the debate is that most people probably wouldn't even be eligible for the public plan. Only individuals without affordable employer-provided insurance and businesses that aren't big enough to buy reasonably priced plans on their own would qualify.

5. Why is the total price of the overhaul so expensive, especially considering that it is designed to bring down costs?

The cost mostly comes from giving people subsidies to buy insurance, and from expanding Medicaid, the federal-state insurance program for the poor, to cover more low-income Americans.

The theory is that once more Americans carry insurance, the entire health system will spend less money caring for them. Those people will have more access to care that prevents them from getting sick in the first place, and they would rely less on costly forms of treatment such as visiting the emergency room. But it could be years before that really reduces health costs, if it ever does.

President Obama often talks about more fundamental fixes for high costs, like paying for quality and blocking doctors from boosting their income with unnecessary tests. But Congress has limited power to change that.

6. What are the most likely ways to pay for the overhaul?

The White House has proposed about $950 billion in savings over 10 years to pay for the plan that include things like lower reimbursements to hospitals that treat Medicare patients. The wealthy are a natural target. One proposal is limiting itemized tax deductions for families who earn more than $250,000 annually, a campaign idea of the president. House Democrats want to impose a surtax on wealthy individuals. Less likely are new taxes on soda and sugary drinks, which many lawmakers see as politically unpopular.

7. Which industries are most likely to lose, and which to gain, from any overhaul?

Perhaps no industry stands to gain more from the changes than health insurers, who would get tens of millions of new customers because Americans would be required by law to carry health insurance. Pharmaceutical companies would sell more prescription drugs because more people would have coverage for drugs and access to doctors who prescribe them. Hospitals and doctors wouldn't have to provide as much free care as they do now.

But each of those groups also could take hits, particularly the health insurers if some kind of public option drives down their profit margins. The big losers would be retailers, restaurants and other businesses with low-income workers who provide little or no health insurance, since they would be forced to start paying for it.

Businesses that are too small to afford health insurance but not tiny enough to fall below the proposed $250,000 annual payroll cutoff that exempts them from providing coverage also could get squeezed by the legislation.

8. I already have insurance through my job - what happens to me?

Not too much at first. A handful of tax-free perks for the insured could get axed. For instance, lawmakers want to end the practice of allowing people to put money into so-called flexible spending accounts, which allow them to pay for everything from cosmetic dental work to surgery with tax-free dollars.

Longer term, a lot could change. For instance, your employer could drop coverage, preferring to pay the penalty for doing so and deflecting employees to Uncle Sam's plan. Cost-cutting efforts in other parts of the system could eventually affect employer-provided plans as well.

9. Politicians have tried for decades to push universal health insurance. Why did they always fail before? Why would this time be any different?

These efforts stretch back to the 1930s, when President Franklin Roosevelt proposed creating a compulsory health-insurance system for all Americans, run by the states. Doctors, worried it would hurt their pay, helped kill the measure, buoyed by opposition from business and labor groups. Other major health overhaul attempts, most notably President Bill Clinton's 1993-94 effort, died because powerful interest groups feared their members would either earn less or have to pay more under the new system.

What is different now is that major health and other interest groups are on board with the idea. Many insurers, hospitals, doctors and drug companies agree that the system is so flawed it isn't sustainable, and they see a bill as a chance to push through improvements like adopting electronic health records, broadening the use of data to show which treatments work best and reducing the threat of malpractice lawsuits. Employers see it as a chance to curb the sharply rising price of covering their workers. Almost no one is arguing that the system is fine the way it is. Mr. Obama's high popularity, coupled with wide Democratic margins in Congress, also grease the wheels for passing a bill.

10. What happens if the effort once again fails?

Lawmakers would likely scale back their plans and try to at least pass a measure that partially expands insurance coverage or helps stall the increase in health costs. But so many parts of the legislation are intertwined that they will be less effective, and perhaps impossible to achieve, if done piecemeal. Lawmakers might be reluctant to take up the controversial legislation ahead of congressional elections next year. So it would probably be several years before lawmakers tried again.

From the Wall Street Journal
by Janet Adamy

Posted by Scott W. Yates, MD, MBA, MS, FACP

Budget Blow for Health Plan

Congress's Chief Fiscal Watchdog Warns of Overhaul's Cost; Ammunition for Critics

Congress's chief budget scorekeeper cast a new cloud over Democratic efforts to overhaul the nation's health-care system, telling lawmakers Thursday that the main proposals being considered would fail to contain costs -- one of the primary goals -- and could actually worsen the problem of rapidly escalating medical spending.

