Thursday, March 5, 2009

What a difference a 15 years makes!

Just a few minutes ago, President Obama wrapped up his White House Summit on Health Reform.

Dr. Jeffrey Harris, MD, FACP, represented ACP at the summit.

I will write more about the summit in future posts, but a few first impressions:

1. This President really, really wants health care reform. He believes - as he said in his opening remarks - that the U.S. has reached the point where "there no longer is a debate about whether to have health care reform, but how that reform should look and work."

2. He rejects the notion that the economic crisis works against health care reform. To the contrary, he made it clear that you can't fix the economy or sustain entitlement programs, like Medicare and Medicaid, without controlling health care costs.

3. He is willing to take on liberal activists, pointedly telling them that they are not going to be able to achieve universal coverage without controlling costs.

4. He understands the importance of primary care. During the question and answers period, he unequivocally stated that, "We have to produce more primary care physicians." Amen!

He also is determined to do everything possible to not to repeat the mistakes that the Clintons made fifteen years ago. Instead of a secret health care task force, he launched his health reform effort today by bringing together key stakeholders and members of Congress from both political parties.

None of this guarantees success. The health care NIMBY-ism that I blogged about on Monday still could cost us health care reform. But in my mind, today was a good start on beginning a process that actually might bring home the "holy grail" of health care reform.

For more information about the summit, go to

Question: Did today's White House summit make you more or less optimistic about the prospects for achieving comprehensive health care reform?


Viral Patel said...

Thanks Mr. Doherty for the Comments!

I definitely think that the initiative that President Obama has in bringing heathcare to the forefront of the media and American public is a great feat. It makes me more optimistic about the future of healthcare and more importantly primary care. This is essential with our population demographics and spiraling costs. He and his team understands that and we have change coming.

Anonymous said...

Assuming the ACP summary is accurate, I do not think you can directly link cost control and universality. One or the other must be chosen as primary and the other adapted to the consequences that emerge from whichever is chosen first.

What's missing is the primary nature of quality outcomes. I think this would have to tip the balance in favor of universal coverage over cost containment as the initial goal.

While there is a shortage of primary care physicians that harms any reform effort, these really reflect market forces. It may be the ACP's organizational sacred cow but it will be difficult for the government to impose a solution to this reality without either losing control of costs or disrupting something else.

rich the furrydoc

PCP said...

The mere recognition of the need to have more Primary care physicians is inadequate. The devil is in the detail of the policy they come up with in the end. That will in the end determine the direction of Physician led primary care.
The proportion of residents we train in the fields of general IM, FP, Pediatrics has not declined. What has changed is the fact that those we do train are choosing careers outside of primary care, whether it be sub specialising, going into Hospitalist medicine, Boutique medicine, Academic medicine, Working for other industry jobs er whatever they can do to run for the exits. One of the few changes during the 90s was an increase in primary care residency positions, ironically(or perhaps not) that has not solved the problem of shortages, because young doctors quite simply don't feel the system supports them and therefore find alternatives. Their careers are continuously undermined by politicians. They do not feel valued or supported. Hence they leave/don't enter primary care.
No amount of money poured into training will solve that. The ACP would be better representing IM if they were to advocate for more support for practicing internists which will attract more to the field rather than for expanded training, which will leave us no better off when the newly trained and disillusioned internists find something else to do.

Bohdan A. Oryshkevich, MD, MPH said...

I was encouraged by the summit yesterday. I feel very confident that Mr. Obama is sincere on health care reform. I just love the man. I watched an Obama television campaign interview yesterday from before the Iowa caucuses and he has certainly grown into the job very well.

In effect, he called a truce, got all the people out of the trenches just as in World War I, and then essentially left them (Congress and some special interests) to solve the problem without him. He has some parameters for them. If they come up with a solution, he is capable of making the right decisions and compromises.

Sadly, he has too much on his plate. Two wars, rising unemployment with people incapable of responding to a mandate, collapsing industries, etc.

