Why Concierge Medicine Will Get Bigger

MarketWatch: "Why concierge medicine will get bigger" (1/17/2013).

The field is rapidly evolving, and there are now many groups offering different tiers of service (depending on how much one wants to spend).

In particular, some of the various "concierge light" models will be very attractive to patients and doctors alike.

The network One Medical Group, currently available in 5 major cities, charges just $200 annually for longer doctor visits, minimal wait time, iPhone appointment scheduling and prescription refills and other amenities. The group has slashed overhead by increasing its use of technology and cutting down on support staff. Doctors weigh in patients and take their vital statistics, which provides a good opportunity for both sides to catch up, said Dr. Tom Lee, One Medical's CEO, who holds both an MD and an MBA. "Because we’ve re-engineered our practice, we can weather most reimbursement storms," Lee said. 

Let's hope the law continues to allow these practices to thrive.

PJM Interview with Ryan Moore: "Carrying a Gun Saved My Life'"

PJ Media has published my interview with my friend Ryan Moore: "'Carrying a Gun Saved My Life': Meet Ryan Moore".

Ryan talks about the time he needed to use his firearm in self-defense, what he learned from the experience, and why he opposes proposed restrictions on gun magazines and so-called "assault weapons".

Although this isn't directly related to health care policy, it is an important issue in the news with life-and-death consequences for ordinary Americans.  Plus many doctors and medical organizations are chiming in on this topic.

So thank you, Ryan, for sharing your story!

And thank you, Glenn Reynolds, for the Instapundit link!

Lipana on the Medical Device Tax

Joshua Lipana of Liberty Against Cancer has a couple of recent blog posts about the medical device tax, where he asked a couple of people for their opinions.

Here is Alex Epstein's response.

Here is my response.

And here are some of Joshua's earlier thoughts.

And a nice positive update on Joshua's battle against lymphoma.

RomneyCare Update

The 1/23/2013 Wall Street Journal has an update on health care in Massachusetts: "The RomneyCare Bill Comes Due".

From the article:

[RomneyCare] was supposed to save the state money. But last August Beacon Hill was forced to impose new price controls and a cap on overall state health spending because "health-care spending has crowded out key public investments," as Mr. Patrick puts it in his budget.

He's right about that: Health care was 23% of the state fisc in 2000, and 25% in 2006, but it has climbed to 41% for 2013. On current trend it will roll past 50% around 2020 -- and that best case scenario assumes Mr. Patrick's price controls work as planned. (They won't.) In real terms the state's annual health-care budget is 15% larger than it was in 2007, while transportation has plunged by 22%, public safety by 17% and education by 7%. Today Massachusetts spends less on roads, police and schools after adjusting for inflation than it did in 2007.

Hence, the need for a "huge new tax increase proposed by Governor Deval Patrick".

I'm just glad residents of the other 49 states won't see similar problems.  Oh, wait...

(Read the full text of "The RomneyCare Bill Comes Due".)

iPhone App Connects You to Nurse or Doctor Anytime

Some progress: "New iPhone App Urgent Care Connects You To A Nurse Or Doctor Anytime".

From the article:

Urgent Care has two main functions: it’s a medical dictionary and encyclopedia, providing direct answers to medical questions, and it also provides instant access to a registered nurse and/or doctor, 24 hours a day, seven days a week. The service however is only available in the US.

The app is available for free download at the iTunes store.  (There is apparently a small fee for the medical consultation.  Also, I don't know to what extent they can offer advice that is actually useful to patients, without crossing the line into unauthorized practice of medicine.)

We're already seeing more doctors and hospital systems taking advantage of new technologies to provide telemedicine (and teleradiology) services.  For instance, patients in the ER at some small rural hospitals can now have a "virtual consultation" with a neurologist in a major urban medical center, who can then decide if they need to send the medical helicopter to transport the patient urgently to the big hospital.

In my own practice, radiologists now read MRI scans and CT scans 24/7 from multiple states, providing subspecialty expertise to hospitals that previously had to rely only on local physicians.

But we could be seeing much more of this, if regulatory barriers were lowered (including laws making it difficult to practice medicine across state lines or international boundaries).

Benjamin Rush Society Yale Debate

The Benjamin Rush Society will be presenting another health care policy debate at Yale Medical School on 2/11/2013.  It looks like a great lineup!

(Also, the recording of their 11/28/2012 debate on "social justice" and health care is now available on their website.)

