Wednesday, December 30, 2009

The Universe might end tonight....

There may be a Higgs Boson tonight. I am currently watching the third installment of the John Adams Miniseries....I am also drinking my third Sam Adams at this time. The potential subatomic effects of such a mixture makes me shudder. This could potentially create a rip in the space time continuum, and even produce the dreaded Higgs Boson. Possibly even to a greater effect then the Hadron collider was predicted to produce....

SO, in essence, if the entire fabric of the Universe should collapse upon itself, I want to apologize in advance now.


(YES, I am a geek)

Founding Fathers and Christianity...

I was in a conversation some time ago with a nurse who is a "devout" Christian....still not sure what that really means...but I digress. Her assertion was that Obama was muslim...which besides being quite erroneous...was a little comical. When I stated, that first of all, he's really not.....but, even if he was.....SO WHAT????? She got quite defensive, and said that this country has always been a christian nation, and should never be led by someone from another religion....I started to laugh. I asked her if she thought that Washington, Adams, Jefferson, et al were christian.....She argued that "OF course they were"......I stated that no, they really weren't....they believed in god, for sure...but they weren't Christian in the sense of how it is defined currently..... She argued that "her pastor said"......This is where things started to bother me. People are all too quick to simply take someone else's word as fact, without bothering to research things themselves. Please keep in mind that this is NOT meant as a slur against Christianity, and that this is NOT implied in my post, but that simply, the founding fathers were more Unitarian, than Christian in their beliefs. Here it is, in their words.

“The way to see by faith is to shut the eye of reason.” Benjamin Franklin Poor Richard's Almanack, 1758

"As to Jesus of Nazareth, my Opinion of whom you particularly desire, I think the System of Morals and his Religion, as he left them to us, the best the world ever saw or is likely to see; but I apprehend it has received various corrupt changes, and I have, with most of the present Dissenters in England, some Doubts as to his divinity; tho' it is a question I do not dogmatize upon, having never studied it, and I think it needless to busy myself with it now, when I expect soon an Opportunity of knowing the Truth with less Trouble...Benjamin Franklin.

“Lighthouses are more helpful than churches.”

“He (the Rev. Mr. Whitefield) used, indeed, sometimes to pray for my conversion, but never had the satisfaction of believing that his prayers were heard.”

“I have found Christian dogma unintelligible. Early in life, I absenteed myself from Christian assemblies.”

“Some volumes against Deism fell into my hands. They were said to be the substance of sermons preached at Boyle’s Lecture. It happened that they produced on me an effect precisely the reverse of what was intended by the writers; for the arguments of the Deists, which were cited in order to be refuted, appealed to me much more forcibly than the refutation itself. In a word, I soon became a thorough Deist.” Benjamin Franklin, from his autobiography

“Religious controversies are always productive of more acrimony and irreconcilable hatreds than those which spring from any other cause. I had hoped that liberal and enlightened thought would have reconciled the Christians so that their [not our?] religious fights would not endanger the peace of Society.” George Washington Letter to Sir Edward Newenham, June 22, 1792

The divinity of Jesus is made a convenient cover for absurdity.” John Adams

“The government of the United States is not, in any sense, founded on the Christian religion.” John Adams, Treaty of Tripoly, article 11

“But how has it happened that millions of fables, tales, legends, have been blended with both Jewish and Christian revelation that have made them the most bloody religion that ever existed.” John Adams, letters to family and other leaders 1735-1826

“Millions of innocent men, women, and children, since the introduction of Christianity, have been burned, tortured, fined, and imprisoned, yet we have not advanced one inch toward uniformity. What has been the effect of coercion? To make one half of the world fools and the other half hypocrites.” Thomas Jefferson, Notes on Virginia

“The day will come when the mystical generation of Jesus, by the Supreme Being as His father, in the womb of a virgin will be classed with the fable of the generation of Minerva in the brain of Jupiter.” Thomas Jefferson, Letter to John Adams, April 11, 1823

“In no instance have . . . the churches been guardians of the liberties of the people.”
“Religious bondage shackles and debilitates the mind and unfits it for every noble enterprise.” James Madison, April 1, 1774's quite clear that while they were religious, and believed in God, they were not enamored of christianity, and I think they would be quite alarmed at the status of our society today.....and also saddened.

The Cleveland Browns

have now won 3 in a row......

News at 11.

OH, and Mike Holmgren has now joined us, with all of the fanfare of the second coming.

Tuesday, December 22, 2009

Health Reform Cartoons....

Enjoy....these are quite good.

Monday, December 21, 2009

MLR, CBO and "the" Bill....

This has been a bit of a longer process than some, and so far, Obama has not had to use the nuclear option (aka Budget Reconciliation).

What was interesting was Lieberman's apparent about face last week. Especially on something that he had wholeheartedly supported 3 months earlier. Something didn't seem right. My friend over at Angry Bear nailed it.

Lieberman has received most of his money from the financial and insurance industry. One of the parts of this bill is a minimum MLR. The insurance CEO's are going completely ape about this. To be fair, the minimum MLR isn't new, it was in the House legislature initially as Sec:116, and due to pressure at that time, was removed. The insurance companies thought they had seen the last of it, they were wrong.

MLR stands for Medical Loss Ratio, and the insurance industry defines it as the number of cents per dollar coming in, that are paid out for medical services. During a hearing this summer, Senator Rockefeller was grilling the insurance companies about this ratio, and many LIED to congress. They stated that their MLR was already 90% or higher. But research then showed, that for employees at large business, the MLR averaged about 84%, for small business it was closer to 80%, and for individuals purchasing insurance, it was only 76%.

This means that for an individual buying health insurance, 25% of their payments goes to administration, marketing, and/or profit.

The initiative in the current Senate bill mandates a minimum of 90% for all insurance companies, while the House bill, only mandates 85 and 80% respectively.

Hence, Lieberman's temper tantrum. It had absolutely nothing to do with the Medicare buy in (which is a bad idea for several other reasons), but everything to do with protecting his money train.

Now, fast forward to this past weekend, and the CBO releases this memo..


The problem is, that this makes no sense. I am trying to understand how mandating a minimum MLR causes THEIR REVENUE and FINANCES to be considered in the federal budget. We regulate the financial industry, we regulate the energy industry to avoid price gouging, and neither are considered in the federal budget.....I don't quite get it, and neither do other economists. Although it now seems in a correction issued yesterday, that the CBO may be backing away from this a little. My initial impression is that this is similar to the HR 1252 bill that was titled "The Federal Price Gouging Protection Act". Not sure, if we mandate insurance, how regulating the insurers causes them to become financial liabilities against the federal budget.

This was on angry bear....

I just listened to the conference call with Gov. Dean and Wendall Potter.
Toward the very end of the call, the issue of medical loss ratio regulation came up. Seems like a reasonable thing to regulate especially if we are going to get Chicago School of Economics style health care reform implemented via the Shock Doctrine method. (Yes, I've finally started that book and I've got to say, what is happening here with health care reform reads all too familiar.)

Unfortunately, according to Gov. Dean, the CBO keeps scoring MLR regulation as a hit (as in mafia take down) to the budget. Seem from CBO's perspective, if you regulate that the MLR can be no less than somewhere around 90%, such a number placed on profit ability makes all of the nation's health care a government budget item. Thus, something like $2.5 trillion gets added to the budget numbers.

Funny thing this CBO view. Basically this means that I (We the People) can mandate that I buy insurance, that I can only buy it from the private market, that I can write the rules of the market that I buy into, but I can't tell a corporation that is granted a privilege by me to spend it's money on the product it has been granted a privilege to provide?

Maybe the CBO figures because I decided to help some people in buying the mandated insurance, that by regulating the MLR, I'm making that money a greater expense on the budget because now 90% is going to health care services and not 70%? I really can't figure this one. Is the CBO really saying that I (and you) the government, can not assure that I'm going to get my money's worth? How come this issue does not come up when the government negotiates drug prices for the VA?

I really think, after watching our congress deal with health care, finance reform, military, that we have a bigger problem in this nation regarding economics and who is the boss here than we are willing to admit. Hint: It's We the People who is the government. It just seems that we have definitely, completely entered the realm of reality where "the market" is the purpose and not the means. We have been turned to existing to serve "the market". We have put "the market" before all our needs and desires for us as people. This is primitive idolizing behavior. This is sick.

I have to go plow now.

This blog noted in PA Professional

Interesting, I didn't catch this at first, but someone else noted that this blog is noted as an example of social media in the December issue of PA Professional. Page 11.

Seems interesting to me, but this has really become more of a policy and research focused blog over time.

Tuesday, December 15, 2009

Wow, 1/3 of democrats might not vote next year..

News at 11...

WOW, WOW, WOW.....

Or as, Wow Wow Wubbzy says, WOW WOW everyone...

Recent Poll, found here:


This is striking: A new national poll finds that fully one third of Democratic voters say that they’re “less likely” to vote in 2010 if Congress doesn’t pass a public option, underscoring the possibility that dropping the provision seriously risks dampening the Dem base’s enthusiasm.

I was sent an advance look at these numbers by the Progressive Change Campaign Committee and Democracy for America, which commissioned the poll from the nonpartisan Research 2000 and will release the results later this morning. The poll asks:

If Congress does not pass a public option as part of health care reform, will that make you more likely or less likely to vote in the 2010 general election, or no effect?

Among Dems, 33% say it would make them less likely, while less than one fourth that amount, 7%, say it would make them more likely. Sixty percent say it would have no effect.

Among independent voters, 21% say it would make them less likely, and 13% say it would make them more likely, with 66% saying it would have no effect, suggesting that passing a public option would have a marginal impact among indys.

The poll also suggests that 81% of voters want to see Lieberman crucified....or at least punished.