"We do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount," Douglas Elmendorf, director of the Congressional Budget Office, told the Senate Budget Committee. "On the contrary, the legislation significantly expands the federal responsibility for health-care costs," he added.

When President Barack Obama and lawmakers set out earlier this year to revamp the health-care system, they had two main objectives: Expand access to health insurance and curb runaway costs, not just for the government but the economy as a whole.

But as House and Senate versions of the legislation have advanced, lawmakers have found it easier to embrace proposals expanding coverage than those cutting the long-term cost of care. Mr. Obama and other Democrats have made several compromises on cost savings to keep key players on board for the overall effort. For example, the White House has softened several threats to extract savings from the powerful pharmaceutical industry, despite the president's campaign pledge to take on drug makers.

Mr. Elmendorf's assessment carries significant weight in the health-care debate, since his nonpartisan organization is used to determine the official costs and impact of legislative proposals. One of his predecessors in charge of the CBO, Robert Reischauer, famously helped derail the last major push to broadly expand health care in 1994 when he testified that President Bill Clinton's proposal would cost far more than the White House had projected.

The CBO assessment quickly reverberated around Capitol Hill, where House and Senate Democratic leaders are struggling to secure votes to advance health legislation before a scheduled break in August. Some Democrats had already grown nervous about the health-care effort in recent days, after House Democrats said they would pay for their plan with a surtax on upper-income families -- a proposal that could cause trouble for some Democrats in Republican-leaning districts.

While most Democratic lawmakers embrace in principle Mr. Obama's goal of enacting sweeping changes this year, many have said they would only support a measure that clearly can contain health-care spending. In recent days, many of those lawmakers have threatened to oppose the proposals crafted by congressional leaders, saying the plans won't do enough on that front.
Mr. Elmendorf's comments gave them new ammunition to threaten opposition.

"We have to take steps to hold health-care costs to the rate of inflation, or we will never balance our federal budget again and health-insurance costs will continue to become less and less affordable for the American people," said Arkansas Democratic Rep. Mike Ross. Mr. Ross is a leading member of the Blue Dogs, a moderate faction of the party's caucus that counts more than 50 members and has a crucial say over whether health-care legislation will pass. Mr. Elmendorf's comments, he said, "only underscore what the Blue Dogs have been saying all along."

Rep. Jim Matheson, a moderate Democrat from Utah, suggested Mr. Elmendorf's assessment "is of great concern" and called for renewed focus on restraining spending. "If we don't reform the system to get costs under control, then nothing else matters," he said. "We're just putting more people into a broken system."

The testimony undercuts one of Mr. Obama's central arguments: that the initiative will control long-term costs for the government as well as ordinary Americans and businesses. Mr. Elmendorf did caution that making long-term assessments is difficult. "It is very hard to look out...and say very accurate things about growth rates," he said. But when asked whether bills moving through Congress would bring the health-care cost curve under control, he responded: "The cost curve is being raised."

The White House played down the significance of Mr. Elmendorf's remarks. Kenneth Baer, a spokesman for the Office of Management and Budget, said "the process is still ongoing" in terms of shaping legislation. He stressed that the Obama administration remains "confident that we will see a final bill that is both deficit-neutral and will reduce the rise in health-care cost growth in the years to come."

But it was clear that Mr. Elmendorf's remarks struck a nerve with House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid, who jointly appointed the economist to his post after the previous CBO director, Peter Orszag, was made White House budget director.

Ms. Pelosi, a California Democrat, complained that the CBO, in calculating the impact of health legislation, doesn't give "any credit" to certain proposals designed to reduce spending, such as preventive-care measures that backers of the bill say will reduce costs throughout the system.

In his appearance, Mr. Elmendorf suggested lawmakers could take steps to control costs. Among other things, he said Congress could reduce the tax subsidy that critics say encourages employers to offer large health-insurance policies. That idea was being considered by members of the Senate Finance Committee, but dropped after Senate Democratic leaders -- including Mr. Reid -- voiced concern. The proposal has been sharply opposed by labor unions, among other groups, that have big tax-advantaged plans.

On Thursday, Mr. Reid expressed disdain when asked by reporters about Mr. Elmendorf's suggestion. "What he should do is maybe run for Congress," the Nevada Democrat said.

Republicans were quick to trumpet the Elmendorf comments in their stepped-up campaign against the health-care effort. "The director of the Congressional Budget Office today confirmed that the Democrats' government-run plan will make health care more costly than ever, making clear that one of the Democrats' chief talking points is pure fiction," said Ohio Rep. John Boehner, the House Republican leader.