More information about the Yale debate from their announcement:

The Benjamin Rush Society Presents The Arthur N. Rupe Debate Series

• Cosponsored with Yale Medical School Healthcare Improvement Group, American Medical Student Association, Graduate and Professional Student Senate and Yale Healthcare and Life Sciences Club •

BE IT RESOLVED THAT
“Markets with Limited Government Intervention are the Best Way
to Control Spending Growth in Health Care.”

February 11th, 2013, 6:30-8:30 p.m.

Pre-Debate Reception at 6:00 p.m.

In Favor
Dr. Avik Roy, MD (NYC)
Author of “The Apothecary”, Forbes
Senior Fellow, Manhattan Institute

Mr. Joshua Archambault, MPP (Boston, MA)
Director of Health Care Policy,
Pioneer Institute of Public Policy Research

Opposed
Dr. Elizabeth Rosenthal, MD (NYC)
Asst. Clinical Professor, Albert Einstein College of
Medicine; Physicians for a National Health Plan

Dr. Theodore Marmor, PhD (NYC)
Professor Emeritus of Public Policy and Management,
Yale School of Management

MODERATOR: Dr. Jack Hughes, MD. Professor of Medicine, Yale School of Medicine

Yale University School of Medicine – Harkness Auditorium
333 Cedar St., New Haven, CT, 06510
Parking is available at the Air Rights and Howard Avenue Garages.

Event is free but seating is limited. Please reserve your seat at http://bit.ly/U1OaDk
For more information or to volunteer, contact daniel.yang@yale.edu

HIT Scam

Greg Scandlen discusses "The HIT Scam" (HIT = "Health Information Technology").

When people and businesses adopt new technology based on their own rational assessment of their needs, they can save enormous amounts of money. But when government pressures businesses to adopt new technologies with top-down government mandates, we should not be surprised when they become expensive boondoggles.

Hsieh Forbes OpEd: Why Doctors Should Not Ask Their Patients About Guns

Forbes has just published my latest OpEd, "Why Doctors Should Not Ask Their Patients About Guns".

My theme is that physicians should not routinely ask patients whether they own guns, because it could compromise the integrity of the doctor-patient relationship.

Here is the opening:

Should doctors ask patients if they own guns? Currently, ObamaCare bans the federal government from using patient medical records to compile a list of gun owners. But following the Newtown, CT shootings, President Obama issued an executive order clarifying that “the Affordable Care Act [ObamaCare] does not prohibit doctors asking their patients about guns in their homes.” The American Academy of Pediatrics (AAP) similarly encourages physicians to ask patients if they own firearms — in the name of protecting child safety.

As a physician, I consider this advice misguided. Instead, physicians should not routinely ask patients whether they own guns, because it could compromise the integrity of the doctor-patient relationship.

I cite Dave Kopel (who was one of many scholars who debunked the standard 43-to-1 flawed statistic about the danger of guns in the house) and also discuss the little-recognized fact that swimming pools are far more dangerous to kids than guns, yet no one asks for background checks for pool owners.

And many thanks to Dr. Matthew Bowdish for permission to quote him at the end of the piece!

(Read the full text of "Why Doctors Should Not Ask Their Patients About Guns".)

Update: Thank you, Instapundit, for the link!

Quick Links: Will, Catron, Mead

George Will: "The time bomb in Obamacare?"

David Catron: "Is Obamacare Socialism or Fascism?"

Walter Mead: "Universities Bludgeon Adjuncts With Obamacare Loophole"

Quick Links: Concierge Medicine Benefits

Gwinnett Daily Post: "Insurance-free doctor prefers quality over quantity"

Business Wire: "Study Proves Dramatic Reduction in Hospitalizations & $300 Million Savings for MDVIP’s Personalized Healthcare Model"

ObamaCare Job Creation

ObamaCare will create more jobs -- at the IRS.

IBD notes the following fact in their 1/11/2013 editorial, "ObamaCare Will Make The Maddeningly Complex Tax Code Even Worse":

All told, the IRS says it needs more than a thousand new auditors and staff to cope with ObamaCare. None of that will make taxpayers' lives any easier.

There's more information about today's IRS and the tax code at the link.

Proposed New NYC Medical Payments

New York Times: "New York City Ties Doctors' Income to Quality of Care" (1/11/2013).

Another possible headline: "Government bureaucrats and doctors' union negotiate over pay incentives to reward/punish doctors for practicing a certain way in NYC public hospitals".

Welcome to the future.

In principle, paying for performance is fine. But when metrics are chosen badly (or because they're easy to measure even when they have little bearing on actual quality of care), then you're setting the stage for all manner of unintended consequences.

