health care reform

Vouchers Are Not a Plan

Opponents of a single payer health care system in the United States like to say it would cost too much, even throwing in the inappropriate complaint that the CBO has not scored any plan.  Of course that won’t happen until congress puts bills such as H.R. 676 through the committee system. As an alternative a voucher plan is often offered up. The only thing that the voucher system offers is a cost-shifting lid on government spending. No control over total health care costs. No access to medical care for those who cannot afford the ever-increasing costs not covered by the vouchers. No system. An improved, expanded Medicare would require hard, thoughtful work and discipline, but it can succeed. We can pick and choose figures to argue over but  there is no ethical and rational alternative.

The financing of Medicare for All is a well explored issue. As far back as 1991 the GAO reported that, “If the universal coverage and single-payer features of the Canadian system were applied in the United States, the savings in administrative costs alone would be more than enough to finance insurance coverage for the millions of Americans who are currently uninsured. There would be enough left over to permit a reduction, or possibly even the elimination, of copayments and deductibles, if that were deemed appropriate.”   Later the same year the CBO reported, “If the nation adopted…[a] single-payer system that paid providers at Medicare’s rates, the population that is currently uninsured could be covered without dramatically increasing national spending on health. In fact, all US residents might be covered by health insurance for roughly the current level of spending or even somewhat less, because of savings in administrative costs and lower payment rates for services used by the privately insured. The prospects for controlling health care expenditure in future years would also be improved.” (“Universal Health Insurance Coverage Using Medicare’s Payment Rates”) .  Fourteen years later the lack of true (not just for the government) cost controls make improved Medicare for All an even more imperative goal.

For a good, up-to-date discussion (2013 figures) of H.R. 676 see the article by Gerald Friedman, professor of economics at the University of Massachusetts, Amherst. Friedman extrapolates on (1) the savings on provider administrative overhead and  pharmaceutical costs, (2) the regressive and obsolete funding sources to be replaced by progressive taxation (in billions of dollars), (3) the savings on administrative costs of insurers, Medicaid, and employers (in billions of dollars) and (4) the savings on federal tax expenditures.

As Professor Friedman states, “On top of the enormous administrative savings of single payer, the savings from effective cost-control would make it possible to provide universal coverage and comprehensive benefits to future generations at a sustainable cost.”


…and study Friedman’s charts

Funding with progressive taxationFunding with Tobin Tax

The Narrative in the Dead Files

Dr. Edwin Leap’s blog in KevinMD is so right on. But I think the murder he describes is more heinous than the picture he paints. In addition to the loss of story from the medical records we also see three additional faults in the trial records. The first is one immediately experienced when, as a patient, you are confronted with a check list that someone is going to enter into the computer. The choices you are given don’t include any answer that approximates your real experience. And you have been instructed to choose an answer closest to your experience. The second (not so obvious) is that these codified answers will end up in an insurance company’s computer as a diagnosis that will follow you for the rest of your life. And thirdly, most importantly, the story that is lost is not just what unfolded from the doctor-patient encounter but what was the true meaning of the patient’s request for help. Dr. Leap mentions the sore throat or sprained ankle as straight forward problems which he says “I can figure out.” But missing from this dismissal is the story of why the patient came for help in the first place. Is it because they have no job sick leave and they are anxious about missing work? Or they had a neighbor who was told he had just a sprained ankle and ended up in surgery because of a missed diagnosis? Or one of their children was diagnosed with a “strep throat” two weeks ago and didn’t get better until they were put on antibiotics. If they have had a flare up of back pain is there any clue to why they come in now? Is it a different pain? In what way? What has changed that makes this more upsetting in their life? Does the change make them worry about something else going on? What have they been doing on their own to try to manage the pain. What used to work and doesn’t any longer? These all important discussions don’t end up in any computerized record. And, contrary to other comments, improved software will not solve this problem unless…unless…the software includes an accurate rendering of a dictated narrative. And, of course, the narrative doesn’t generate ICD-10 codes and can’t be used to measure “value” under the latest pay-for-value scheme. As personal medical care is disappearing we may be witnessing, not murder, but genocide.