Monday, December 14, 2009

Terminology and Doctoral Level Education

Using, and knowing your terminology....

I am an economics geek, I always have been. Can't help it, it's what moves me, draws me towards policy, and shapes how I see the world.

As many of you know, I am completing my doctoral degree now, and am in the midst of classes. One of which currently is, “Health Policy Development”...Yeah, I know, for me this is like...JACKPOT...I even have my professor asking ME for tips. Of course, other courses are not this far up “my alley”.

But I digress, I recently had a reply to a post of mine discussing free market economics and healthcare (for those of you who don’t know, I am only 3 classes short of my BS in economics, and it is one of my main interests as pertains to healthcare). My classmate, in essence wrote, “the elasticity price in health care cost has escalated. In fact, since year 2000, the premiums for family coverage have raised by 87%” although I am paraphrasing to a degree in order to preserve anonymity.

Some of my classmates have stated that perhaps I was a bit vigorous in my reply.
However, my thought is, at this level of education. If you are going to state something, you better know what you are saying, and you better know how it relates, and is used, and in what context. This isn’t undergrad, this isn’t even graduate level, this is terminal degree level. Using terminology incorrectly needs to be addressed.

My reply was:

Not to be nitpicky, but there is no “elasticity price in healthcare costs”

Price Elasticity refers really to the price elasticity of demand, and to a lesser degree supply, and is a tool measuring the responsiveness of a function or commodity to changes in parameters or, in this case, price. Simply put, the amount to which a supply or demand curve changes relative to changes in price determines the elasticity. Products or goods which are considered essential, like healthcare, or utilties (electric, gas, water) have scores of 0 or -1. This indicates inelasticity which means the goods are NOT SENSITIVE, or at least, not AS sensitive to price changes, because people will continue using them regardless of cost. This is part of what is driving the escalation in healthcare costs today. Additionally, this means that market forces, will be LESS likely to change behaviour.

Now, if we look at the electronic goods market, like TV’s and Computers, their elasticity scores are much higher. This denotes an elastic good, and this means, that if prices rise, demand will fall. This is why you can buy a 47” LCD HDTV for under 1000 dollars now.

If we really want to get fancy, we can look at the math:

PED = (∆Q/∆P) x P/Q. (∆Q/∆P)

But that is really inconsequential for our purposes.

I don’t know, but I don’t think I was harsh in the least.

Markets, Healthcare, and why things don't work...

This is something I've been meaning to post for awhile, but I log on, check out some of my colleagues blogs, and find that I've been beaten.....


Bob has it right. I've said this before as well. One way of keeping costs down, is working within an HMO or PPO network. Simply allowing insurers to cross state lines, won't fix this. In fact, out of state insurers, won't have established networks, won't be able to offer lower prices, or even really compete with in state companies, and won't alter the fact that insurance premiums continue to increase by 10% or more annually.

Now, sadly, most conservatives can't get past this...they can't reconcile the fact that "THE Market" can't fix everything.

Sometimes, competition doesn't help. But don't try and tell the Republican party that, they're rather myopic in this view.

Senatorial Ineptitude

Not suprisingly, and as I have predicted in the past, things have come to a screeching halt in the Senate. The House was predictable, and passed HR3962, which the CBO scored favorably, at least at first.

The problem was, that they also passed HR3961, which basically eliminates the SGR, and calls for a moratorium on Medicare cuts until 2019. The CBO, when evaluating the two bills together, found that it would INCREASE federal deficit spending by 84 billion over the next ten years. Which really isn't bad, but to paraphrase an old saying, "Don't lie to my face, when your screwing my ass!" In other words, be honest.

NOW, the gears have slowed, and the senate is crawling to a stop. Because of several individuals, (cough) BLUE DOGS (cough), as well as Senator Lieberman (cough) TURNCOAT (cough)....the idea of a robust, real public option is likely dead. So, there is now a proposal to extend Medicare coverage.

This is problematic on so many levels as to be comical. Medicare isn't even accepted by many physicians secondary to a dismal reimbursement structure. It is not financially solvent over the long term, and will likely be bankrupt before the next decade is over. This a dog...

Actually, it's worse, it's a dog with fleas.

Sunday, December 13, 2009

Physician Assistant Professional Paradigm Shift

Yep, that's what we need.

Over on Clinician One, there is a thread posting an homage to Mary Mundinger, and her incredible work on behalf of the NP profession.

Someone then mentions that we need a Mary Mundinger for our profession, then, someone mentions that they think that person is me. I am humbled by their thoughts, and I think that we do need an aggressive change in direction, but I think that comparing me (really, in the start or beginning of my political/advocacy career) to someone who has been at this for a long time is a bit premature.

I will however, state, that Ms, sorry, Dr Mundinger, understands the importance of language. I will also state that the entire APN profession has understood that quite well since their inception. Words matter, Titles matter, Descriptions matter. Dr Stead understood this with the initial impetus of calling our profession Physician Associates, however, we have since lived in essentially indentured servitude to our medical masters. I say NO MORE.

Here's a list of some that are used in the lexicon of the PA profession:

Physician Assistant
Supervisory Agreement
Delegatory practice
Dependent licensure

Despicable. EVERY single one of them. I understand their utilization when our profession was young, weak, and politically insignificant, but now I can think of much better substitions.

Physician Associate
Collaborative Arrangement
Specialty Dependent practice
Independence/Completely autonomous licensure

We need to adapt. All professions grow, they change, they are by their very nature dynamic. Like the economy, it is not a static unchanging thing. The PA profession HAS grown since it's inception, but it is now reaching the parabolical end of the rope.

It's time to change again.






I am so happy, I don't even know what to say. That was a great game to watch, and the Brownies almost have me thinking that we have a defense. But then I come back to reality, and realize just how far the Steelers have fallen....

Car Accidents Suck.....

SO, I am leaving work this past Thursday, on my way to pick up my 3 year old daughter, when I get into a car wreck....

Ugh. At least NO ONE got hurt. That's about the only good thing.

5400 dollars in damage to my truck.

I'm still quite a bit sore as well.

Saturday, December 5, 2009


For those of you that regularly follow this blog I wanted to apologize for the recent absence. I just finished arguably the toughest quarter of my doctoral degree, and during November had so many papers, projects, etc. due, that I needed to put this on the backburner for awhile.

But not to worry, I will be posting several posts a week again, starting tomorrow.

Best Regards,


Tuesday, October 20, 2009

Malpractice Reform Paper

Interesting read....stretching my brain a bit....but good read

the economic modeling is QUITE intensive, so you might want to skip parts...but the conclusion is here:


The impact of liability for medical malpractice on the cost of medical care has been one
of the highest profile issues in debates over the U.S. health care system for many years.
Malpractice payments have grown enormously over the past 15 years, but this has likely had a
modest impact on the cost of health care in the US. It may have other significant effects, such as
decreasing the supply of physicians or changing the nature of treatment. Our findings, however,
suggest that limiting malpractice liability is no panacea for rising health care costs.
Moreover, while the mortality benefits of malpractice may be quite modest, these seem
more likely than not to justify its direct and indirect health care costs. Therefore, we conclude
that — for values of statistical life traditionally employed by US regulators —reducing
malpractice costs is not likely to be a worthwhile policy goal in itself. As emphasized by Currie
and MacLeod (2008), however, specific policies must be evaluated on a case-by-case basis, as
they can have unexpected effects on physicians’ expected liability and incentives. In addition,
there may be policies that reduce malpractice costs but have other social benefits; we do not rule
those out, but note that the case for their adoption rests on their auxiliary effects.
At a minimum, our analysis reveals the tenuousness of the case for tort reform, but it is
important to note its limitations. First, we account only for impacts of tort reform on medical costs and mortality, excluding its impacts (if any) on morbidity, physician utility, and patient
satisfaction. These quantities are extremely difficult to measure objectively. In addition, we do
not account for the adjustment costs (e.g., on the utilization of the health care system) that would
be induced by any large-scale reform project. The size and even direction of these excluded
effects is not clear. Finally, even if we ignore these limitations and accept the estimates at face
value, the probabilistic nature of our analysis means we cannot rule with (even approximate)
certainty for or against tort reform over conventionally accepted values of life.
Putting our results together with earlier work suggests that malpractice may have
substantial impacts on the care and costs of specific patient subgroups — like heart attack
patients — but much more modest impacts on the average patient, and on health care spending as
a whole. Future research should endeavor to determine whether tort reform can be targeted
toward these subgroups in a cost-effective manner.
Another important avenue for future work is to evaluate whether malpractice has effects
on more fine-grained outcomes in the health care system, such as morbidity, disability, or the
nature of care delivery. Medical costs and mortality are likely to be the first-order costs and
benefits of changes to the malpractice system, but the auxiliary effects may be quite significant.
If, for example, malpractice risk has had limited impacts on costs but appreciable positive
impacts on average outcomes other than mortality, the malpractice “crisis” may be anything but.
If, on the other hand, it has negative impacts on outcomes, the major costs of malpractice may be
in health rather than in dollars.

Mortality and the Economy....

This paper:


Describes mortality as procyclical....very upside down it you you can see from the attached graph, mortality seems to increase with decreased unemployment. Or, conversely, economic expansion seems to INCREASE mortality in OECD countries, and economic recessions seem to DECREASE mortality. This not what I think most would expect, and although it is not a new topic, having being described since the 20's, this is a newer article that may be somewhat apropos given the current economy.

