There are many things to look forward to in the New Year: possibly a fresh start for those physicians changing their day-to-day lives, maybe moving from a single practice to a group practice, or for baby boomers, a chance to finally curtail their hours as they promised themselves all those years ago.
But this column isn't about fresh starts, exactly.
This is about the carry-overs, issues that unfolded in 2010, and will continue to be especially important for physicians in 2011, whether physicians are changing their practices or cutting back on their hours. These are certainly hot-button issues that we will be keeping an eye on in the coming year.
1.The 'Doc Fix'. Seriously, aren't we all sick of it? At the end of the year, Congress again dealt with the doc fix by putting it back another year, instead of only a few months. It seems the doc fix is the ultimate in procrastination and definitely a driver for much unpleasantness especially among physicians. President Obama, in signing a one-year delay in implementation of the Sustainable Growth Rate Formula, said, "It's time for a permanent solution that seniors and their doctors can depend on."
There is keen frustration among many that a permanent solution to the SGR formula for Medicare funding hasn't been found. The formula has called for cuts over the past decade, which include a 25% reduction in Medicare reimbursements that would have taken effect January 1, 2011. Congress delayed five times in dealing with the doc fix, as Elliot reported, and the longer it stalls, the longer the toll on the federal budget and reimbursements. Look for more delays until Congress gets its act together.
2.EHRS.Meaningful use tops the list of healthcare industry challenges in 2011, according to a recent PricewaterhouseCoopers report. How are physicians going to fare with electronic medical records? Are they -- or enough of them -- going to join the ranks of the modern era and get moving digitally, or will they fall behind?
Instead of going forward with electronic health records, some will get out of the business altogether. But many physicians on the fence should follow the example of Anne Brooks, DO, a 72-old physician in rural Mississippi told me she would do "whatever it takes to improve the quality of life for my community," even if it means embracing electronic records.As I write this, let me remind you that CMS and the Office of the National Coordinator for Health Information Technology announced that registration will begin January 3 for eligible providers hoping to participate in the Medicare electronic health record incentive program.
3.Impact of Primary Care Shortages. Against the backdrop of the primary care shortage, the soothsayers, pundits, and other prognosticators are saying definitely there will be an increase in mergers among physicians and medical group practices; it's starting already. In the meantime, the shortage of primary care physicians is threatening prospects for new healthcare models. To wit: the Medical Home Model.
As my colleague, John Commins, wrote in November, " Shifting specialists' routine followup care to primary care physicians in a medical home model under the new federal healthcare reforms could save time, money and free specialists for more complex patient care. However, the lack of primary care physicians could make such a policy difficult to implement, Commins writes, describing a new study by the University of Michigan Health System." The reason? Redistributing half of the routine follow-up care for patients with common chronic conditions, "would require either thousands of new primary car doctors or an extra three weeks of work a year form the primary care physicians in the current work force. Either way, good luck.
4.Accountable Care Organizations. Talking about the New Year and not mentioning ACOs, is like whistling Auld Ang Syne, and not saying Happy New Year in the next breath. So many in healthcare are soooooooooooooooo excited about the prospects of ACOs, and for the most part, rightfully so. Anything involving large organizations however, needs some caveats to keep us all grounded.
As PricewaterhouseCoopers reported in its predictions for 2011, "while ACOs hold great promise for reduced costs and improved quality, the challenge will be keeping people in the ACO and engaging them to stay health, which could be the difference between profit and losses."
In any event, for physicians, ACOs are a point of concern. Despite all the excitement and hype for pilot ACOs that begin in 2011, at least 42% of respondents in a September HealthLeaders Media report, Physician Alignment in an Era of Change, say there will be strained relations between hospitals and physicians with the advent of accountable care organizations.
The ACO movement, however, is likely to make its presence known in the years to come. In its wake, there will be "creative destruction" of the fragmented fee for service system, and "consequently the actions of physicians and hospitals during this period will determine the structure of the delivery system for many years," write Robert Kocher, MD and Nikhil R. Sahni, BS, in November 10 issue of the New England Journal of Medicine.
5.The American Board of Internal Medicine. Through much of 2010, the ABIM was dealing with the fallout of its proposed sanctions of 139 physicians for passing along and receiving exam questions from a test preparation company, which could result in dismissal of certificates for the accused physicians. At the outset, I got the impression from ABIM that it would resolve the issue expeditiously. Not the case. Appeals and settlement processes have begun, but months after the initial announcements of the alleged cheating, no formal declaration of what will eventually happen to the 139 physicians is really in sight Hopefully, the situation is resolved in 2011, with equanimity and justice for all involved.
Yes, from the uncertainty surrounding the American Board of Internal investigation to the uncertainty surrounding the Doc Fix, the diagnosis for physicians in 2011 is, well, we'll have to wait and see…
As head of a think tank that searches for private sector alternatives to government programs that are not working, Goodman is in his element when causing a stir. Whether it's being at odds with the White House or Democrats or Republicans in Congress, Goodman takes special delight in taking jabs at health policy makers. [Sponsored by Emdeon]
Healthcare reform is setting off a multitude of repercussions throughout the U.S. healthcare system, not least of which is the changing relationship between physicians and hospitals.
In last September's HealthLeaders Media's intelligence report, Physician Alignment in an Era of Change, many survey respondents said they believed that hospital and physician relationships would continue to be strained in the wake of healthcare reform. They also said that hospitals planned to employ a greater percentage of physicians over the next several years.
With more employment, and increasing strain, it is clear that physicians and hospitals will continually need to work on alignment issues. One of the most significant areas of potential change in those relationships may involve hospitalists, whose numbers are increasing.