He is yet to call for a mandate. A mandate or order for the unemployed to pay for their own insurance is already totally unrealistic at this time. It is going to get even more unrealistic in the next few months. Recent events are outpacing the proposed campaign solutions.

I hate to quote the single payer solution, but simplification (as called for by many at the main forum yesterday) of layers and layers of transactions will require movement into the single payer direction. EMRs is not going to do that. Jump starting primary care will also need Presidential attention. .

I would ask how do you get to universality without the financial controls and discipline that single payer gives you? I unlike PNHP am open to any solution out there. But since I spent six years in Canada, I have to ask that question.

What people fail to understand in America is that the single payer in Canada was passed by the CONSERVATIVES. I remember being at a meeting at the Montreal General Hospital central offices. This is the largest Anglophone hospital in Montreal. It is the best hospital and oldest hospital in Canada. We call it “the other MGH.” On the table in front of me was a terribly overdue bill for tens thousands of dollars due to Bell Canada. Also shortly after I left there was a scandal in Quebec because the top senior managers of our hospital were being paid 45,000 CAN instead of $40,000. In Canada a hospital gets an annual or a quarterly check from the government and then has to figure how to live on that. The remarkable thing is that the workhorses in the trenches, the residents, get paid first.

One of my best friends is a gastroenterologist in Montreal. He gets paid $100 per colonoscopy. His plate is full since he is booked days if not weeks in advance. As a board certified allergist, we were trained at McGill to practice allergy without allergy shots and following the evidence, we did man, many, many fewer skin tests than our American compatriots in Albany New York. Allergy shots were not prohibited but they paid $2.00 per injection and were not worth the effort to the allergist.

(VanArsdel PP Jr, Larson EB. Diagnostic tests for patients with suspected allergic disease. Utility and limitations. Ann Intern Med. 1989;110: (4) 304-312.
Allergy testing. American College of Physicians Ann Intern Med. 1989 Feb 15;110 (4):317-20.)

Canadians spend less than we do and they cover everyone. They are like us. Everyone of us would feel comfortable and at home in Toronto, Vancouver, or Sarnia, if not in the Yukon.

We do not have to adopt Canadian Medicare. But Canada provides a parameter by which should measure ourselves. They spend far less, cover everyone, and are healthier. They also practice more fee for service medicine than we do.

The current situation is going to require very strong leadership and we need an FDR or LBJ SOB to force rationality upon our situation. Eloquence is not the equivalent of governance. We do not have that yet.

Further commentary by me:

Bohdan A. Oryshkevich, MD, MPH
former WK Kellogg Fellow
New York City

Jay Larson MD said...

I am more optimistic about the prospects for achieving comprehensive health care reform. The White House health care summit was inspiring. I think I heard a chorus of kumbaya at the end. The $64,000 question is how much each player is willing to negotiate for the greater good.

Dr. Nana said...

Agree with PCP that "devil is in the details". Whether reform tweaks the fee for service system or whether the tilt is toward more government controlled universal care, increase in number of primary care physicians is essential. Adequate evaluation and diagnosis leads to fewer high tech procedures.
The ACP needs to be at the forefront of pushing this agenda. Already, the Amer Acad of NursePracitioners is positioning to become the "primary care providers" under health care reform.(see their website,
ACP needs to STRONGLY push the necessity for physician management.
One of the reasons for lack of interest by med students in primary care is the lack of respect for primary care. Minute clinic with their PAs and NPs challenges us on treatment of simple outpatient illnesses. Hospitals are pushing for full time hospitalists. Where does that leave the physicians out in practice?
At a regional ACP meeting I attended several months ago, the physician speaker representing ACP actually had a set of slides produced by ACP which referred to "primary care provider". If that is how we'll be known even by our own organization, forget about anyone entering primary care IM.
The other part of the equation for health care reform is tort reform. We can't be expected to skip the high tech procedures when a malpractice case always looks for everything to be done.

Bohdan A. Oryshkevich, MD, MPH said...