One example are rules to pay/not-pay based on whether patients develop a certain type of catheter-related urine infection. These rules have resulted in switching to different protocols that reduce that particular type of infection, but can cause more patient pain (which isn't measured) and elevates the risk of different kinds of bladder infection and/or injury.

Of course, this isn't a problem limited to medicine. Nor is it solely a problem of government (vs. badly run private bureaucratic organizations). But far too many of the proposed "quality measures" I've seen are the equivalent of "security theater".

Yes, I've definitely seen many cases of quackery and bad medical practice. But the response by too many policy-makers has been to advocate purportedly "objective" or "evidence based" protocols, which many doctors criticize as being too rigid or "cookbook medicine".  Bad doctors can inappropriately use their medical autonomy unwisely. But the solution is not blunt tools that reduce medical autonomy across the board.

On a personal note, my wife Diana has some thyroid problems and she's an outlier on how she responds to certain treatments. If she were treated according to the standard protocols, she'd be in constant misery. Fortunately, she was able to find a physician specializing in her type of problem and is willing to judiciously stray outside the standard guidelines. As a result, she has done well.

But in many of the new payment models, this treatment course would be presumed to be bad medicine, even though it is completely appropriate for the small but non-trivial segment of the population that doesn't respond well to the standard therapy.

There's room for constructive debate on incentive structures and their effect on medical quality. I've practiced in academia (as a salaried university medical school professor), in a large HMO (Health Maintenance Organization) where doctors were paid on a "capitated" basis, and in traditional fee-for-service private practice. All of those systems have pluses and minuses, and all of those systems can create good incentives as well as perverse incentives to "game" the system.

My big concern is that proposed payment "reforms" will not accomplish its stated goals, but will create far more unintended consequences than its proponents realize.

Catron on Getting Hoist By Ones Own Petard

David Catron's latest American Spectator piece describes, "A Pimp for Obamacare Feels the Pain".

Specifically, he discusses a pro-ObamaCare supporter who is also an ER physician.  But as Catron noted:

He has finally discovered what I and others told him years ago: Medicare rules are, as he apparently now realizes, “arbitrary and disconnected from reality.” He has also noticed that, when a physician runs afoul of these bureaucratic vagaries, the government is the judge, jury, and executioner. The immediate cause of his disillusionment is Medicare’s trick of performing a superficial audit of a doctor’s billing practices and, based on a hopelessly flawed statistical sampling method, accuses him of fraud.

Read more at "A Pimp for Obamacare Feels the Pain".

And BTW, there are now 106 new ACOs (Accountable Care Organizations) for Medicare patients.

Here's the downloadable list (PDF format).

Patient Tips If Your Doctor Sells His Practice

Dr. Cary Presant has just written an informative blog post, "Your doctor has sold his practice: 6 tips for patients".

Basically, more and more doctors are leaving private practice to become hospital employees.

Many will continue to practice good medicine, but the new arrangement can also create some potential conflicts-of-interest when doctors have to balance the patient's medical interests against practice requirements imposed by their new employers.

Here are some of the tips offered by Dr. Presant:

• First, when your doctor is recommending tests or treatments or hospitalization for you, take the time to ask if you really the treatments – ask if the doctor would do the same for a family member
• Second, ask for a second opinion to determine if you need the recommended care – this should be your standard reaction when tests are ordered
• Third, ask the office manager and doctor is there is a performance requirement in the practice to generate more tests, treatments or admissions – these “goals” could be influencing the doctor’s decisions regarding your treatment
• Fourth, take notes and record conversations with the doctor (on a smart phone or small tape recorder); doctors will be very honest when answering direct questions
• Fifth, ask the doctor if the recommended treatment complies with national guidelines, or if it is different and why. Don’t know the guidelines? Take some time to research them before committing to any treatment
• Finally, if you suspect your doctor has a conflict of interest, always get another opinion and if necessary, find another doctor in whom you have complete confidence. There are multiple online databases and forums where patients comment and critique different doctors, facilities and treatment courses – take advantage of the experiences of others. 

Also, sometimes the national guidelines may be appropriate for your particular individual case -- and sometimes they may not be.  You may need to seek additional opinions to know if the care you receive is best for you.

More than ever, it will be up to you to be your own best medical advocate.

(Read the full text of, "Your doctor has sold his practice: 6 tips for patients".)

Freedom Vs. Central Planning

Some compare-and-contrast.

NCPA: "How Consumer-Directed Plans Affect the Cost and Use of Health Care"

Some take home points:

[E]mpirical analysis suggests that people with consumer-driven health plans are able to achieve cuts in health spending while retaining quality care.

* In 2011, about 17 percent of Americans that were covered by their employers were enrolled in a consumer-directed health plan.