Even though there may be stress with physicians, hospitals view hospitalists as valuable partners in improving quality of care, and rightfully so. In a recent report, more than half—57% - of C-suite leaders in California expected to increase their hospitalist programs within the next two years, according to a study in the Journal of Hospital Medicine.
That's no surprise to Adam Singer, MD, chairman and CEO of IPC the Hospitalist Company, based in North Hollywood, CA was one of the pioneers in the hospitalist development in the 1990s.
Singer was honored in October as the Physician Executive of the Year by the Medial Group Management Association and the American College of Medical Practice Executives. Singer's company, IPC, The Hospitalist Company, is a provider of management services to hospitalist practices to more than 500 facilities, with employment of more than 1,000 affiliated healthcare providers.
It was the first award for a hospitalist from the groups. Indeed, with increasing numbers of hospitalists, they are in a position to become clinical leaders who drive improvements within hospitals, Singer says. The results could be a mutually beneficially relationship for better patient care.
Singer is an unabashed enthusiast for hospitalists, saying those physicians are in a potentially better position to take care of patients "then a doctor going back and forth to an office."
Back in the 1990s, Singer began his own hospitalist journey. "I took on those contracts for physicians where I would manage their entire population of patients, whenever patients showed up at the hospital," he says. Singer says he was among "pulmonologists trying to grab market share for (pulmonary) practice."
Over the past decade, the number of hospitalists has increased to more than 30,000; have increased, and the need for hospitalists is expected to grow in the wake of healthcare reform. A report cited by The Hospitalist this fall shows that median compensation for adult hospitalists is $215,000 per year. And many hospitalists are happy about hospital subsidy programs that are used to buttress hospitalist programs.
But within the healthcare system, there are concerns. "A highly functioning hospitalist program can help hospitals operating more efficiency," writes Ron Greeno, MD, in Healthcare Financial Management. "Yet despite the potential hospitals have to positively affect hospital operations in the areas of quality, safety and finance, hospitalist programs do not always generate expected returns."
The reason, Greeno writes, is often linked to how a hospital funds such a program, with hospital subsidies linked to hospitalist productivity but not necessarily on their ability to make hospital care more efficient or better, he adds.
Singer appears to embrace some of those concerns as well, and notes that many hospitals have a difficult time establishing a well-balanced partnership with hospitalists, particularly in their failure to align goals and objectives of the hospitalist group with the hospital.
The subsidy program for hospitalists also ironically seems to have a detrimental impact on hospitalists' efforts to have a greater say or become partners in their health care facilities.
"It is unclear if many hospitals are willing to give doctors a stake in performance," he says. "The reason is that today most hospitals that employ or even contract with hospitalists are having to pay a subsidy to begin with. In essence, they are paying for the performance up front in anticipation that a hospitalist program will produce results that are in excess of that subsidy. I see very little upside to these subsidies being offered today."
Singer has been fighting the subsidy arrangements for years. Back in 2003, he told Today's Hospitalist saying he believes that "anything that smacks of financial support and prevents hospitalist programs from flying solo financially is a bad thing."
"It's hard to build a new specialty when the underlying assumption is that it's not financially viable—that hospital medicine requires a subsidy to exist," Singer stated seven years ago.
He feels the same way today.
Aside from the subsidy issues, Singer has called for certain strategies to be initiated by hospitalists to be treated fairly "at the table."
For that to happen, hospitalists need to take clinical leadership, as well as ensuring a stake in hospital performance, in all ways: clinically, operationally and financially. While there have been inroads in many areas, there isn't enough, Singer insists.
To make inroads into being a complete part of a hospital, hospitalists need to develop clinical leadership, he says. "Hospitalists should be totally involved in the committee structure of the facility. They should be aspiring to be chief of staff of that hospital. They have been clinically involved in every level of the building."
"Doctors haven't figured out how to align with hospitals," he says.
So despite all these years of growth among hospitalists and health care systems, some basic issues need to be resolved, such as whether they are partners in treating patient care, and hospitalists are still trying to find their identity. Singer says healthcare reform may begin to help the process, but no one knows for sure.
The award-winning hospitalist says the term itself may be sort of a misnomer. "It is not that I do not like the term hospitalist," he says. "The issue is that we continue to evolve toward an environment of inpatient and outpatient only doctors. The generic term 'hospitalist' does not describe how many of these doctors identify themselves."
In one of my favorite sections of David McCullough's biography of John Adams, the author relates a vivid scene of Adams and Benjamin Franklin about to share a room in Newark, N.J., and not being very happy about the prospect.
They argued over whether to keep the window open or not. Adams, saddled with a head cold, didn't want any part of the chilly night air. Franklin enthusiastically sought out the fresh air. Franklin won; the window was left open through the night.
Adams may have been reluctant about the window, because he had a history of colds. He was also into a bit of self-diagnosing. "You know I cannot pass a spring or fall without an ill turn and I have one of these for four or five weeks—a cold as usual," Adams wrote to his wife, Abigail, according to historians. "Warm weather and a little exercise with a little medicine, I suppose, will cure me as usual."
Franklin had his own ailments. He may have had diseases linked to his diet, with biographer Walter Isaacson noting he had gout and kidney stones.
What if Adams and Franklin had been under the care of a lifestyle management coach and physician? Adams would have certainly been encouraged to keep exercising, and he might also have been helped with a strategy to combat his perpetual colds, such as washing his hands more often. And a coach might have introduced the idea that fresh air is pretty good. (Adams, too, had stress issues. I'll get to that later).