Economic recessions have paradoxical effects on the mortality trends of populations in rich countries. Contrary to what might have been expected, economic downturns during the 20th century were associated with declines in mortality rates. In terms of business cycles, mortality is procyclical, meaning it goes up with economic expansions and down with contractions, and not countercyclical (the opposite), as expected. So while most nations enjoyed sustained declines in mortality during the last century, the pace of the decline has been slower during economic booms and greater during so-called busts. The first rigorous studies demonstrating this trend have appeared only in the past 9 years, although the concept is not new. In contrast, for poor countries, shared economic growth appears to improve health by providing the means to meet essential needs such as food, clean water and shelter, as well access to basic health care services. But after a country reaches $5000 to $10 000 gross national product (GNP) per capita (or gross domestic product or gross national income per capita, all of which are similar for our purposes here), few health benefits arise from further economic growth 1 (Figure 1). Health trends in Sweden illustrate this effect.

It's the economy stupid.....

NO, I am not James Carville, but this post by the admittedly conservative Heritage Foundation is a little scary


Social Security, however, is not the gravest fiscal crisis that America faces. The 2005 Medicare trustees’ report estimates that providing promised Medicare benefits over just the next 10 years could require over $2.7 trillion in new tax revenues. Raising taxes by that amount would eliminate almost 816,000 jobs per year, on average, and shave an average of nearly $87 billion from the real (inflation-adjusted) gross domestic product (GDP) between 2006 and 2015. Even worse, the Medicare trustees project that providing promised Medicare benefits over the next 75 years would require $29.9 trillion in new tax revenues. Raising taxes to meet Medicare’s 75-year shortfall would cost an average of 2.3 million jobs and well over $190 billion in real GDP annually through 2015.
Economist Laurence Kotlikoff estimates that U.S. payroll and income taxes would need to rise to almost 40 percent of wages to cover future retiree’s promised health and pension benefits.[2] This would put the United States in the economic territory now occupied by continental Europe, whose countries have had far higher taxes on labor income for decades. Europe also provides a cautionary tale: its countries have experienced declines in employment rates, average hours worked, and GDP growth since the 1970s—outcomes that many economists, such as Nobel laureate Edward Prescott, attribute to higher taxes.[3] Kotlikoff estimates that the result of raising taxes to fund promised old-age benefits would be a 25 percent drop in the U.S. standard of living by 2030.

Monday, September 28, 2009

Democrats killing health reform...

There are so many people who are absolutely convinced that the republicans are killing healthcare reform. This usually makes me laugh a little, because, while they have certainly not been very helpful, the republican minority has very little real power currently, and are really bystanders in this whole affair. The REAL problem is the democrats. In particular the blue dogs who control a certain amount of power within both the house and senate, and are staunchly against the public option.

The real problem for Obama lies in what to do. He could choose to ram something through with reconciliation, although many on both sides would likely cry foul. If he succumbs and doesn’t pass a real, substantive healthcare reform bill, then he will alienate many of the more liberal democrats who strongly supported him. He ran on “Change”. The bills currently are not change. The WH hands off approach is not change.

The Baucus bill currently sits with 564 proposed amendments. It will likely not survive in any recognizable form. This article below describes what is happening. Schumer and Rockefeller are prroposing an amendment to include a public option, but Conrad and Baucus have already indicated that they will vote against it. Reid is calling on Obama to act as a referee for the senate sausage procedure, and the House leadership is stating that they will not even consider passing any legislature without a public option.

This is in the midst of RAPID escalations in healthcare spending, and significant growth in the ranks of uninsured thanks to a Wall Street induced recession.

Too bad, we could maybe actually fix something, but I really don’t think Congress is capable of doing the right thing here.

See more HERE

Healthcare Premiums

So, I've held off being really critical of the Baucus bill for a while, even though it is complete garbage. I am actually, quite certain that one of the insurance industry executives actually wrote it. Cause they win big. Yeah, they have to get rid of their history of recission, and of denying coverage for pre-existing conditions, BUT, with the mandate, and the exclusion of a public option, they stand poised to rake in hundreds of millions in additional revenue.

This article describes quite nicely the net effect of healthcare premiums next year. Even though the economy is rather static, although no longer contractile, healthcare premiums are expected to jump by 10% for workers, and 6% for employers.....

See article HERE

Does anyone really think that this might put more inflationary pressure on small businesses, and result in even more people losing work based coverage. It is truly bad enough that only 38% of small businesses currently offer health benefits.

The real sad part, described in the article, is how workers have seen their premiums triple in just the past 8 years. This is not sustainable long term. While they it may not be wall street brokers, trading default swaps, this represents a real threat to our long term economic vitality.

Friday, September 11, 2009

Budgetary concerns...

SO, I had a nice, long holiday weekend, and then had some work and family obligations over the past several days, and I apologize for my short absence.

Talking to a friend the other day, who works as a CFO for a large corporation, and showed me some interesting data from the Institute for Trend Research, a company he uses from time to time.

We were discussing the deficits, and the economic implications of ramped up deficit spending. These numbers are a little mind boggling.

Based on the current CBO estimates of future deficits, If there is a 1/2 of 1 % increase in real market interest rates (50 basis points), the governments debt service as a % of total budget outlays will grow to approximately:

13.0% in 2009
25.5% in 2012
34.1% in 2015

This excludes any effect from a change in Health care.

That's scary, like REALLY scary. 34.1% possibly in debt service obligations within 6 years??? WTF?? OH, and we haven't even touched on inflation yet. Which could become rampant if US debt obligations accelerate, which, in turn, could devalue the dollar.

This is multifactorial, and due to the deficit spending of the last administration, the Afghanistan/Iraq wars, and the recent stimulus package.


Friday, September 4, 2009

Obama's crisis

As usual, Bob Laszewski has it right again.

Obama is stuck between a rock and a very hard place. If reform fails, or becomes too compromised, the left may never forgive, not after his campaigning, and initial statements on the importance of health reform.


He talks about the two options available to the President. Neither are very appealing, and Bob is right, both have serious possibly political consequences, not only for the President, but perhaps for the entire Democratic Party.

I imagine the conversations in the Oval Office are quite heated indeed.

Now we see the death of reform

After speaking with more politicians than I care to really think about, I am convinced that congress cannot effectively pass good healthcare legislation. They simply do not have the ability to do so. Perhaps if two-term limits were in place, things would be different, but that is an entirely different discussion. Speaker Pelosi is now saying, as some of her colleagues have earlier in the House, that without a public option, a health bill WILL NOT pass the House.

Here's the problem. The Senate is faced with a much tougher problem, particularly from a certain group of Democrats who are, at this point, opposed to a public option. This is why the "Gang of Six" are still in session. What's funny is that many people are blaming Republicans, and to be sure, they have not played nicely in this debate, but it is the blue dog democrats who are going to run this bill into the ground.

What good is having a majority, if the majority won't follow you.


Medical Home Model

So this was interesting. We have all heard talk now for years about the medical home concept, and how this would help retain primary care physicians, increase patient satisfaction, and lower costs.

It would seem that now, someone has studied that.

The Group Health Home Cooperative performed a study comparing a medical home model with a control group.

“A medical home is like an old-style family doctor’s office, but with a whole team of professionals,” said Robert J. Reid, MD, an associate investigator at the Group Health Center for Health Studies and Group Health’s associate medical director for preventive care. “Together, they make the most of modern knowledge and technology– including e-mail and electronic medical records – to give patients excellent care and reach out to help them stay healthy.”



During the medical home pilot, each primary care doctor was responsible for fewer patients – a total of 1,800 patients, as opposed to 2,300. This reduction allowed physicians more time to coordinate care, have daily “team huddles” and allow for extended 30-minute office visits per patient.

The reduction in patient-to-physician ratio also created a need for extra staffing. The study found that the medical home was investing $16 more per patient per year, and that the home needed 72 percent more clinical pharmacists, 44 percent more physician assistants, 18 percent more medical assistants, 17 percent more registered nurses and 15 percent more primary doctors.

“Our evaluation showed these costs were recouped within the year,” Reid said. "The main reason was emergency room savings of $54 per patient in the course of the year.”

“These findings are important because they provide a 'proof-of-concept' that investments in a medical home can achieve relatively rapid returns across a range of key outcomes," he added.

Is the AARP suffering from Alzheimers?

They seem a bit confused.


So the AARP which was initially very supportive of Obama’s healthcare initiatives is now impersonating John Kerry.

First they were for it, now they are impartial?

Please. This is one of the reasons that we will not see substantial, and/or real health reform this year. I’m sorry, but congress is simply incapable of making the right decisions, and while the AARP is certainly not congress, their lobby carries a bit of weight on capitol hill, and the same pressures that are being applied to the AARP are also being applied to congress.

More at this LINK



Thursday, September 3, 2009

Minnesota payment system

Similar to a system like Prometheus that uses a "bundling" paradigm, Medica in Minnesota has developed such a package of "Paying for Value" with Fairview Hospital system.

More on NPR

I hope that more hospitals, and systems realize that this sort of reform can acutally have a lasting effect, and hopefully begin to slow, or curb HCE growth.

Thursday, August 27, 2009

Propofol sedation and Michael Jackson..

Okay, I like Happy's blog for the most part, we have been in MASSIVE disagreements over the utilization and deployment of PA's, and NP's, but I also for the most part respect his opinion....

HOWEVER, here, I think Happy has lost it.

Trying to assert that giving propofol in a persons bedroom, and leaving 10 minutes after administration to go to the restroom, is similar to administration in an outpatient healthcare setting is just crazy. That is truly, jumping the shark.

I give propofol frequently for shoulder and hip dislocations, fracture reductions, central line placement, chest tube placement, etc. I also use etomidate, versed, and other sedatives/anesthetics. But never, unless I have airway equipment at the ready, including a laryngoscope and ET tube, and never without proper monitoring. In fact, I had to take a course on concious sedation and prove competency prior to being able to use them. Which is a GOOD thing.