Mr. Elmendorf addressed his analysis generally to the main bills moving in the House and Senate. He suggested the analysis is evolving, noting the House bill was only released "two days ago." He made clear he wasn't referring to legislation being fashioned by the Senate Finance Committee, because leaders of that panel "have not yet released" that bill.

While the CBO storm may have set back the move for rapid action on health care, the effort also got an important boost Thursday when the American Medical Association offered support for the House proposal.

In a letter delivered to House Ways and Means Chairman Charles Rangel, a New York Democrat, the doctors' group expressed "appreciation and support" for the bill. Among other things, the AMA welcomed a provision that would put in place a new formula for payments to doctors under Medicare, avoiding deep cuts scheduled to take place next year and in future years.

Opinion: The Wall Street Journal
By: Greg Hitt

Posted by Scott W. Yates, MD, MBA, MS, FACP

Signing On to an Obama 'Dream'

Editorial Opinion - The Wall Street Journal

Health providers agree to Obama health plan's notion of cost savings

At a news conference yesterday, President Obama said, "I will not rest until the dream of health-care reform is achieved in the United States of America." Normally dreams cost you nothing, but Mr. Obama's determination not to rest until his becomes reality is likely to cost plenty. Yesterday a coalition of private health-system providers, seeing no exit from the administration's reform plans, signed on to the dream.

They agreed in principle to try to shave 1.5 percentage points off the growth rate of U.S. health-care costs over the next decade, about $2 trillion. This vague, probably illusory promise isn't much as a matter of policy, but it is a major political development in what is the Obama Presidency's No. 1 priority.

The private groups are calculating that they can better influence this year's bill if they're "partners" instead of villains. They've no doubt seen what happened to Wall Street and Chrysler bondholders. All the same, they must surely know they have made a Faustian bargain that in time will result in price controls and restrictions on care.

The Obama Administration, by contrast, is convinced that it is smart enough to engineer more efficient medical practices out of D.C. The dominant White House voice on health policy is Peter Orszag, the budget chief. He cites research out of Dartmouth that shows health-care spending varies wildly between regions, often with little or no correlation to health outcomes.

Mr. Orszag champions "comparative effectiveness research" -- studying the patterns of clinical practice to determine which drugs and treatments work best. The Administration thinks it can use such analysis to weed out wasteful or unnecessary care by paying more "if the treatment has been shown to be effective and a little less if not," as Mr. Orszag recently told the New Yorker.

The irony is that the history of post-1965 U.S. health care policy is littered with similar government attempts to control health spending, not least comparative effectiveness. The "managed care" movement of the 1990s grew directly out of the peer-review panels created by Congress in 1972 to monitor the quality and appropriateness of care for Medicare and Medicaid patients.

Under managed care, doctors and hospitals had to undergo prior "utilization review" by HMOs to reduce unnecessary hospitalizations, surgeries, tests, prescriptions and so on. This cost-effectiveness gatekeeping disciplined health spending. What happened next to this version of the dream is known to all.

Administrative hassles led to a consumer backlash, with patients feeling they were getting inferior care in return for insurer profits. The political class eventually forced the HMOs to dilute or end most of their cost-control strategies.

Democrats have now acknowledged that the managed care dream will work only if government is the one doing the managing. That is, we can only control costs with a new government entitlement. More is less.

But you can only allocate a scarce resource in two ways: market prices or brute force. In health care the brute force will come as price controls and waiting lines for rationed services. The implicit assumption in the providers' deal announced yesterday seems to be that the private companies will do the price controlling so the government won't have to do it for them. But when the savings prove illusory, as in the past, the feds will step in and order them to do so. To win a false reprieve for themselves and give cost cover to the politicians, these private CEOs are offering to make themselves even more unpopular with patients. By that point, most patients will have no choice but to assent, since most of them will be in one government program or another.

Lest anyone remains in doubt about the ultimate goal here, Ralph Neas of the leftist National Coalition on Health Care got out a quick statement throwing ice water on the industry's concession. With perfect clarity Mr. Neas said: "Voluntary efforts -- without legislated requirements and enforcement -- have not worked well in the past."

The only benefit here is that it is now possible to see where this issue is headed: A new legislated entitlement for the middle class will ensure that the next great health-care argument to engulf the political system is going to be over how and when to ration care.

Printed in The Wall Street Journal, page A16

Posted by Scott W. Yates, MD, MBA, MS, FACP

How ObamaCare Will Affect Your Doctor

From The Wall Street Journal
By Scott Gottlieb, MD

Expect longer waits for appointments as physicians get pinched on reimbursements.