* Families that switched to a consumer-directed health plan spent an average of 21 percent less on health care. 

* Two-thirds of savings came from the fact that there were fewer episodes of care; the other one-third came from less spending per episode. 

* If enrollment in consumer-directed plans increased to 50 percent, there would be an annual savings of $57 billion.

In contrast, Peter Suderman discusses "Why Obamacare's Health Care Cost Controls Won't Work".

Adalja on Pre-Existing Conditions

Dr. Amesh Adalja has a new OpEd in the 1/8/2013 Forbes, "If Insurance Companies Can't Utilize Pre-Existing Conditions, Then They're Not In The Insurance Business".

One excerpt:

As part of a way to mitigate against excessive risk, insurance companies may elect to not insure an individual whom they judge possesses a high likelihood of incurring costs because of a pre-existing condition.  When insurance companies are barred -- by law -- from considering pre-existing conditions in their evaluation of potential customers, what is being prohibited is the exercise of judgment. In the place of the expertise of insurance actuaries, government fiat is substituted.

This ability of insurance companies to discriminate is essential because insurance companies are, properly, in the business of making money. It is the very profitability of insurance companies that allows their continued existence and the ability of many individuals to procure insurance policies. If insurance companies ceased to be profitable, their extinction would shortly be forthcoming and all individuals would be worse off.

What this decree of the Affordable Care Act will do, and is designed to do, is completely distort the entire insurance industry by rendering  painstaking risk calculations irrelevant.

Over time, this demonization of profit and forcing insurers to cover risks without compensation will destroy private insurance. Of course, for some single-payer advocates, the destruction of the private insurance industry is a feature not a bug.

(Read the full text of "If Insurance Companies Can't Utilize Pre-Existing Conditions, Then They're Not In The Insurance Business".)

Your Genome, Your Data

Susan Young: "Why We Have a Right to Consumer Genetics" (MIT Technology Review, 1/2/2013)

From the article:

Because interpreting the results is so uncertain and the relationship between genetics and disease risk is sometimes weak in the first place, some critics oppose selling these tests directly to consumers. Such sales are restricted in some countries, such as France, and in a few U.S. states, including New York and Maryland.

The American College of Medical Genetics and Genomics’ stance is that the tests should be taken with guidance from an expert who can assess the validity of the results and explain the actions that could be taken in response, says executive director Michael Watson. New studies on the connection between DNA and disease or drug response are published every week. Some of these studies establish a previously unknown link; others may add more weight to a known association; yet others may contradict or disprove what was once thought to be meaningful. “The results of many of these tests are very complex,” says Plon.

Yet this “father knows best” attitude is irksome to many; surely people have a right to such data about themselves, regardless of the complexity and ambiguity of the results. “To tell somebody you don’t have the right to access information about your own biology, for any reason, is pure paternalism,” says Misha Angrist, an assistant professor at the Duke University Institute for Genome Sciences & Policy.

Moreover, most family doctors, and even many specialists, are unfamiliar with genetic tests, and those who’ve been out of medical school for several years may have no training in genomics at all. In many cases, the consumer might well be better informed...

Gorman on CO Medicaid Expansion

The 1/4/2013 Denver Post reported on CO's planned Medicaid expansion.

They also quoted Linda Gorman of the Independence Institute explaining why this is "reckless". (More information at Patient Power Now.)

Medicare Whipsaw

ER doctor "Shadowfax" describes the Medicare whipsaw for physicians: "Medicare made the rules and now punishes doctors for following them".

The unintended consequences are due to a combination of coding rules, electronic medical records, payment rules, government definitions of "medical necessity", and presumption of guilt.

Unintended Consequences

A few "unintended consequences" developing in 2013:  

USA Today: "Health care law may mean less hiring in 2013" (12/30/2012)  

Forbes: "Why Rating Your Doctor Is Bad For Your Health" (1/2/2013)  

NYT: "Employers Must Offer Family Care, Affordable or Not" (12/31/2012)

Analysis of the NYT piece by Walter Russell Mead: "This Looks Like A Loophole" (1/1/2013).

Some Medical Progress

Two nice advances, both from my field of radiology:

"Wireless Interventional Ultrasound System from Siemens"



"GE Unveils Virtually Silent MRI Technology"

Light Posting Notice

Blogging may be lighter than usual for a while, due to some other demands on my time.

I will continue to post about noteworthy health policy issues and commentary as they come up.

I also wanted to say "thanks" to all who have helped encourage and support my work during 2012.

Here's to a healthy, happy, and productive 2013!