These are serious drugs, and one has to have a VERY healthy respect for them. Using them in someone's bedroom is crazy. Using them, and then leaving 10 min in (which, btw, is just about when they will be awakening with propofol) to go the restroom is criminal.

But that's my opinion.

Great description of elasticity modeling in healthcare

In economics, several of the words that you might hear, are elasticity, inelasticity, and contractility.

Jason over at Healthcare Economist does a great job describing price elasticity in medical services in a relatively straightforward manner.

Price elasticity estimates how consumer demand changes as prices change. For instance, the price elasticity of medical service is defined as the percentage change in quantity of medical care demanded divided by the percentage change in price of the same commodity. Most academics believe that the price elasticity for medical services is between 0 and -1. This means that if prices increase by 10%, the demand for medical services decreases, but by less than 10%. This means that medical goods are inelastic.

This is in large part, the reason we are seeing a failure of the medical markets to respond to the pressures of the current recession.

Wednesday, August 26, 2009

RIP Teddy

Senator Ted Kennedy died today.

Regardless of where you stood politically, there are very few politicians who have had the true passion for helping others that he had. He also may have been more involved over the course of his career in pursuing healthcare reform, than any other politician in US history.

So the last brother passes.

Tuesday, August 25, 2009

Football is upon us....

It's the first sign of the coming autumn. Football is here. THANK god, I love football, I love everything about football. My beloved Cleveland Browns will hopefully not suck TOO badly, and my fantasy team seems decent.

Can't wait, for brats, beer, and chips/pretzels. But what I really miss.....

I really miss playing football. I was discussing this the other night with a nurse at work, and she asked me why. That's easy, I miss the pain. I miss the contact. There was nothing better in this world than watching a wide receiver come across the middle and go up for a ball...I was a free safety...and then to make the hit, and make it so hard, to stick it, to actually feel his wind being expelled from his lungs and watch him hit the ground hard is a feeling that is hard to replace.

I never wanted to injure anyone, and no one I knew, or played for wanted to see that either. But to smack someone REALLY hard, and make them think twice about where you were the next time they were running a route was a great feeling. I even liked getting smacked myself. I remember once getting ready to nail a wide reciever coming across the middle from the right side, and I didn't see the tight end coming from the other side. I got smacked...knocked about 10 yards..I loved it.

I really miss the contact....the only thing that might compare is drunken kickboxing, but that is a WHOLE nother story.

The Drug Seeker Dance

I love drug seekers, I love everything about them. I actually get a BIG smile when I see the complaint, and recognize the name. It wasn't always that way, I used to despise them. I used to groan, and complain about seeing them, and I would dread the coming confrontation. Not anymore. Now I've dealt with them so many times, that I actually enjoy it. I'm not known as being a "dispenser", in fact quite to the contrary, there have been times working at some of my locations where I have watched a familiar patient walk in, see me working, and watch their mouth open and sigh, and watch them walk right out the door. It's an unusual thing.

However, after seeing so many, there seems to be a common dance that they all do...regardless of whatever flavor they may be seeking.

Step 1, As you enter the room, the patient greets you with a smile, and an enthusiastic expression. (the first part of the buttering up phase), and seems to be comfortably sitting there...BUT wait, something is amiss....they are complaining of 10 out of 10 pain.....Hmm, now that's odd.

Step 2, As the interview progresses they repeatedly ask about your personal life and family, IE; do you have kids?, how old are they?, etc. (the second part of the buttering up phase).

Step 3, Now for the exam, this is almost always benign, and usually completely unremarkable, yet they might try to grimace, or act as though something is really wrong. The trick is to get them to repeat the motions, or pressure without them thinking it is an exam. IE; ask them if they need help sitting up, and press on the tender point in their back.

Step 4, the dreaded confrontation, I used to hate this, but now I don't mind at all. You calmly confront them about their frequent visits for narcotics, and how they should be obtaining ALL narcotics from one solitary primary care provider. This is where the patient goes almost invariably through several stages. First there is disbelief, and subsequently a defensive posturing. Then there is usually an excuse or story, IE; my meds got stolen, I lost them, my doctor is out of town, etc, followed by an attempt at bargaining.

Too bad it rarely works. I have no problem treating real pain, and I might be more liberal than some when treating fractures, occasional isolated migraines, pain related to cancer, etc. However, when I see a frequent flyer in the ED, with chronic pain, who is chronically drug seeking, and doctor shopping, well.....Not so much.

Eight Stages of American Medicine

From Happy's blog:

Phase VII: Destruction of the Tax Base, and With It, Government Health Care

Believing they could continue to soak the rich for all their needs; With massive deficits that must be repaid; With 50% of the population paying just 3% of the tax base; The government finally killed off the productivity that drives American growth. With a tax base massively skewed to the productive members of society, the ones that take all the risk of capital, the tax burden became too much. No longer were folks willing to take risks to see rewards which were confiscated to the tune of 90% or more in federal tax rates. Tax rates that continued its northward spiral in a misguided attempt to pay spiraling entitlement programs. Programs that bought off the populace years prior.

As growth plummeted so did jobs and productivity. And with that came the lose of tax revenues to fund the already shrinking and rationed government health care entitlements. Ultimately what the government realized was the wisdom of their ways. They realized they could not continue to promise FREE=MORE to a poor and middle class population while also funding that obligation from a small and shrinking rich population burdened under the weight of massive tax hikes and anti growth programs.

At this point the government made an amazing proposition to its entitled masses. Either the poor and middle class would now have to cough up more than 3% of the federal tax revenue, or they would have to dismantle the entitlement programs funded almost entirely on the backs of the rich, a population who's numbers have dwindled drastically since the tax and spend policies were initiated two decades prior.

The people now had a choice. Pay their share or go without. One hundred years on the road to socialism was finally meeting its demise.

I especially liked stage VII, how apropos. I have been stating similar things on here for awhile, but perhaps, not so eloquently (who knew a hospitalist could write?)

Folks, if we don't dramatically reduce costs, and realize that we might need to raise taxes on more than just the rich, than this will fail. It will fail epically.

BTW- this is why I support Zeke's plan. A national VAT tax rate of 10% to fund a single payor system. EVERYONE PAYS.

10.5% increase in health care premiums..

Nice, but this is economically part of the problem.

Found THIS in the Washington Post today.

So, it begins, employees will likely begin to see wage stagnation, a decrease in real purchasing power (ESPECIALLY if the newly minted deficit of 1.6 trillion causes devaluation of the dollar, and subsequent inflation), and possibly an increase in healthcare deductions.

Not only that, but prescription drug prices are expected to rise 9.3%.....I mean REALLY????

We need real cost controls, and a real effort to reduce healthcare expenditures.

Monday, August 24, 2009

Wake Forest fires the first shot....

Here we go, Wake Forest University fires the first shot. Found this over on the forums.


Wake Forest University School of Medicine
Winston-Salem, North Carolina
Applications are invited for the position of chair of the Department of PA Studies at Wake Forest University School of Medicine. The chair has overall responsibility for all activities of the department and reports directly to the dean of the School of Medicine.
The Department of PA Studies was one of the first PA programs in the country. It is a pioneer in the use of problem-based learning (PBL) and had over 700 applicants for the 56 positions available in the class starting in 2009. Wake Forest will be the first institution in the country to offer a combined Master of Medical Science (MMS) and PhD program, pending final approval by the University’s Board of Trustees.
The successful candidate will have an established record of leadership in PA education (including exposure to PBL) and extensive administrative experience. A doctoral degree (or one in progress) and research experience are highly desirable. We seek a leader who is well grounded in all aspects of PA education and who also has a vision for the continued growth and development of the field.
To apply, send a curriculum vitae and letter of interest to

Burton V. Reifler MD, MPH
Chair of the Search Committee, at

Wake Forest University School of Medicine is an affirmative action, equal opportunity employer. Women and minorities are encouraged to apply.

So, it sounds like an entry level PhD program for PA's....Which is groundbreaking, this has the potential to really, and dynamically affect PA education, although not necessarily for the better. The proof is in the details, and still remains to be seen.


Sunday, August 23, 2009

Mandatory PA Residencies...

Now, for something not so popular with some of my colleagues. PA residencies. They've been around for years, and I believe there are now 48 or 49 programs. The Baylor/Army EM residency program is 18 months and awards a doctoral of science degree, or a DSc at it's completion. I think someone mentioned that it contains 5600 clinical residency hours, and 516 didactic hours.

The point of this discussion, is that the PA profession is changing. Our roots were based in experienced health care workers, at the beginning, military medics, who could recieve additional training and be a complement to the physician. Medicine, and PA training have changed however. Physicians, healthcare policy wonks, and even the market itself is starting to see more and more PA's practicing with more indirect physician supervision. PA's are increasingly becoming practice owners, and hiring supervising docs to work with them. We have branched far from our initial purpose, which was to provide primary care in rural and underserved areas, and are now working in almost every single specialty, including interventional radiology.

Concomitantly, programs have transitioned from a certificate or associates based training, to the majority being held at a Master's degree level. This has meant more and more younger students coming straight from undergraduate into PA school with nominal, if any prior healthcare experience.

Should we mandate mandatory residency training? I am thinking this is an idea whose time may be upon us. Not all of them need to, or should offer a Doctoral degree. But I think any PA who wishes to practice outside of primary care, should complete a residency.

BTW-this is not a very popular idea with a lot of PA's

Here's a link to an article about the Baylor/Army program.

Here's another that needed to be resurrected.

Bill Maher is my hero....


From his show the other night...

And finally, New Rule: Just because a country elects a smart president doesn't make it a smart country. Now, a couple of weeks ago, I was asked on CNN if I thought Sarah Palin, and I said, "I hope not, but I wouldn't put anything past this stupid country." Well, the station was flooded with emails and the Twits hit the fan. And you could tell these people were really mad because they wrote entirely in capital letters!