As for Franklin, a lifestyle management coach might have led him toward cutting back on certain foods and preventing the gout to begin with.
Today, there is increasing debate about physicians entering into lifestyle management for patients, and seriously, not about whether rooming house windows should be left open or closed. But there are other areas, of more consequence that come into play, including stress, and especially eating habits.
Gout is still an issue in this country, which it was in Franklin's day, as it is often linked to diet. But obesity and the spread of diabetes are becoming of far more concern in modern day America than in colonial times.
And unlike Adams, who sometimes tried to figure out his own health plan, more patients now are turning to physicians for their long-term maladies linked to diet. And the physicians, trapped by time, and in some cases uncertainty involving nutrition, are finding that adding a lifestyle coach to a practice is both good business and good for patients. Others, however, say that lifestyle coaching generally may not be long-lasting enough to truly help patients over the long haul.
John W. Wilson, a family practioner in Daly City, CA, uses a lifestyle educator to help with his practice because he doesn't have the time to handle nutrition issues faced by his patients. He uses a FirstLine Therapy® program, developed by Metagenics of San Clemente CA, in which a lifestyle educator is appointed as a patient coach to do health assessments, to help patients lose weight, lower blood pressure and deal with metabolic syndrome, diabetes, cardiovascular disease and other chronic conditions. Medical foods are also included under the plan to augment diet and exercise.
Wilson says he sees more patients with commorbidities in his practice. "We've got a terrible obesity problem in this country and diabetes issues aren't far behind," he says.
While traditionally trained, Wilson says he was always interested in alternative approaches, including holistic methods, to help patients "but never found evidence to support it."
As he cared for more patients with chronic conditions, he says he was "prescribing more and more medications, and there was more unknowns and I wasn't seeing great results." He says he would suggest patients "eat better, but I didn't have a structured way of dealing with nutrition."
"I had to intervene in a different way," Wilson says. Metagenics states that clinical trials have shown that it developed a medical food that enhances cardiovascular disease risk lowering benefits of a Mediterranean-style low glycemic-load diet.
Wilson hired a lifestyle educator because "I didn't have the time to do it myself. I know I don't have an hour to spend on an initial visit unless I stop seeing other patients," he says.
Generally, Wilson says his patients are seeing better results. "They feel better and are getting lower medication in the process," he says. "They are seeing themselves gaining lean mass and losing fat."
While he works on the "decision-making and treatment plans," the lifestyle educator he hired is handling nutrition education for his patients. "The patients have been excited about it," he says. "They come in with low expectations and they start seeing how quickly they start feeling better on the eating plan."
Wilson says data from his program has shown fiscal success for his practice. Under the program, about 250 patients have enrolled over the past two years, he says. Without providing exact numbers on ROI, Wilson says his income went up by $50,000 to $70,000 with a lifestyle educator working twice a week, which he says is a good return given the minimal overhead involved.
Nationwide, there has been much discussion over the value of intensive lifestyle intervention versus drugs for certain illnesses.
During this year's Endocrine Society annual meeting, it was reported that at least one physician reported that intervention was a better front line intervention than drug therapy for prediabetic conditions. There are also reports indicating that the efficacy of lifestyle intervention can reduce the incidence of type 2 diabetes.
But Sunder Mudaliar, MD, an associate professor of clinical medicine at the University of California, San Diego School of Medicine, said "lifestyle intervention is effective, but its efficacy wanes over time; it is durable, but its durability goes down over time," according to Endocrine today.
Alas, we are all human, dealing with consistency, and constancy over a long period, to maintain wellness.
Adams walked up to several miles a day, but he still had stress to deal with.
In 1781, while ambassador to England, a doctor who had been with Adams spoke of his "inexpressible anxiety" and the "strain bore down upon his appearance every bit as much as it did his personality," according to John E. Ferling, in his John Adams: A Life. Adams himself described his "nervous" state, Ferling wrote.
Franklin, who often partied in Paris, did not always live in moderation, but as a writer he could advise otherwise.
"Be temperate in Wine, in eating, Girls and Sloth, or the Gout will (seize) you and plague you both," he wrote in Poor Richard's Almanack, published in 1734.
Even without life management coaching, both lived long lives. Franklin died at 84. Adams lived to be 90, the longest living president.
Indeed, in colonial times, there wasn't a life management coach in sight. But neither were there office cubicle, Triple Whoppers the size of small boulders, or sugar-laden soft drinks the size of farm silos.
The nonprofit Physician Foundation bills itself as a "grassroots" organization that examines doctors' attitudes and takes their pulse. "We know pretty much what's going on," says Walker Ray, MD, head of the organization's research committee.
The foundation, a nonprofit grant making organization committed to improving the "medical practice environment" for physicians and patients, released a survey last month that took a look at physicians' opinions about the state of healthcare. Short version: not good.
The physicians' frustrations with healthcare reform, and a host of other issues, as Ray puts it, "tort reform not being addressed, the viability of medical practices jeopardized, the time spent with patients jeopardized, the SGR formula issue" are among the concerns addressed in the survey.
There's a "tsunami out there," Ray says. While many physicians want to leave practices, there is a pressing need for primary care, while younger physicians are "wanting a life" and not long hours and seeking to join hospitals. And in the years ahead, there is the looming reality of millions more now uninsured into the system, never mind the crunch of aging baby boomers eventually needing not only medical help but also government assistance.
The Physician Foundation's latest report, Health Reform and the Decline of Physician Private Practice, conducted and compiled by physician recruiters Merritt Hawkins, includes results from a national survey of 2,400 physicians, only 26% of whom said they would continue practicing the way they are in the next one to three years.