I agree with Dr. Nana. Internists cannot afford to compete with first responders. At the same time they cannot be subspecialists. I am working on a job description of an internist being the physician of record who knows enough medicine to both appreciate the first responder (NP, FP), manage the patient in depth and control and refer to the subspecialist when necessary.

I think that one role for NPs and PAs is as proceduralists for internists. This would reduce costs and give cognitive medicine the supervisory role that is necessary. Nurse proceduralists have been snown to do excellent work in England and the Netherlands. Internists will have to give up their proceduralist identity to preserve cognitive medicine.

Bohdan A. Oryshkevich, MD, MPH
New York City

internaldoc said...

The solutions to the healthcare issues in this country; access, coverage for all, spiraling out-of-control costs, etc. are going to be difficult to solve. Add to this the lobbying power of the insurance payors and the "not in my backyard mentality" and the mountain becomes even bigger. I applaud the President for getting the issue onto the table and for at least saying he is willing to listen to all sides.

Whatever change may come the primary care physician will be at the forefront. Not only must a way be found to direct (?entice) more young physicians into primary care, but the established physician must be retained. This also is a complex issue involving reimbursements, the 'defensive' practice of medicine, the 'reactive' versus a 'proactive' style of medicine, lifestyle, the high cost of a medical education with subsequent loan repayments, etc.

It is going to take strong leadership in the public as well as the private sectors to come up with a workable solution.

Don Mitchell said...

I am one of those "liberal activists"—and quite proud of it—that President is "willing to take on…pointedly telling them that they are not going to be able to achieve universal coverage without controlling costs." (Your Point No. 3.)

In addition to being an ACP member, I am a member of Physicians for a National Health Program (PNHP), and chair of its Western Washington (state) chapter. Unlike Dr. Bohdan A. Oryshkevich, we publicly support and specifically advocate for a single payer system—publicly funded, privately delivered health care. Such a system will truly provide health care for all of our citizens.

In addition, a single payer system of health care financing has the potential of substantially reducing our current health care costs by eliminating the administrative costs incurred by the health insurance companies. Such costs amount to 16-30% of the insurance premium dollar. In contrast, the cost for administering Medicare is 3-4%.

Professor Uwe E. Reinhardt of Princeton discussed this in some detail in the Economix, the New York Times Blog, on November 21, 2008, " Why Does U.S. Health Care Cost So Much? (Part II: Indefensible Administrative Costs)":

"The United States spends nearly 40 percent more on health care per capita than its G.D.P. per capita would predict. Given the sheer magnitude of the estimated excess spending, it is fair to ask American health care providers what extra benefits the American people receive in return for this enormous extra spending. After all, translated into total dollar spending per year, this excess spending amounted to $570 billion in 2006 and about $650 billion in 2008. The latter figure is over five times the estimated $125 billion or so in additional health spending that would be needed to attain truly universal health insurance coverage in this country."

In the Position Paper in January 2008, "Achieving a High-Performance Health Care System with Universal Access: What the United States Can Learn from Other Countries," the ACP acknowledged that a single payer system is one way to achieve universal coverage. Now is the time for our country to implement such a system—both to guarantee access to quality, timely, comprehensive, and affordable health care for all and to substantially reduce health care costs.

Donald W. Mitchell, MD
Chair, Western Washington chapter, Physicians for a National Health Program

Fred Smith, MD, FACP said...

I listened on CSPAN to the breakout group moderated by Melody Barnes and Bob Kocher. I was impressed by the sense of comity there and the understanding even by Republicans (like Rep. Emerson of rural Missouri) that there must be universal access enforced by a universal mandate. This gave me some optimism.

However, I fear that the emphasis on an AMERICAN approach that places private insurance first will prevent reducing costs (non-managed Medicare is much more efficient & less burdensome to doctors, by orders of magnitude) and thus interfere with the increased funding necessary to cover the uninsured and the Primary Care Medical Home.