Worst of all, Bill O'Reilly refuted my contention that this is a stupid country by calling me a "pinhead." Which, a) proves my point and b) is really funny coming from a "doody-face" like him!

Now, before I go about demonstrating how sadly easy it is to prove the dumbness that is dragging us down, let me just say that ignorance has life and death consequences. On the eve of the Iraq war, 70% of Americans thought Saddam Hussein was personally involved in 9/11. Six years later, 34% still do.

Or, look at the healthcare debate going on now. At a recent town hall meeting in South Carolina, a man stood up and told his congressman to "keep your government hands off my Medicare." Which is kind of like driving cross-country to protest highways.

This country is like a college chick after two Long Island ice teas. We can be talked into anything. Like wars. And we can be talked out of anything. Like healthcare.

We should forget the town halls and replace them with study halls.

Listen to some of these statistics. A majority of Americans cannot name a single branch of government, or explain what the Bill of Rights is. Twenty-four percent could not name the country America fought in the Revolutionary War. More than two-thirds of Americans don't know what's in Roe v. Wade; two-thirds don't know what the Food and Drug Administration does.

Some of this stuff you should be able to pick up simply by being alive. You know, the way the "Slumdog" kid knew about cricket?

But, not here. Nearly half of Americans don't know that states have two senators. And more than half can't name their congressman. And, among Republican governors, only three got their wife's name right on the first try.

People b*tch and moan about taxes and spending. They have no idea what their government spends money on. The average voter thinks foreign aid consumes 24% of our federal budget. It's actually less than one percent. A third of Republicans believe Obama is not a citizen. And a third of Democrats believe that George Bush had prior knowledge of the 9/11 attacks. Which is an ABSURD sentence, because it contains the words "Bush" and "knowledge."

Sleep tight, bat-****. Sarah Palin says she would never apologize for America, even though a Gallup Poll says 18% of us think the sun revolves around the earth. No, they're not stupid; they're "interplanetary mavericks."

And I haven't even brought up religion. But, here's one fun fact I'll leave you with: Did you know only about half of Americans are aware that Judaism is an older religion than Christianity? That's right. Half of America looks at books called the Old Testament and the New Testament, and cannot figure out which one came first.

I rest my case.

The stupidity of the average american just never ceases to amaze me.

BTW, those statistics are should be enough to scare anyone. More than 2/3 don't know what's in Roe V Wade???

I'm seriously starting to think that we need to start curbing the growth of the stupid in this country.....

This goes in the "duh" category....

This is so astronomically obvious, that it might even eclipse the sun. Unfortunately, our country is exceedingly stupid, and what is blatantly obvious seems to escape many.


SO, let's see, premiums are rising faster than income. Well, golly, I'm shocked, SHOCKED I tell you.

Until half of this country begins to take their collective heads out of their collective asses, we are in real trouble.

PA name change.

This has been an issue for a long time, and has been debated in PA circles ad nauseum. When our profession was first created. Dr Eugene Stead, the professions founder, wanted to name us Physician Associates. The AMA at them time, in their infinite paranoia (think of the DO profession, and pretty much the AMA reaction to anyone else in healthcare) thought that the name "associate" was misleading, and could lead people to think of PA's as physicians, or physicians in training. What a crock. The Yale program (Yes we have Ivy league programs), still to this day calls their graduates Physician Associates, and at the hospital there, they are titled as such.

There are many in our profession who think of the "assistant" title as denigrating, and demeaning. Count me among them. Patients and the public frequently misconstrue us as "medical assistants", and while I have nothing against medical assistants, that implication is insulting. Assistant implies that I have nothing to offer besides helping a physician with a specific task. It implies a lack of training.

PA's own their own practices. They serve as FLAG officers (yes, admirals, etc.) in the military, when VP Cheney was sick, he wasn't cared for by an MD initially, he was cared for by a PA. In most specialties, PA's function with a HIGH level of independence, and autonomy. In one of the ED's I work in, specifically, Waseca Medical Center, the ED is solely staffed by PA's. There are NO MD's in the ED. Overnight, we cover the floors as well. Guess what, in the fall of 2008, the ED had the HIGHEST patient satisfaction scores in the COUNTRY..not just the state, the COUNTRY. Does that sound like what an "assistant" does?

More here

It is time to return to our roots, it is time to return to the name that Dr Stead initially intended for our profession. We have outgrown the old one.


Thought I would resurrect this, as I like this discussion, and my desire for a name change has only become MORE resolute

Thursday, August 20, 2009

Rationing of Care

This is an editorial that I just published in the latest issue of PA Professional, as many of you likely do not GET that journal, I thought I would also post here.

Rationing of care, yep, it’s a scary term I know. Yet, while it’s an emotionally charged and difficult topic to discuss, it remains one of the most complex and pressing issues for a society heading rapidly towards health reform.
We ration care now. However, now it’s rationed simply on a financial basis, i.e. those who cannot afford insurance, and do not qualify for state assistance have little in the way of options for chronic medical treatment. Even those with Medicare and Medicaid can sometimes find it difficult to obtain appointments or a provider, as many do not accept those insurance plans.
I have had my more conservative friends tell me, that those without insurance can simply obtain care “in the ER”. Sadly, this observation plays itself out in reality more times than not. However, the care that is provided in the emergency department (ED) setting should, in no way, be compared to the comprehensive care, and management that an experienced and competent primary care provider could provide for chronic disease management.
I discuss health policy on a daily basis, and one of the frequent things that I try to tell people is that, discussing health care reform without discussing how to provide care for an increased number of people, while lowering costs at the same time, and not discussing rationing, is ignoring the 800 pound gorilla sitting in the corner of the room. It’s a difficult discussion because – unlike our European counterparts – there are cultural forces at work in the United States.
Many patients have a rather defiant attitude towards death. This is problematic when we realize that the majority of patient health care expenditures occur in the last months of life. For example, Taxol is used in the United Kingdom in the treatment of ovarian neoplasms, but it’s often withheld in advanced ovarian cancer. Elderly patients, who have multiple co-morbidities and develop conditions like renal failure, may not be eligible for services like dialysis. Their system has decided that the cost/benefit ratio is simply not acceptable.
Other industrialized countries, with more governmental control of health care, use similar methods to ration care. Now, ask yourself how you would feel if it were your loved one? Does that change your response? These are important questions, and I am not going to pretend to know the answers, but this is a necessary discussion, and there is a definite fiscal reality that we as a nation, are going to have to confront.
As provider’s, we all have the ability to influence the health care reform debate to some degree, and if we want to have any sort of real honest discussion about health reform, or universal coverage, we need to first be honest with ourselves, because it’s still the 800 pound gorilla, sitting there in the corner, staring at you.

For those interested, it is in Vol. 1, No. 2 of the PA Professional.

Clinician One

Dave Mittman from Clinician One has asked me to, and I will begin to post this blog on the Clinician One site. I will try to crosspost here as much as possible as well, but thought that I should inform you.

I will post the direct link, once I have it.


MORE on Prometheus....

I've posted about this before, but here is an article from the NEJM, which is a bit more substantive.

Prometheus....NO, not the god who was forever condemned to watch his liver being eaten every day, but a healthcare payment system that was first implemented in Rockford, Ill.


Prometheus in Practice

A 63-year-old white man with chest pain and a history of unstable angina is admitted to a teaching hospital. The patient has hypertension and diabetes. An electrocardiogram reveals ST-segment elevation in the lateral leads. The man is taken to the cardiac catheterization laboratory, where coronary angiography reveals severe triple-vessel disease as well as 60% stenosis of the left main coronary artery. A left ventriculogram shows mitral regurgitation (grade 2 to 3) with papillary muscle dysfunction. The patient is then taken urgently to the operating room, where he receives two venousgrafts and a left-internal-thoracic-artery graft. In addition, a mitral-valve reconstruction procedure is performed to correct the mitral regurgitation. The surgery is a success, and the patient returns to the intensive care unit in stable condition. However, his blood sugar is out of control, and he requires an insulin drip. His stay in the intensive care unit is prolonged by 2 days, and he must stay another day in the step-down unit. He is discharged 8 days after surgery in stable condition. One week after discharge, he is readmitted for a wound infection in his leg from the vein harvest site. He requires wound débridement and a course of antibiotics.

Under fee-for-service payment, the hospital would receive $47,500 for the bypass surgery, and the surgeon would receive $15,000 for performing the procedure. The extended hospital stay that was necessitated by the uncontrolled diabetes would result in an additional $12,000 for the hospital and $2,000 for the physician, and the readmission costs would total $25,000, for a grand total of $101,500.

Under Prometheus, the case-payment rate for this patient would include a severity-adjusted budget for typical costs of $61,000 for the hospital and $13,000 for the physician. The severity-adjusted allowance for PACs would be $15,300, for a total budget of $89,300. Had the readmission been prevented, the hospital and physician would effectively have earned a bonus of $12,800 ($101,500 – $25,000 = $76,500, which is $12,800 less than the Prometheus budget).

BTW, Doctors HATE this concept. But they pretty much hate anyone telling them what to do.....

Thursday, July 30, 2009

Best Damn Editorial in a long time.

Those of you that faithfully follow this blog know a few things, number one, I am not a fan of the DNP degree mandate for several workforce supply issues and reasons that I have expanded on in the past. Secondly, I have been saying for months, that trying to simply expand coverage, and NOT implement or attempt to reign in the substantial increases in healthcare spending that occur annually, will NOT WORK. It's that simple.