Instead, the survey and report predicts that physicians will become employees, part-time workers, and administrators, operate cash-only. The remaining 74% said they would retire, work part-time, close their practices to new patients, become employed and/or seek non-clinical jobs as John Commins reported Nov. 22 in HealthLeaders Media.
The importance of the survey /report was reflected in a simple fact: "We just want to get our viewpoint across," Ray says of physicians.
It hasn't been?
Physicians don't think so, not before and during healthcare reform debate, at least, Ray says. The Physicians Foundation report noted that in its survey "physicians approached unanimity in believing their viewpoint was not conveyed to policymakers during the preamble to the health reform debate.
Years before Congress was considering healthcare reform, and he was helping with the report for the Physician Foundation, Ray was seeing the proverbial handwriting on the wall for his own medical career. It gives him a broader understanding of the responses to the Physician Foundation report.
Ray, who is based outside of Atlanta, GA had been in solo pediatric practice for 25 years and 13 years in a group practice prior to that. Three years ago, at age 67, still in good shape, playing tennis several times a week, he maintained that he loved working with patients.
But that year, he decided to retire, walk away what he had been doing for 38 years. "I could have gone on, but it wasn't possible," he says. He was still in good shape, playing tennis, and most importantly loved working with patients.
"The reimbursements were getting to the point that it was untenable" to continue working, Ray says. As he was dealing with personnel issues at the office a top assistant told him, "you are going to be broke in two years."
That didn't happen, but the fiscal climate prompted his retirement, or he might have considered concierge medicine. "I'm angry that I was forced to stop working," he says. "So many physicians don't want to work, and I was going 'til I almost fell over. I would have gone on several more years. Now I don't miss the hassle, but I miss the patient care."
But Ray keeps working for the Physician Foundation to keep getting the issues out front, that "viewpoint across," he says.
Of the many issues upsetting physicians, one of the most nagging is the SGR formula debacle in Congress. Congress has repeatedly put off proposed cuts, the latest reprieve for a scheduled 23% Medicare cut is now slated to begin January 1.
"It's been a broken promise from the government difficult feelings and mistrust, both parties have never stepped to the plate. Physicians cannot absorb the Medicare cuts. There needs to be a political will."
The largest group in organized medicine, the American Medical Association, has routinely criticized the SGR formula. Recently, the AMA asked Congress to stop the cut for a year. The AMA favors a repeal of the SGR to be replaced by a system that more closely tracks the Medicare economic index.
But the Physician Foundation's report notes that the AMA endorsed healthcare reform "though many physicians at the grassroots level were not in favor of the law." As a result, the report stated, there has been a "disconnect" between those physicians and the AMA, which has been essentially a disappointment in engaging physicians in the wake of healthcare reform, in Ray's view.
"It's so sad the AMA sold us out and how this legislation was rammed down our throats against the will of the majority," says one of the 1,200 physician comments submitted to the Physician Foundation for its report.
Others also criticized the AMA, but the organization was not the only target. "The state of medicine is in need of significant improvements but a rushed, sloppy policy that does not include the input of physicians is akin to malpractice," says another.
"No one," says yet another, "in the policy making world understands the problems physicians face. I wish they could follow me through my practice for one full week."
Physicians need to be heard, Ray says, not only to discuss the issues but also to influence others to be doctors, and physicians to stay on in their profession.
"By golly, I want people to be motivated to go into the medical profession," Ray says. "I'm 70 years old and I'll be needing a doctor myself."
"I knew this fight was important…Working together, we proved the cynics wrong."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is Nancy Pelosi's story.
She's 70 years old, wears impeccable Armani suits and white pearls, is a grandmother of six, and steered healthcare legislation that she says was as momentous as the passage of Social Security or Medicare. And when healthcare reform was finally adopted, House Speaker Nancy Pelosi got a call from the President of the United States, who said he was more overjoyed about that legislative victory than when he won the nation's highest office.
In effect, Pelosi told Barack Obama: Don't be silly.
"After the final votes were cast, I received a call from President Obama, who told me he was happier at that moment than the night he was elected," Pelosi tells HealthLeaders Media. "My response: I was happy as well, but not as happy as when the President won the election. Because without that election, we wouldn't have made it this far."
If history books say that healthcare reform came about under President Obama's watch, it certainly came about in great measure because of Pelosi, for better or worse.
The longtime San Francisco Democrat became an unbridled force, pressuring yet sweet-talking her way toward making healthcare reform a reality.
She is often a lightening rod for criticism from opponents because of her mostly assertive and sharp-edged liberal style, making her one of the most disliked of politicians who oppose her. But her supporters say she has an uncanny ability of marshalling the forces within her party; and that she did, to get passage of healthcare reform. While others historically have failed dramatically over the years in trying to piece together a comprehensive healthcare package, Pelosi was a key driver of the administration's plan, and even though its passage was not inevitable, and despite the disappearance of some prized elements during the unwieldy debate process, it reached a destination.
"There were several months when naysayers said we should give up and claim that health reform was dead," Pelosi said. "But I knew this fight was important; I never stopped believing we could get this done and I recognized that it would require every ounce of effort, commitment, hard work, and cooperation to reach our goal. Working together, we proved the cynics wrong."
In the months since the enactment of the legislation, Pelosi says she is pleased how it has moved forward. "Health reform has evolved in a way that benefits all Americans," she says. "Through the legislation we created a Patients' Bill of Rights—correcting some of the worst anti-consumer practices of the insurance industry," Pelosi says. She ticks off the impact: Insurers can no longer deny coverage to children with pre-existing conditions, no longer drop someone's coverage when they get sick; young adults can stay on their parents' insurance until age 26; senior citizens are getting checks to help close the Medicare prescription "doughnut hole."