At the heart of President Barack Obama's health-care plan is an insurance program funded by taxpayers, administered by Washington, and open to everyone. Modeled on Medicare, this "public option" will soon become the single dominant health plan, which is its political purpose. It will restructure the practice of medicine in the process.

Republicans and Democrats agree that the government's Medicare scheme for compensating doctors is deeply flawed. Yet Mr. Obama's plan for a centrally managed government insurance program exacerbates Medicare's problems by redistributing even more income away from lower-paid primary care providers and misaligning doctors' financial incentives.

Like Medicare, the "public option" will control spending by using its purchasing clout and political leverage to dictate low prices to doctors. (Medicare pays doctors 20% to 30% less than private plans, on average.) While the public option is meant for the uninsured, employers will realize it's easier -- and cheaper -- to move employees into the government plan than continue workplace coverage.

The Lewin Group, a health-care policy research and consulting firm, estimates that enrollment in the public option will reach 131 million people if it's open to everyone and pays Medicare rates, as many expect. Fully two-thirds of the privately insured will move out of or lose coverage. As patients shift to a lower-paying government plan, doctors' incomes will decline by as much as 15% to 20% depending on their specialty.

Physician income declines will be accompanied by regulations that will make practicing medicine more costly, creating a double whammy of lower revenue and higher practice costs, especially for primary-care doctors who generally operate busy practices and work on thinner margins. For example, doctors will face expenses to deploy pricey electronic prescribing tools and computerized health records that are mandated under the Obama plan. For most doctors these capital costs won't be fully covered by the subsidies provided by the plan.

Government insurance programs also shift compliance costs directly onto doctors by encumbering them with rules requiring expensive staffing and documentation. It's a way for government health programs like Medicare to control charges. The rules are backed up with threats of arbitrary probes targeting documentation infractions. There will also be disproportionate fines, giving doctors and hospitals reason to overspend on their back offices to avoid reprisals.

The 60% of doctors who are self-employed will be hardest hit. That includes specialists, such as dermatologists and surgeons, who see a lot of private patients. But it also includes tens of thousands of primary-care doctors, the very physicians the Obama administration says need the most help.

Doctors will consolidate into larger practices to spread overhead costs, and they'll cram more patients into tight schedules to make up in volume what's lost in margin. Visits will be shortened and new appointments harder to secure. It already takes on average 18 days to get an initial appointment with an internist, according to the American Medical Association, and as many as 30 days for specialists like obstetricians and neurologists.

Right or wrong, more doctors will close their practices to new patients, especially patients carrying lower paying insurance such as Medicaid. Some doctors will opt out of the system entirely, going "cash only." If too many doctors take this route the government could step in -- as in Canada, for example -- to effectively outlaw private-only medical practice.

These changes are superimposed on a payment system where compensation often bears no connection to clinical outcomes. Medicare provides all the wrong incentives. Its charge-based system pays doctors more for delivering more care, meaning incomes rise as medical problems persist and decline when illness resolves.

So how should we reform our broken health-care system? Rather than redistribute physician income as a way to subsidize an expansion of government control, Mr. Obama should fix the payment system to align incentives with improved care. After years of working on this problem, Medicare has only a few token demonstration programs to show for its efforts. Medicare's failure underscores why an inherently local undertaking like a medical practice is badly managed by a remote and political bureaucracy.

But while Medicare has stumbled with these efforts, private health plans have made notable progress on similar payment reforms. Private plans are more likely to lead payment reform efforts because they have more motivation than Medicare to use pay as a way to achieve better outcomes.

Private plans already pay doctors more than Medicare because they compete to attract higher quality providers into their networks. This gives them every incentive, as well as added leverage, to reward good clinicians while penalizing or excluding bad ones. A recent report by PriceWaterhouse Coopers that examined 10 of the nation's largest commercial health plans found that eight had implemented performance-based pay measures for doctors. All 10 plans are expanding efforts to monitor quality improvement at the provider level.

Among the promising examples of private innovation in health-care delivery: In Pennsylvania, the Geisinger Clinic's "warranty" program, where providers take financial responsibility for the entire episode of care; or the experience of the Blue Cross Blue Shield plans in Pennsylvania, Michigan and Virginia, where doctors are paid more for delivering better outcomes.

There are plenty of alternatives to Mr. Obama's plan that expand coverage to the uninsured, give them the chance to buy private coverage like Congress enjoys, and limit government management over what are inherently personal transactions between doctors and patients.