YOU CANNOT ESCAPE THE RULE OF 6.9%. In a year, FY2008, which saw the worst economic collapse in five decades, and saw the year finish with NEGATIVE GDP growth. Yep,
-5.8%, healthcare spending still increased by 6.9%. Businesses which saw record losses, and had to cut staff, production, and benefits, saw health premiums increase by 5% on average. The current iterations put forth by the house, and the HELP version from the Senate DO NOT DO THIS. SO, we will simply be spending ourselves further and further into oblivion.

Right now, by 2050, Medicare and Medicaid spending alone will consume almost all federal taxes levied, and by 2080, Medicare will consume MORE than all federal taxes collected. This year, 2009, the predicted increase in healthcare spending will be close to 7.4%, and for every year now for decades, healthcare spending increases have outpaced GDP growth. It cannot continue.

This idea, of taxing healthcare, may help. It is one of the few ideas coming out of congress that actually has merit, but it is politically unpopular, cause most americans don't really understand macroeconomics, or the real, REAL need for restraint in healthcare spending.

If the economy could stay elastic and continually expand, we wouldn't even have any of this conversation, but it cannot. In fact, right now, it is still contracting, although the latest economic indicators show that this had slowed substantially, healthcare does not respond like a typical commodities market. Cause it's not. Right now, as most of you know, we have a mixed payor system. Unfortunately, this is the worst of both worlds. Anyway, please read:


Trip Home with my Daughter

SO, I decide to take my 3 year old daughter home last week for a family reunion. Let me tell you folks, a 12 hour car ride BY YOURSELF with a 3 year old is not something to be taken lightly. She did so, SO good though. She truly was Daddy's big little girl. She loved being at the farm and seeing my mom, and at the tender age of 3, rode a horse for the first time BY HERSELF. Last year, she'd sit on the saddle, but only if mom or dad were with her. For those that are wondering, my wife's brother is terminal with stage IV adenoca of the lung, and her father is also quite ill as well. She does not have much leave from work currently, and decided to stay home to save leave.

I will say that having a 3 year old cry, and scream that they have to "GO POTTY" while you are stuck in construction with no exits anywhere in sight is a new experience for me.

Friday, July 17, 2009

Prometheus is upon us.....

WHOA, the physician community is not so happy about this.

This is a new system funded by the Robert Wood Johnson foundation, and is akin to forced capitation. Obama and the current administration are quite interested in this, and various states, including my own are thinking about implementing it as well. I'd be interested in Happy's take on this.

I wonder how the guys in McAllen would take this.....(ducks)


20th High School Reunion

Wow, what the hell happened? HOW has it been 20 years already. I didn't go to my 5th or 10th, or any of my other reunions, but I just finalized my travel plans to go back in about 3 weeks for my 20th. Like anything, there will be some people I really want to see and catch up with, and others that I didn't know really well. Oh well, a good bottle of 21 year old MacCallan, and life is good.

Pneumonia SUCKS

Wow, I can't remember being this sick in a long time. I was diagnosed almost two weeks ago. Left lower lobar consolidation. Treated appropriately, but I am still coughing stuff up. Missed a couple of days at work initially, cause I just couldn't go. I can tell I am getting older. When I was 15 years younger, I would have recovered in a few days, but I am still getting over this 2 weeks later.....WTF?

Sunday, July 5, 2009

Pay Cuts for Specialists, and increases for Primary Care..

Obama's initiative to CMS, re-allocate your re-imbursements! Estimates are that primary care physicians could see a pay increase of 6-8%, while some specialists, specifically cardiology as mentioned, could see BIG decreases. 11% overall, but up to 42% for procedures like echocardiograms.

Big changes...


Thursday, July 2, 2009

AMA does 180

SO, I think the AMA is doing their very best imitation of John Kerry at the moment, first they were against it, and now.......not so much.


Just gotta wonder.

Walmart...makes me laugh

SO, Walmart, the nations LARGEST private employer with 1.4 million employees is supportive of an employer mandate from congress for all employers to provide insurance. If only they were so accomodating to all of their employees. While I am not opposed to a mandate, I find it somewhat comical that a company with 36,000 employees on MEDICAID, yes, Medicaid, and has historically been somewhat reluctant to expand employee benefits would suddenly "see the light". I think that this is likely more of a power play by Walmart, to force some of their smaller competitors to provide benefits that they themselves are not even currently providing. I find it somewhat interesting considering that according to this article, only 53% of Walmart employees have health insurance sponsored by Wally, and 6% of their employee population is completely UNINSURED. Interesting statements made by them.

See more HERE

Wednesday, June 17, 2009

Idiots, the Private Insurance Idiots...

No, they didn't fly to Washington on private jets, and ask for money from congress, but the three top insurance company leaders did testify before congress about rescission. Rather than being in tune with the tone of the country, economy, and congress as pertains to health reform, and possibly eliminating the practice, they basically thumbed their noses at the public, and said NO.

What sheer audacity, matched only by it's sheer stupidity. This is not smart practice to begin with, and in this particular climate, it's akin to committing political suicide.


An investigation by the House Subcommittee on Oversight and Investigations showed that health insurers WellPoint Inc., UnitedHealth Group and Assurant Inc. canceled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over a five-year period.

It also found that policyholders with breast cancer, lymphoma and more than 1,000 other conditions were targeted for rescission and that employees were praised in performance reviews for terminating the policies of customers with expensive illnesses.

Thursday, June 11, 2009

The AMA is, if nothing else, predictable.

SO, finally the AMA has broken their silence, and released a press release regarding the possibility of a government backed plan to compete with private health insurance.

I don't think anyone will be surprised by their opinion.


Too bad their relevance is vanishing. Once a proud, vibrant, and powerful organization, they have lost a lot in the way of membership, and their revenues continue to decline.

They did it to themselves, and really have no one else to blame. They have fought against ANY, and ALL change within the healthcare system. First, they labeled physicians practicing in group practices as "communists", then they claimed that a DO's education was inferior, and would not recognize them as physicians, they have also picked battles with virtually every other group in the medical arena.

These acts have diminshed their power, much as the boy who cries "wolf", the AMA is not as respected as it once was. Physicians now overwhelming join their specialty groups. They are becoming what the republican party has. A shadow of their former selves, finding themselves on the outside, trying to find any sense of relevance.

Waste, Taxes, and an inept congress.

As usual, my friend an colleague Bob Laszewski has it right.


From his blog

Most experts estimate that the final health care bill will cost at least $1.2 trillion over those same ten years. It looks like the Democrats are getting ready to propose paying for half the cost of a health care bill with new taxes.

So, out of that $35 trillion we can’t find a little more than a trillion dollars in savings to pay the full cost of a health care bill?

Just taking the $17 billion that government will pay over the next ten years, we can’t find a trillion dollars there either?

Most experts agree that our system costs so much because we waste something like 30% of what we now spend.

At 30% in waste, that would mean that of the $35 trillion we will spend on health care over the next ten years there is more than $10 trillion in waste. Just in the $17 trillion government will spend on health care there would be more than $5 trillion in waste.

Just think about the logic of that for a moment.

It appears we are on our way to a $600 billion to $800 billion tax increase for a health care bill because we can’t find that amount of money in a system that will waste $10 trillion over the same period.


For starters, their is an estimated 60 billion in Medicare fraud annually, that the CMS does little, if anything about. They don't report many of their administrative costs, as they want to keep the illusion that their admin costs are under 2%, yet research done shows that their admin costs, without factoring in fraud and abuse, are actually closer to 5.8%. NOW, add in 60 billion. If we were to simply eliminate Medicare fraud, at 60 billion annually, we would save HALF of the money needed for Obama's healthcare reform plans by that action alone. We would save 600 billion over a ten year period. This isn't even touching on the 30% of waste that is estimated to occur in healthcare spending.

It makes me sick. I agree with Bob, these guys are morons. For, instead of actually DOING something to control cost increases, eliminate waste, eliminate fraud (which is illegal anyway), we are going to simply shift the costs to the taxpayer.

The more I see of both parties, the more I realize that they are simply indistinguishable from each other any more. There truly is little if any difference between them. They are concerned only with the accumulation, and maintenance of political power.

Wednesday, June 10, 2009

Putting it mildly

This article in the Washington Post might be the understatement of the century...


Much of current climate, and the current excitement in the democratic party is ominously reminicsent of the failed Clinton reform efforts of the early nineties.

The only thing that has possibly changed is that the public is likely more receptive, mostly due to the current economic downturn. Unfortunately, the american publics ideological opposition to any and all things government may not engender Obama's plans to the public. Only time will tell if his efforts will be more successful.

Thursday, June 4, 2009


Well, at the academy, I got to see a lot of old friends, and a lot of my friends and colleagues in both academia, research, and the academy leadership. One, Bill Kolhepp, suggested that perhaps I might be a good candidate for an upcoming opening on the NCCPA Board of Directors. This might be interesting. It was a good trip overall, the House of Delegates was relatively quiet. The only item that even engendered any real interest was the debate over the switch to a 10 year re-cert instead of the current 6 year term. It was referred back to committee. Not bad considering that Medical Marijuana was on the agenda, and many of us who have been around for awhile were expecting a lot of heated debate over that.

Got to see old friends, and sat up one evening having drinks with two of the most respected PA researchers in the country. It was a little flattering that they both were quite interested in my opinions, and both are wishing to possibly do projects with me in the future.

All in all, a good trip.

Mayo Clinic and The New Yorker.