As Pelosi moves forward, once again a target of conservatives, and with the Democrats' continued hold of the House uncertain, healthcare reform has become a major refrain for whatever song she is singing about her accomplishments. The impact of its legislative journey is certain to spill over on any political races for some time to come.
As a representative of one of the most liberal districts in the country for more than 20 years, Pelosi is the first woman to be Speaker of the House, third in line to the presidency. The daughter of a Baltimore mayor and congressman, Pelosi, however, often describes herself in terms of being a mother of five and grandmother of six. In talking about being a grandmother, she once told 60 Minutes: "It's great. It's fabulous. It was my goal in life and now I've achieved it."
Politically, through February and March while Washington was besieged by blizzards, the Californian had her finest hours. She moved healthcare reform legislation through twists and turns, trying to get votes, displeasing the Republicans. As the volume of criticism against her increased, she intensified her focus.
"Without question, the most significant moment of the debate came at the end: passage of health insurance reform," she says.
Before the Obama administration, history hadn't been kind to passage of any kind of healthcare reform. The effort eluded President Bill Clinton and longtime Sen. Ted Kennedy, among others. Even when Obama seemed to be retreating, Pelosi kept pushing.
When top House Democrats considered giving up, Pelosi was quoted in terms that almost sounded like Winston Churchill during World War II. "We will go through the gate. If the gate is closed, we will go over the fence," Pelosi said. "If the fence is too high, we will pole vault in. If that doesn't work, we will parachute in. But we are going to get healthcare reform passed for the American people."
Vice President Joseph Biden declared Pelosi more powerful and successful than Obama or himself in terms of the healthcare reform. At one point during a campaign event in Philadelphia, Biden took issue with comments by Rep. Allyson Schwartz, D-PA, who referred to Pelosi as "the most powerful woman in American politics."
"I would rephrase that: the most powerful person in American politics," Biden said. "The single most successful, the single most persuasive, the single most strategic leader I have ever worked with is Nancy Pelosi." The vice president dubbed Pelosi the "mother of healthcare."
Despite such praise, even some Democrats avoided her; but she has continued to raise millions of dollars for Democratic incumbents. Pelosi says she's unfazed by GOP attacks that focus on her and healthcare reform.
"This is the Republican Party's agenda—and the American people will not stand by and allow Republican leaders to return us to the failed policies that left too many uninsured and too many without access to the care and treatment they need to lead healthy lives," she stated to HealthLeaders Media before the mid-term elections.
As Republicans began to make inroads this fall, Pelosi refused to discuss her future, or the state of the Democratic Party, but said, "health insurance reform moved America to a new direction." She added, "America is better off because of our work."
"It's not the insurance companies' fault. Government is the main problem."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is John C. Goodman's story.
As president and CEO of the National Center for Policy Analysis, a think tank that searches for private sector alternatives to government programs that are not working, John C. Goodman is in his element when causing a stir. Whether it's being at odds with the White House or Democrats or Republicans in Congress, Goodman takes special delight in taking jabs at health policy makers.
Goodman has been doing that for more than 20 years, and over that time has been involved in the public debate, whether it's over Roth IRAs, health savings accounts, Social Security, or healthcare reform.
The NCPA had its origins in what he says was a ramshackle office building in Dallas with a constantly leaking roof that eroded his files. The first two years he was unable to raise money; he waived his salary and paid expenses out of his own pocket.
Today, Goodman has thrust himself and his organization into the thick of healthcare reform debate, especially through his well-known blog on healthcare. He has written nine books on health policy and tax issues, as well as more than 50 studies; he has testified extensively on Capitol Hill.
"We try to be objective, recognizing the costs and benefits" of reform, he says. "With the White House all you see is the benefits, they never talk about the costs," Goodman says. "I put a discussion on the healthcare blog and was accused of not being objective. I failed their test but I'm more objective than others."
But Goodman says he doesn't fight because he enjoys being in the arena. He says he can offer more in the healthcare reform debate especially with respect to economics, which he says is too often downplayed as politicians move healthcare plans along.
The result, he predicts, will be healthcare reform laws that inevitably will be reshaped or refined or even thrown out as Congress continues to tackle the issue.
For instance, while there has been much optimism over the possibilities for accountable care organizations, Goodman dismisses them as "HMOs on steroids." While the White House nurtures its healthcare reform plans, Goodman says it has not only missed its mark in attempting true reform, but is misleading the public.
In the end, healthcare reform will continue to necessitate major changes because, Goodman says, patients may get lost in the shuffle.
And when he has some free time, he tackles New York Times crossroad puzzles, sometimes spending up to two hours on a Saturday trying to solve them. He often does, taking care of them in pen, not pencil. It gets him away from one passion, politics and healthcare policy, to another—learning different subjects. "It forces me to be aware of more things going on, to pay attention; sports, Broadway, and the movies, and Greek gods," he says, laughing. He doesn't want to have "too narrow thinking" about just economics and public policy.
There is no doubt, however, that politics and health policy are his passions, and he doesn't mind a good fight over his ideas.
In the 1990s, Goodman was credited as being a key force in thwarting Hillary Clinton's proposed healthcare reforms initiated by then President Bill Clinton. Goodman doesn't talk party politics, but he does sure talk politics and does not apologize for being right of center. The Wall Street Journal has called Goodman the "Father of Health Savings Accounts" (of which Goodman is quick to remind us).