Rep. Nydia Velazquez (D., N.Y.) has introduced a bipartisan measure, the Small Business Cooperative for Healthcare Options to Improve Coverage for Employees (Choice) Act of 2009, that would make it cheaper and easier for small employers to offer health insurance. Mr. Obama would also get bipartisan compromise on premium support for people priced out of insurance to give them a wider range of choices. This could be modeled after the Medicare drug benefit, which relies on competition between private plans to increase choices and hold down costs. It could be funded, in part, through tax credits targeted to lower-income Americans.

There are also measures available that could fix structural flaws in our delivery system and make coverage more affordable without top-down controls set in Washington. The surest way to intensify flaws in the delivery of health care is to extend a Medicare-like "public option" into more corners of the private market. More government control of doctors and their reimbursement schemes will only create more problems.

Dr. Gottlieb, a former official at the Centers for Medicare and Medicaid Services, is a fellow at the American Enterprise Institute and a practicing internist.

Printed in The Wall Street Journal, page A17

Posted by Scott W. Yates, MD, MBA, MS, FACP

How to Make Primary Care Better

By Benjamin Brewer, MD

I wasn't invited to any inauguration parties for President Obama. If I had been, I would have tried to bend his ear with some ideas on how to revive primary care in this country.

It's high time to build a modern primary care system that meets the needs of all Americans. It won't be easy and will require an uncomfortable discussion about medical costs and benefits. But judging from Mr. Obama's inaugural address, he may be the man to get change started.

I would have told him to fund primary care adequately. We also need to change how we pay for it, starting with an overhaul of Medicare, so our medical system gets the results we deserve for the money we're spending.

I agree with his call for better use of technology to improve care and lower costs, and I would have told him that the country needs to put in place standards for health information technology and infrastructure.

The need for change is clear. We spend twice as much as many other developed countries on health care, yet we have worse quality. The countries that do better all have systems that are based on effective primary care.

My patients intuitively understand where we need to go. The hallmarks of an effective system are ready access, a provider who can be the main source of care for most needs, comprehensive care and coordinated care.

Decades of research have shown that good primary care reduces costs and improves outcomes, yet we have ignored these fundamental facts to our detriment. I see this blind spot as the biggest flaw in our current system.

Medicare, Medicaid and private insurers all contribute to poor quality by providing incentives for primary care doctors to churn patients through their offices as quickly as possible.

A lot of the great care I give is viewed as worthless by the folks who control payments. If the care didn't happen during an office visit, then Medicare, Medicaid and most commercial insurers pretend it doesn't exist.

Services that earn me the least are often the ones patients value most, such as email messaging, phone advice, and calling in prescriptions to avoid an ER visit.

Why doesn't Medicare pay me to hold a family meeting for a patient suffering from Alzheimer's or to coordinate care among multiple consultants? How about the uncompensated work I do researching cases, reviewing charts and completing disability reports.

I think every small town and urban neighborhood should have a family doctor, just like my community of Forrest, Ill. Sadly, few medical students want to take the modest pay or put up with the hassle to practice primary care practice where it's most needed. We have a problem with an inadequate primary care work force because we have a problem in funding.

Over the long haul, flooding the country with foreign trained M.D.s won't cure the primary care shortage. Even these doctors will find soon enough that they won't be able to cover their operating expenses with what the government is paying.

To get real reform we're going to need to put more money into primary care. I have a few suggestions about where to start looking for it.

The first dollars can come from the Medicare Advantage program. We can lower payments to hospitals for surgical care, radiology and other high-margin services and move the money to primary care.

We can revoke the tax exemptions of supposedly nonprofit hospitals that don't fulfill their mission of community service. We can cut down on costs for office visits to doctors by paying a lesser amount for phone and email contact instead.

We can lower the Medicare pay scale for specialty care, lab tests and procedures. Let's expand the use of non-physician personnel to deliver repetitive procedural care like colonoscopies, not just simple checkups or minor illnesses. We already use advanced practice nurses in specialized and technical fields like anesthesia and neonatology.

There will be tough challenges. An expensive, national health information project won't solve the bulk of our health-care problems, despite the hype.

One reason is that slapping software on top of screwy systems for documenting care only goes so far. It's essential that we simplify the delivery of care and ease the administrative burden on those providing it.

In the end, an adequately funded system of primary care is the key to the health-care reform our country really needs. The community of primary care physicians, nurses and physician assistants stand willing and able to do this work, if the tools and resources are made available.

Posted by Scott W. Yates, MD, MBA, MS, FACP

The Constitution

They keep talking about drafting a Constitution for Iraq .... why don't we just give them ours? It was written by a lot of really smart guys, it has worked for over 200 years, and we're not using it anymore.

-- Anonymous

Posted by Scott W. Yates, MD, MBA, MS, FACP