Atul Gawande has written a great piece in the New Yorker about the costs of healthcare in this country. For his comparison, he has chosen McAllen, Texas, and of course, the Mayo Clinic in Rochester, MN. My home, and place of employment. The article is


It is a well written piece, and Dr Gawande seems to have an excellent grasp of the facts. I, in fact, chuckled at one point in the article when he describes being a visiting surgeon at Mayo, and being astonished at the preoperative care of one patient. I felt similarly after coming here from Cleveland Clinic, and although CCF is an outstanding instituion, practicing at Mayo is different. I also felt that the conversation with physicians in McAllen was a particularly insightful part of this piece as well. I also agree with him in principle on some of the problems inherent in many of the high cost areas within this country. He is also quite correct when he states that local influence, and/or "culture" is absolutely imperative as a means of cost controls. However, I disagree with his conclusion or assertion that Mayo as a model, is losing ground to more expensive models. I think the current administration's focus, particularly Orszag's, as well as an emphasis on the "Medical Home", Pay for Performance initiatives, and the rising emphasis on Evidence Based Medicine, and quality metrics shows quite the opposite. In fact, in the near future, judging from some of the grumbling amongst the physician community, the "Mayo Model" may become the ideal, a visionary example of excellence in the medical community, not only in the treatment of disease, for which we have achieved considerable recognition, but in the DELIVERY of care.

Make no mistake, there will be resistance, likely considerable resistance, and while there is certainly already some, judging from my conversations with physicians and providers around the country, it will likely increase substantially. The truth may become difficult to hear above the noise, and dogmatic expressions from both side will dominate any real discussion. But, and this is a huge but, IF we can see with clarity, work with purpose, and focus our efforts, real reform may be possible. As I have said on here previously, our problems are many, and many have not even been clearly delineatd yet, however, this should not deter us from striving for true and lasting change. Our patients, and their families deserve nothing less.

Monday, June 1, 2009

Shamu must die!

So, in San Diego, at the conference, I managed to sneek away a few times for a little family time. My daughter, at the tender age of 3, wanted to go to Sea World, which was really cool.

We not only watched the Shamu show, but had "Lunch with Shamu", which for the rather exorbitant price tag should have had prime rib served with a nice bottle of wine, but instead we got a cafeteria style meal, and watched giant orcas swim about us.
This was all fine, fun was had by one and all. A monument, an image in time.

HOWEVER, she has not stopped talking about Shamu now. Like constantly. For days on end. Like to the point where I have been begun to formulate an imaginative strategy for his demise. I am now living in that fantastical world of imagery, and hyperbole. Shamu, your days are numbered my friend.

At least, I hope they are in my household.

Comparative Effectiveness Study...

Alright, so I am back from sunny San Diego, had a good time at the annual AAPA conference. The HOD was relatively boring this year, and got to take in some of the sights.

I am about to undertake the monster, my Moby Dick, the whale that no one wants to deal with. I am about to do, and have submitted for IRB approval, a comparative effectiveness study evaluating the care provided by PA's, working autonomously, vs MD attendings. This, at least to my knowledge, has not been done in the ED setting before, and I am interested in examining the results.

In order to keep the study manageable, and in order to obtain good results, we will be limiting the study to 3 diagnoses.

1. Renal Stones
2. Thromboembolic Events
3. Asthma Excacerbations

I chose these 3 diagnoses, as they all have defined endpoints within the ED setting, and am interested in comparing clinical outcomes, ie; did the PA group treat the patients in the same manner as the physician group?, Were there any missed diagnoses? Was there an increase in complications? etc.etc.
Also, I want to examine the financial impact, ie; we claim to be more cost effective, but is the PA group ordering more tests, and/or unnecessary interventions when compared to the physician group, thereby negating the cost savings?

As my friend, and colleague James Cawley noted, you may find things that you might not like. Which, at least in my mind, is even more of a reason to do this. If we are NOT meeting benchmarks, then we need to know this.

May be interesting.

Also, we have one NP in the group, and she will be included in the study group as well.

Wednesday, May 20, 2009

Sorry for the's been a HARD week.

Sorry for all of my regular readers, I have been a bit absent lately. I've been involved in many different meetings, and than have had a bit of an emotional time at home.

On last thursday morning at 5am. One of my wife's friends from High School died from Acute Lymphoblastic Leukemia. She was diagnosed in 2006, underwent a bone marrow transplant, and subsequent treatment, but the disease prevailed. She was 38, and leaves behind 7 and 9 year old daughters, and a 16 year old son.

She would frequently stay with us when she came down to Mayo for treatments.

More here

We wanted to be at her funeral, but we JUST got back from Colorado Springs visiting my wife's brother who is now terminal with stage IV adenocarcinoma of the lung, he is on supplemental oxygen now, and is undergoing palliative chemo, but his time is likely measured in months.

Her father was there too, is 82, can barely walk, and needs help to even get out of a chair now, not to mention suffering from increasing dementia. He also has two AAA's that have doubled in size in the past year.

My poor wife is about to break. I can see it. I just wish I could do more for her. That's all from my corner.

Hug your loved ones.

I will post more in the coming weeks after the AAPA conference, and after my life settles down slightly.

Thursday, May 7, 2009

Medicare Advantage Plan Cuts

10.4 million enrollees, 3,354 plans with an estimated expense, or cost of 12 billion more than treating those same 10.4 million patients with traditional Medicare. Defenders claim that these plans offer expanded benefits, that poorer retirees will not be able to otherwise get, as they cannot afford a supplemental Medicare plan.
The problem lies in the fact that these plans will generate about 157 billion in additional costs over the next decade. Obama has said that he wants a bidding process to cut the proposed expenditures for the Medicare Advantage plans. Baucus, Grassley, et al, would like some other way of solving this problem without cutting payments.

Ahh, the joys of congress. Sen Baucus and Grassley, need to realize, that the pie is only so large, and you cannot simply keep taking MORE out of it, without adjusting the size of the pie. It'll be an interesting debate.


Friday, May 1, 2009

Changes to blog...

As my career evolves, so does this little piece of my life. I have now enacted comment moderation. It was suggested to me when I started doing this, to be very provocative, and to post controversial ideas. I will try to continue to do so, but I will be certainly taming down some of my more inflammatory comments. I have been as guilty as anyone in the past. I have enacted the comment moderation, mainly in order to ensure, and hopefully maintain very civil, thoughtful discourse.

We have a range of problems in our healthcare community, we have needs that are many, and many that have not even been adequately defined yet. I want this blog to evolve into a place where PA's, NP's, and even MD's can come and discuss difficult, and sometimes thought provoking commentary on health reform and policy.

I am spending more and more of my time in this arena, and I have decided to post my name on this blog as well.

My career is continuing to rise, I was just asked to possibly accept an appointment with the Mayo Medical School giving some talks/presentations on Health Policy to the medical students.

I look forward to continuing to have more fruitful discussions of healthcare reform, policy, and healthcare economics. With the occasional patient story thrown in as well.

Best Regards,

Michael Halasy, MS, PA-C

Monday, April 27, 2009

Symposium on Health Education Reform, Day One

WOW....surrounded by heavyweights...all of them.

Had breakfast with Polly Bednash, who is the Executive Director of the AACN, Darrell Kirch, the current president and CEO of the AAMC, and my friend, and colleague, VP of the AAPA Bill Fenn.

Attendees include:

President Emeritus AAMC
Chancellor Emory University
Director, Division of Undergraduate Medical Education, AMA
President and CEO of the Institute for Healthcare Improvement
Professor and Dean of Vanderbilt School of Nursing
CEO Henry Ford Medical Group
Senior VP of the American Board of Medical Specialties
CEO and Executive VP, American Colleges of Pharmacy
CEO Accreditation Council for CME
CEO National League Nursing
President and CEO ACGME
President American Association of Colleges of Osteopathic Medicine
Coordinating Producer ABC News Health Care Task Force

as well as NUMEROUS other deans and presidents of various medical schools.

It was a good day.

First session started with a review of the four cornerstones of health reform for the Mayo Clinic.

Discussion also focused around reforming medical student education to NOT teach disease treatment, but to teach healthcare delivery. There was a lot of focus on integrated classes for medical students, WITH MANY classes being taken with other health professionals. For example. Anatomy. There was discussion that medical students, nursing students, PT students, and PA students ALL TAKE THE SAME ANATOMY COURSES TOGETHER. There was talk about incorporating a course that would solely teach and focus on teamwork, and (sorry Happy) teaching the physician that they are an EQUAL with other members on the team, and not always in charge.

There was a lot of discussion about the Intermountain group, that manages 30,000 diabetic patients with only FOUR endocrinologists. HOW? They use non physician providers.

The next session was about Licensure, Accreditation, and Certification. There was a lot of debate about having a SOLITARY interdisciplinary certifcation process.

There was a talk about Professionalism, and having medical students NOT graded on individual exams to test medical knowledge that they won't remember, but to test them on the concepts, and the ability to find the answers when they need them. ALSO, to test them on HOW WELL THEY FUNCTION IN THE TEAM MODEL.

The next session included Realigning the Health Care Training System Toward Coordinated Patient Centered Care, again discussing the team model, and dramatically changing the current medical school structure.

Finally, we were asked to submit a singular answer from EVERY table as to HOW to best reform the health care system.

Then, we had dinner, and a discussion on Driving Change in Academic Medicine.

I'm tired now. A lot of information, a lot of very intense discussion amongst a group of highly accomplished and intelligent folks.

I will update you tomorrow with the findings at that time.

Here's some more information:

After the introduction, Denis Cortese, M.D., presented an overview of the Mayo Clinic Health Policy Center’s consensus-driven cornerstones for health care reform in America: create value, coordinate care, reform the payment system and insure everyone. He noted that medical education must play a crucial role in preparing individuals to provide high-value, coordinated care and introduced several issues for education professionals to consider, including specific curriculum designed to increase value, student selection criteria, instruction methods, assessment and financing.