Goodman uses wit and sarcasm in his criticism of the healthcare landscape. It seems he hardly mentions the White House healthcare plans without mentioning the phrase "Obamacare."
"Before the bill was passed, they zeroed out all the money they set aside to train doctors, nurses, and paramedics personnel; so what's going to happen?" Goodman says of Congress' health reform legislation. "There will be huge increase in the demand for medical care, among the 32 million of the newly insured, and millions of those people who have no copayments, no deductibles for preventive care. The biggest problem we are going to have with Obamacare is that we have this huge increase, the demand for medical care, and they've done almost nothing to increase the supply."
The NCPA is self-described as a nonprofit, nonpartisan public policy research organization "dedicated to developing and promoting private alternatives to government regulation and control, solving problems by relying on the strength of a competitive, entrepreneurial private sector." Goodman says he is simply in favor of patient-centered, consumer driven healthcare.
When he began the NCPA in 1983, during the Ronald Reagan presidency, there was not enough debate about "social insurance areas, Social Security and healthcare and disability" Goodman says, noting those were among the reasons why he started his organization in the first place.
One of Goodman's favorite activities is engaging debate prompted by his blog, which he describes simply as the "most thoughtful conversation anywhere in health policy; you find we consistently have discussions on health issues from an economic point of view, which others do not. And with a sense of humor that you certainly don't find elsewhere."
In one blog, Goodman noted his view of pilot programs. "This is about the only idea for controlling costs in the Patient Protection and Affordable Care Act, and before I heap on all the scorn and opprobrium it so richly deserves, let me say that on rare occasions pilot programs can generate very useful insights," Goodman wrote.
Goodman says he's proud of a "consumer's guide" that the group has put together, "What Does Health Care Reform Mean to You", which he claims is the "first effort anyone has made to even try to be objective is rather amazing."
Most of the mainstream media has published 'talking points' lists of the benefits, prepared by the White House, according to Goodman. "Even health policy journals have largely ignored the costs of reform and who will bear them. On the other side, Internet screeds warning of 'death panels' have exaggerated from the opposite direction."
Although there has been much criticism of insurance companies seeking rate hikes, Goodman says, "It's not the insurance companies' fault." He adds, "Government is the main problem."
As healthcare reform moves along, and the political debate continues to unfold, Goodman says he's convinced that eventually Congress and the White House will have to make some revisions, or possibly retreat on healthcare reform. Whether it's with the Tea Party or other groups, the fighting over healthcare reform is really just beginning, he says.
Over time "we are going to start over," he says. "Two years of guerilla warfare."
Ramin Ahmadi, MD, director of medical education and research at Danbury Hospital in Connecticut, is finding a way to get more primary care physicians into his community.
Follow the money. The government's money, that is.
Ahmadi has been doing it for years, no matter where's he's been. He doesn't just follow the money, he tries to get ahead of the game. He watches legislation and gets a sense of what Congress is up to, what the government may want to see among those communities seeking money. He does research, helps residents get started, writes grants, and tries to get a sense early on where the money may be flowing.
After he graduated from Yale medical school and worked in New Haven years ago, he wrote grants to help get more primary care doctors into that area. At Griffin Hospital in Derby, CT, he did the same thing. So, while he was working at Danbury Hospital, Congress was putting together the "stimulus package" from the American Recovery and Reinvestment Act funds, and Ahmadi was already thinking ahead, seeing the monetary possibilities to help the hospital and the community attract more primary care physicians.
Danbury put in its application for a grant early, and by the time the government was deciding where to put the money, Ahmadi was pretty sure Danbury, a 371-bed regional medical center and university teaching hospital, was going to get some of it. Sure enough, it did.
The hospital received a five-year, $1.2 million grant to establish an innovative primary care residency program that focuses on the "patient-centered medical home" model and encourages primary care physicians to care for the underserved. The grant from the Department of Health and Human Services essentially is designed to strengthen the primary care workforce and provide community-based intervention.
Danbury Hospital is a "designated professional health storage area in the area of primary care," Ahmadi says. It is one of only two Connecticut institutions and eight in the nation to receive funding for the program under the Health Resources and Services Administration. As Danbury Hospital attempts to make a dent in the primary care physician shortage, its effort also is testament to Ahmadi's work as a grant writer, and the value for providers to wade through the bureaucracy, to get the money, as well providing care.
Ahmadi notes that an internal assessment completed by the hospital's staff showed that there was a shortage of nearly two dozen physicians within the Danbury service area. The city of Danbury itself has a population of 75,000.
Ahmadi says Danbury received the grants for primary care physicians, and while there is a need, he acknowledges, there is plenty of need throughout the country. He says Danbury's situation may be a "local magnification" of that need.
As Ahmadi sees it, it was up to him to lay out for the federal government what that need was&mdashand is.
Under the five-year federal grant, Danbury Hospital will establish a three-year residency program for a total of 18 candidates with six primary care physicians graduating each year. Four physicians have begun training at the hospital already. If the funding is extended, more will follow.
Even before the grant was approved, "we started developing a curriculum and training program," he says. "A few months after they announced the grants, I was ready and had a program in place, and now proposing to expand it." Expanding the "primary care workforce," Ahmadi says, "is a national priority."
Of course, there's a whole backstory to this, and it's something that healthleaders are all too familiar with, but obviously must be mentioned.
In case anyone needs a reminder, the Association of Medical Colleges estimates the nation will need 124,000 physicians by 2025, with primary care physicians representing 37% of the shortage. In addition, there is the upcoming potential shock of the wave of 32 million now uninsured people entering the system under the government's healthcare reform, beginning in 2015.