I believe the College should argue vigorously for a Medicare-for-all option available to employers as well as the self-employed and the indigent, regardless of employemnt or resident status. Why should private insurance NOT compete with public insurance if the latter provides better results?

Fred Smith, MD, FACP (palliative, geriatric and internal medicine)

Bohdan A. Oryshkevich, MD, MPH said...

I do support universal health insurance. I also think that a single payment mechanism (global budgeting) is very excellent mechanism of maintaining discipline in containing costs.

At the same time, I realize that we have a fifty state problem with wide cultural differences. A universal health insurance plan with global budgeting (as they call it in Canada) requires certain presumptions and government actions that PNHP has never supported or even addressed. So I look upon PNHP as a romantic advocate for universal insurance. I would call myself a realistic advocate of universal insurance.

I actually have six years experience in Canada unlike almost everyone in PNHP. Americans who have had experience have a less romantic view of the Canadian system. According to one Canadian analyst at McGill, five million Canadians have trouble finding a primary care physician. At the same time, we have the cultural divide between the USA and Canada. For example, I am an admirer of Minnesota and of the Mayo Clinic. But I also realize the tremendous cultural differences between Minnesota and Mississippi.

I worked for “a single payer” publically in Albany New York from 1985 to 1994. I moved there from Harvard via a short side trip to work inside the pharmaceutical industry. I started a process in 1988 in motion that resulted in the New York State Assembly passing “a single payer plan”. Governor Cuomo and the Senate never did anything. I believe that is the only passage of a single payer plan ever in the USA.

I find that PNHP is part of the problem. One only has to read the blogs. It is “single payer or nothing” position. It is part of the immature approach of American politics that Professor Uwe Reinhardt so clearly outlines. It leaves no room for negotiation or for implementation on how to get there. There are several ways of getting to economical universal care. Health care reform is not a mantra.

Second, universal insurance with global budgeting requires as a first step the universal public financing of medical education so that you have a workforce to make it work. In all the years of its existence PNHP has not addressed that issue. Dr. Himmelstein and Woolhander have never addressed that issue even on their own Harvard campus.

Imposing a Canadian style fee for service system on our procedure oriented specialist workforce would be disastrous. In Canada, we were taught to practice medicine responsibly and frugally. I have found that fundamentally absent in American medicine and medical education. I personally communicated with the founders of PNHP to address this issue. They never did. You cannot advocate a plan for which you do not support the prerequisites. It is a fundamentally flawed approach. It is no different than wanting to have a publicly funded system and then refusing to levy taxes.

Third, while I was working for universal health insurance with global budgeting in the eighties and nineties, Himmelstein and Woolhandler were demonstrating publicly their counter culture lifestyle. The hostile media never failed to print photos of Dr. David Himmelstein with his waist length pony tail and unkempt beard. The implicit message was “Would accept universal health care or a health care system from this man?” Such a counter cultural approach may work in Berkeley California, Boulder Colorado, Madison Wisconsin and Cambridge Massachusetts. But it is not likely to give us universal health care here in America. I think that it is fundamentally irresponsible and teenager like (according to Professor Reinhardt) to feed into the propaganda of your critics. I do not think that Canadians would accept medicine from counter culture figures.

It will take another organization to promote successfully a universal health care plan with global budgeting. That organization will have to find a better way of learning from abroad, speaking to the American people and to realizing what needs to be done to get there.

My dream would be to found an organization of American physicians who have gone abroad to learn within a variety of systems: Scandinavia, France, Canada, etc. They would bring back first hand knowledge from the bedside, the clinics, the hospitals, the public health centers, and the public policy centers from the best systems in the world. I have even approached the Canadian Doctors for Medicare in this regard. Let us send our best and brightest abroad and then welcome them back and learn from the knowledge that they gained.

I have done this for Ukraine and it is beginning to pay results for that country:

Anyone who would want to join forces with me in this endeavor is welcome to write to me.

Thank you for your attention.

Bohdan A. Oryshkevich, MD, MPH
New York City