Zoë Baird then introduced the panel and framed the discussion around how to train students to create a healthier America. All panelists agreed that the educational system must be redesigned to break down professional silos, creating an educational environment in which physicians, nurses, other allied health professionals, community health workers and family caregivers learn to work together on behalf of the patient.

“There is concern about a shortage of physicians today,” said Michael Johns, M.D. “I think if we gave allied health staff the ability to practice to the full extent of their skills, that shortage would be a lot smaller.

“We need the right person at the right time to provide leadership to the care team,” he continued. “Physicians need to be comfortable not being at point all the time. Every person is important.”

Panel members also noted that the curriculum must incorporate elements of engineering and health delivery science in addition to biological science.

Dr. Cortese commented that the current education system encourages learners to focus on accumulation of knowledge rather than innovative ways to deliver health care to individuals.

The group also called for the development of novel assessments – including measurement based upon patient outcomes, teamwork and individual performance.

“We need to move away from GPA and standard examinations as our primary or sole assessment tools,” said Jack Stobo, M.D. “There is no correlation between these tools and how students perform in practice.”

“We are in control of health professional education… it’s ours to win or lose,” he emphasized. “There currently is a mismatch with how we’re educating professionals and what society needs.”

10-11:30 a.m. – Licensure, Accreditation and Certification: Achieving Harmonic Resonance

Susan Wagner, Producer, Dr. Oz Show

Geraldine Bednash, Ph.D., Executive Director, American Association of Colleges
of Nursing
Claire Bender, M.D., Director for Education, Mayo Clinic in Minnesota
Richard Hawkins, M.D., Senior Vice President for Professional and
Scientific Affairs, American Board of Medical Specialties
Thomas Nasca, M.D., CEO, Accreditation Council for Graduate Medical Education

Moderator Susan Wagner provided introductions and began the discussion by asking the panelists to define licensure, accreditation and certification. Then, discussion revolved around identifying steps to change licensure, accreditation and certification standards/processes without a clear sense of what reforms will shape the care delivery system.

Geraldine Bednash, Ph.D., R.N., discussed efforts in advanced practice nursing to bring together the different standard-setting groups to agree on a common set of standards for certification and accreditation. Dr. Bednash noted that licensing occurs at the state level by government and is influenced more by political considerations instead of evidence of capability of providers.

Expanding sharing opportunities is an area that can be explored immediately, according to Claire Bender, M.D. Dr. Bender described new efforts at Mayo Clinic to bring different providers together in the same class when curriculum is applicable to both. It has been successful in demonstrating that different providers have and need different skills. The model also provides an environment that allows different health care professionals to become familiar with each other and respect the abilities of each type of provider.

Thomas Nasca, M.D., pointed out that it will be difficult to get hundreds of professional societies, accrediting bodies and licensure boards around the table, but that it may be possible to begin agreeing on unifying themes that move across discipline boundaries. It will be important to make sure that licensure, accreditation and certification standards don’t prohibit change, and reinforce core competencies that learners can carry forward as health care delivery systems evolve.

Richard Hawkins, M.D., discussed how assessments can be redefined to reinforce the principles of teamwork in a reformed health care environment. He suggested creating a feedback cycle from clinical care into the education and certification process.

Participants spent a portion of the session submitting ideas for changes in licensure, certification and accreditation to aid in transforming the educational system to support patient-centered, coordinated health care reform. The following actions received the highest endorsement.

Introduce team-based minimum standards for training and care models for both certification and accreditation.

Introduce team-based exercises as part of individual certification.

Certification should more closely mirror real-life clinical situations.

Consider use of a public/private entity, independent of Congress, to bring societies and professions together and adopt more common standards for training, certification and accreditation.

Noon-1:30 p.m. – Professionalism - The Critical Element in Health Care Education

If doctors falter in their professionalism, health care reform efforts will come up short, said Jordan Cohen, M.D., president emeritus of the Association of the American Medical Colleges and professor of medicine and public health at George Washington University.

“Professionalism is when physicians know the right thing to do and then do it,” he remarked in his keynote luncheon address. “It’s the behavior required of doctors in fulfilling their compact with society. They are honor bound on their own volition to work in patients’ best interest and use their knowledge and expertise to that end.”

Dr. Cohen said that nurturing professionalism is one way to advance needed changes in U.S. health care, and he recommended six ways for educators to promote professionalism:

Adopt and approve admission criteria. Few medical students fail to graduate and fewer still fail to get licensed. Educators have a fundamental role as gatekeepers to the profession.
Establish explicit learning objectives. Adults learn best when they have prospective understanding of what they are going to learn.
Address the rationale for adhering to the precepts of professionalism in the formal curriculum. Future physicians need to be mindful of temptations and ways to withstand conflicts of interest.
Be proactive and intentional in the informal curriculum. Educators need to model behaviors emblematic of professionalism. Informal curriculum is one of the most powerful influences on adopting the norms of the profession.
Articulate institutional expectations. “We need to be unabashed about communicating these expectations,” says Dr. Cohen.
Evaluate and reward behaviors that are emblematic of professionalism. Sanction and call out those who are not professional.

Americans long to trust their physicians and polls show that they largely do, Dr. Cohen added. And, trusting doctors is good for patients. “It increasing compliance and improves outcomes,” he remarked. “But that trust is earned, not owed. The surest way to lose that trust is to abandon professionalism.”

1:30-3 p.m. – Realigning the Health Care Training System for Coordinated Patient- Centered Care

Maggie Mahar, Ph.D., health care fellow, Century Foundation

Mark Kelly, M.D., Henry Ford Medical Group
Lindsey Henson, M.D., University of Minnesota
William Hersh, M.D., Oregon Health and Science University
Beverly Malone, PhD, RN, FAAN, National League of Nursing
Alyce Schultz, RN, PhD, FAAN, EBP Concepts

Today’s medical education system has holes that prevent the next generation of doctors, nurses and allied health professionals from learning how to provide patient-centered care.

That was the premise of moderator Maggie Mahar, Ph.D., health care fellow, Century Foundation, as she opened the session titled “Realigning the Health Care Training System for Coordinated Patient-Centered Care.”

She was joined by representatives from, nursing, medical education and medical center leadership to discuss how the core competencies identified in the Institute of Medicine’s 2003 report “Bridge to Quality” might fill those gaps.

Panel discussion centered on the core competencies, most taken from the IOM report, including:

Providing patient-centered care
Working in interdisciplinary teams
Using evidence-based practice
Applying quality improvement
Using informatics
Shifting culture toward professionalism

The discussion sparked more than 30 recommendations to keep patients at the center of coordinated care. The top-ranked recommendations encompassed common themes of teaching future providers how to work in teams and across disciplines. The recommendations challenged educators to find ways to increase learning opportunities in real world settings.

Participants ranked these recommendations as most important:

Introduce (early in training programs) team-based and reality-based standards and experiences that reflect all health care team members contributing at their highest level of training.

Establish an institutional/unit commitment to patient-centered collaborative care.

To understand patients, students should interface with the patients in their communities experiencing medical care through their patients eyes and experiences

Incentives for students (i.e. evaluation) must be aligned with team learning.

Health education schools need to work across disciplines to develop areas of shared curriculum to teach students team care delivery

Create a non-punitive culture for understanding and learning from mistakes and inefficiency

3:30-5 p.m. – Your Views Concerning Change – What is Required to Create the Health Care Workforce of the Future?

Event co-hosts Pat Mitchell and Dr. Cascino challenged participants to brainstorm ideas to answer the same question posed to MD Connector Competition participants:

“In order to create a health care workforce equipped to provide a high-value team approach to coordinated, patient-centered health care, what is the most important change required of the health care education system?”

The group spent an hour discussing potential changes, and submitted their consensus responses. Responses will be compiled during the evening, and participants will review and prioritize the recommendations during the opening session on Tuesday morning.

7-8 p.m. – Driving Change in Academic Medicine

Darrell Kirch, M.D., president and CEO, Association of American Medical Colleges provided perspective on the need for change in academic medicine.

Dr. Kirch emphasized the importance of focusing medical and health care education reform on the training of all professionals who work in the delivery of health care. Individuals who practice in any portion of care delivery are a vital part of the team approach to medicine and need to have a voice in the evolution of training.

Dr. Kirch noted that many buzzwords are associated with health care reform. One of these words is “change.” He focused on two degrees of change:

Incremental, which is usually considered good in academic settings, and
Revolutionary, which encompasses broad change

Dr. Kirch proposed the need for a middle ground in education: transformational change. This involves sweeping, fundamental change that recognizes the tremendous good in the current system – especially the dedicated people.

A primary barrier to change, he noted, is true culture shift in medical and health care education. Dr. Kirch cited the 1910 Flexner Report as the last true culture shift in medical and health care education. Flexner emphasized an academic culture which has medical research at its core. While this is a valid foundation, Dr. Kirsh said that this focus has led to competition among individuals in research and practice.

A New Culture
Dr. Kirch discussed that today’s patient expects teamwork in medicine. The current health care practice – which emphasizes individualism – is unsustainable, and there is broad recognition that teaching and learning have to be different. Health care professionals need to use information rather than retain information.

Dr. Kirch concluded his presentation by outlining five items for medical and health care education reform:

First, health care systems and educational systems need to be partners. This involves training organizations that are accountable for developing value in the health care system.

Second, the medical and health care training system needs to put aside culture and focus on training that meets the needs of patients.

Third, medical and health care education schools must be increasingly transparent with financial and tuition information.

Fourth, medical education must develop future leaders, building a bottom-up approach that focuses on teamwork and consensus.

Fifth, the health care system must examine the factors that drive medical and health care education training. This must include the concept of justice in the health care system. Dr. Kirch emphasized that the current health care system is unjust or fundamentally unfair, which is not a political issue but a core ethical issue.