Connecticut—and Danbury, in particular—faces physician shortages with the potential retirement of primary care physicians, Ahmadi says. "My colleagues in New Haven, they say they aren't taking new patients; maybe there will be a year before you get an appointment if you are a patient. I could only imagine by 2015 and 2018."
So, he says, the idea is to try as much as possible to get more primary care docs into the system. He has been a primary care doctor and has loved the work. But he acknowledges the litany of reasons why especially younger physicians don't go into the field. For many younger physicians, "they like to be comfortable. Primary care is complicated and not very well controlled. At a hospital, there is predictability, safety, and security to a young doctor in training," he says.
He says Danbury Hospital will begin an innovative, multidisciplinary curriculum that focuses attention on primary care work, including the patient-centered medical home, which is expected to become a cornerstone for patient care in evolving healthcare reform
Ahmadi says the residency program is an innovative approach, and he hopes the residents will continue to use such approaches when they go on to practice in the community. "We need innovative ways to accomplish what we want, I'm telling you that."
The Obama Administration has announced $168 million for training more than 500 new primary care physicians by 2015. In addition, the White House says it is supporting training for new physician assistants, working to improve primary care work in underserved areas, initiating tax benefits and better access for primary care through Medicare and Medicaid. "Primary are is the backbone of preventative healthcare," the White House says bluntly.
But more is needed, Ahmadi says. "We need stakeholders getting together and the federal government to draft a plan that radically re-engineers the process to attract students to medical schools and engage them to stay in primary care."
So he is excited about the federal grant and the physician residency work ahead at Danbury Hospital. Still, there are no guarantees that these physicians will stay in primary care. "But I have a 100% track record," he says, laughing, and referring to his last go-round of grants for primary care residents, who decided to stay in primary care.
For much of her life Anne Brooks, DO, was a patient, and then she became a doctor, and through her journey learned what caring is all about. Brooks is a Roman Catholic nun and 72 years old, and works in Tutwiler, MS, an impoverished flat country of cotton and blues near the Mississippi Delta. Many of her patients cannot pay, are "incredibly sick," and wouldn't have a clue what a wellness program is. Those stricken with diabetes, have "their minds blasted with sugar," she says.
"We are dealing with a lot of sick people," says Brooks, an osteopathic physician. "It's challenging."
Oh, and one other thing: "It's a lot of fun," she says.
Brooks and I were on the phone the other day, and she expressed her unwavering love of patient care, as well as the terrific need to bridge the gap between poverty and healthcare policy. And she discussed her constant pitches for donations, as well as her venture into the land of electronic medical records. As a CEO of a health clinic in town, it's something she just has to do.
Anne Eurcharistia (which means thanksgiving in Greek) Brooks became a nun with the Sisters of Holy Name of Jesus and Mary at age 17, and within seven years was diagnosed with rheumatoid arthritis. She lived with a back brace and wheelchair for the next 17 years.
And then her life as a patient and physician collided, happily.
While teaching in Florida, Brooks was treated by a specialist in chronic pain, who used osteopathic manipulation of her joints and acupuncture and changed her diet. Eventually, she not only got out of the wheelchair, but also was inspired to become a doctor. She went to Michigan State University College of Osteopathic Medicine and earned her doctorate at 44.
Two decades ago, Brooks resurrected a clinic in Tutwiler that had been shut down for years. When she arrived in the town of now 1,200 people, there were no nearby doctors, she says. That's what attracted her to the delta to begin with. The poverty. The need. The average household income is $23,000 per year.
Brooks wanted to not only start at the economic bottom, but also stay there, she says. When she took over the clinic, the local press reported at the time patients paid with catfish and collard greens. The Tutwiler clinic is funded in part by the Catholic organization.
Mississippi is one of the states challenging the constitutionality of the healthcare reform law. The state's lawsuit bothers her a great deal, Brooks says. The state is suing the government because the governor "doesn't' want to be forced to buy insurance for the marginalized and the poor," she says.
If healthcare reform stays in place – uncertain, in part, with the GOP takeover of the House – "people will have better options, and hopefully get better education, and insurance to care for themselves," Brooks says. "Here we have a very poorly educated population that has no clue on how to take care of themselves."
A major aspect of her work is to help educate the patients. And that involved educating herself, Brooks says.
One of those elements was the need to embrace technology, even though some physicians are reluctant to do so. She says she'll do "whatever it takes to improve the quality of life for my community."
Two internists Brooks knew a while back were discussing medical records, and that got her interested in such programs. Eventually, she received a grant, and now, "electronic records are very exciting," Brooks says. The clinic purchased a Sage Intergy system that she says makes it more concise with her medical charting and dictation. The end result is more efficiency and savings, she says.
With the technology, the practice continues to evolve, and she continues to administrate the constant flow of care and need, Brooks says. The electronic records help in so many ways, big and small, she says. "My handwriting is small and my nurse scrawls. She no longer has to constantly ask her associates, "What did you say?'
"I don't want a barrier between me and my patients," she says.
More than 21,000 patients are listed in her fairly new database. "We try to set up projects with the hospital and get a discount when they order a CAT scan or something," she says. "I see Medicaid patients after they have gone to their own doctor for their 12 visits and use (the payments) up."
The local hospital doesn't have electronic medical records, but is heading in that direction soon, and she's happy for that. "They didn't have a yardstick to measure performance," Brooks says of hospital officials. "I'd invite them over and show them stuff (on her computer)." She's involved in a local task force to encourage healthcare workers to be knowledgeable about electronic medical records.
Learning the new electronic programs isn't easy, she says. "My personal transition has been pretty time consuming, but it's worth it," Brooks says.
Even though she doesn't use a wheelchair, pain and exhaustion shadow her daily routine. To this day, she isn't sure if she had rheumatoid arthritis or not. "They say it was a misdiagnosis," she says. There was a possibility it was Lyme disease, Brooks adds.
She begins each day at 5:30 a.m. and usually ends it at 7:30 p.m. She sees her patients, but knows that she must take time off each day so her body recuperates. "If I wash the car, for example, and I don't lie down, the muscles ache all afternoon," Brooks says. " If I take a 10 minute break, I'm OK," she says. When her colleagues sit down for lunch, "I go home and take a nap," she says.
Although she is being dubbed the "high tech nun" in the community, Brooks says, in effect: Let's not be ridiculous.
Brooks acknowledges that she straddles between the old world, of print, and the electronic era. She still makes house calls, and in those situations, she sticks to her notebook and pad, with a clipboard, and still relies occasionally on simply keeping information stored in her head, not a computer.
"I like to draw pictures and need to write stuff down," she says.
Still, Brooks has dreams for her clinic to one day to fully coordinate computer technology with nearby hospital labs where "everyone's data entries would be dumped to make things easier," she says.
Ah, she says. "I'd do it one of these days if we found a rich uncle."
In this 24/7-work world, it seems we're working all the time. Everyone I talk to says the same thing. It's relentless. For surgeons, there are added concerns; the exceedingly long shifts have a potential impact on patient care stemming from a physician's psychological trouble spots: burnout, depression, career dissatisfaction, and problems at home.
An extensive study from Johns Hopkins University School of Medicine and Mayo Clinic that surveyed more than 7,000 physicians shows a strong connection between increased hours and nighttime work, and a detrimental psychological impact on surgeons.
It's not surprising. And one answer seems to be pretty simple: reduce work hours.
But it never is simple, is it? Forced reduction in work hours may not be the solution for the busiest surgeons, according to authors of the study, published in the November issue of the Journal of the American College of Surgeons. For one thing, surgeons don't like punching a time clock, they say.
In fact, the authors don't suggest many restrictions on work hours—perhaps, tweaking them a bit, and usually on terms of the physicians, themselves. The best solution: identify the burnout potential before it becomes a full-fledged fire of concern.
In the study, a survey of surgeons working 80 hours per week, 50% met the criteria for burnout; 39% were screened positively for depression, and 11% said they made a significant medical error the previous three months. Moreover, one in five surgeons who worked more than 80 hours a week said he or she would not become a surgeon if they had a chance to do life's planning all over again.
Despite the survey suggestions linking workload to stress, Charles M. Balch, MD, professor of surgery at the Johns Hopkins University School of Medicine, says he doesn't particularly advocate restrictions on work hours. "There is no evidence that reducing hours would make all doctors more satisfied, or lead to better patient care," Balch says in a statement.
The survey shows that two-thirds of surgeons say they did not want limits put on their hours, including those who work more than 80 hours a week, or are on call more than three nights a week.
"If hours were regulated," he says, "the reality is that people would have to punch time clocks and I don't think surgeons necessarily want their workload monitored."
Co-author Julie Ann Freischlag, MD, senior investigator for the study, and head of the department of surgery at Johns Hopkins University School of Medicine, tells me, however, that while physicians may not want their workload monitored, there should be some flexibility, perhaps reduced work hours reflected in working arrangements with other physicians.
"Different kinds of physicians choose their specialties for all different sorts of reasons," Freischlag says. "Most people find surgeons tend to be aggressive; how much they do. It's just sort of their nature. They tend to move around a lot, don't sit in an office."
Long work hours, indeed, "do not correlate with burnout," Freischlag says. "Physicians like being busy. They like what they do. But sometimes when things go awry and things are conflicted—something is happening at home or work, and they want to be both places at the same time"—and the stress occurs, not unlike the rest of us.
But in the physician workplace, there is an increasing need for "self-regulation" of doctors' hours, particularly surgeons, to offset potential depression or burnout, she says. "There's got to be this realization—yes, it's ok for time off."
"You need time off," Freischlag, 55, says. "The new generation knows they should have time off. When I came up, there were 110-hour workweeks. Now they know they need time away from the office; they are smarter and know how to pace themselves."
More attention should be made to "earlier identification of surgeons at higher risk for burnout problems," according to Balch. The survey showed that surgeons who were on salary were more likely to favor restrictions in work hours than those whose pay was based entirely on billing.
Surgeons are learning, over time, to work better cooperatively, and to stay away from the office, and know they can be replaced on certain days, Freischlag says. She adds that that's the way she practices, and she has learned to fit in her home life with her busy practice, among other things.
Freischlag has been editor of the Archives of Surgery and has served on several editorial boards. She also has published more than 150 transcripts, abstracts and book chapters.
"If I'm not there, a partner can make up for me or a nurse practitioner," Freischlag says. "It works well. It is the shifting sands of how we practice."
"Part of it is the aging process," Freischlag says of making adjustments in her practice. "You don't need to prove to others. And, you get tired. It's the nature of things; how you set up your life and balance it. I think it's the nature of things; how you want to set up your life and the balance in it."
"I'm in and out of town, I take vacations, [that's] one of the reasons I'm still a surgeon," says the mother of three.
And then Freischlag laughs. "Sometimes I don't do a very good job (of the relaxation), and there's too much on your plate."