Improve-Don’t Destroy-Medicare

The recently passed House of Representatives “doc fix” is a warning and should serve as an inspiration to forge ahead in improving and expanding Medicare for all.  Instead of sticking with the necessary goal of repealing the Sustainable Growth Rate (SGR) the Republican lead House has started on its quest to privatize (cost-shift back to out-of-pocket expensing) Medicare and cut back on Medigap benefits. Those of us who are concerned about the health care of everyone in our country need to get serious about the job of improving Medicare even before we move into universal coverage. We could start with proposals for quickly eliminating the donut hole in drug coverage. That, combined with eliminating the proscription against negotiating prices with the pharmaceutical industry, would offer affordable availability of even the specialty drugs for cancer, hepatitis C, multiple sclerosis, rheumatoid diseases, etc.  A quick fix should be made to the physician payment system until workable substitutes for our present volume based system can be developed under a single payer plan. That fix could be a simple up-adjustment of evaluation and management codes and down-adjustment of procedural codes with a budget neutral end point. And we could stop wasting time, money and other resources on the present catch-word pay-for-performance and pay-for-value experiments. Attention could be focused on mental health and long term care needs. Expandable systems could be developed for these areas even before Medicare moves to universal coverage. We should also be making the necessary changes to eliminate the need for Medigap policies, Part D coverage, and Medicare Advantage Plans. Not solely related to Medicare but open to immediate action would be improvement in the recruitment and financing of the primary care pipeline from first year medical students through residency training programs. We could also take a few steps back to re-think the present electronic medical records push and its Meaningful Use regulations. This has been a poorly thought out, expensive, provider exhausting  effort with a huge disconnect between the stated goals and the existing technology and financing resources.

We should be improving Medicare, not destroying it. We should all be putting pressure on our Congressmen and administration to eschew any actions that disregard the above goals.

Obamacare Unsustainable

Geyman's Books

Dr. John Geyman has published his latest book on the state and future of American health care.* He has written a series of books on this subject over the last 13 years.** His latest, “How Obamacare is Unsustainable” should be must reading for every congressmen, CMS employee and medical reporter and blogger as well as President Obama and his staff. It should be recommended reading for everyone else concerned about health care in the United States.

Dr. Geyman discusses the failure of the Affordable Care Act (ACA) to effectively address the four biggest challenges of health care reform: restricted access, increasing costs, increasing unaffordability even for people with insurance, and poor quality of care compared to the rest of the industrial world. He first reviews the history of the corporation led charade that created the byzantine ACA. Political corruption, lobby money, and media entanglements with corporate stakeholders (especially the pharmaceutical and insurance industries) disfigured the initial goals beyond recognition.

In Chapter 10, after reviewing where we stand now, 5 years into the ACA, he elaborates on the ten lessons we should have learned (and were predictable):

1) Health care “reform’ through the ACA was framed and hijacked by corporate stakeholders, themselves in large part responsible for system problems of health care and dedicated to perpetuating their self-interests in an unfettered health care marketplace.

2) You can’t contain health care costs by leaving for-profit health care industries to pursue their business “ethic” in a deregulated marketplace.

3) You can’t reform the delivery system without reforming the financing system.

4) The private insurance industry does not offer enough value to be bailed out by government.

5) It is futile to embark on unproven and disproven incremental tweaks to our present system while ignoring health policy and experience around the world.

6) In order to gain the most efficiency of insurance coverage we need the largest possible risk pool to spread the risk and avoid adverse selection.

7) The ACA is a massive bailout of private interests profiting on the backs of sick or injured Americans.

8) The single-payer alternative was considered “politically unfeasible” by being “too disruptive” to the existing system; instead, look at how disruptive the ACA has been compared to the simplified single-payer alternative.

9) The ACA is unaffordable for many patients and their families, is byzantine in its complexity, and is unsustainable in the long run.

10) We cannot trust many states to assure an adequate safety net for the insured and underinsured.

Dr. Geyman goes on to define the need for, and the barriers to the development of a single-payer system in the United States. He describes what a single-payer system would look like and what the political prospects are for developing such a system.

This evidence-based analysis of our health care non-system offers the most comprehensive, accurate, and functional map of the road to universal health care in the United States.

* Geyman, JP. How Obamacare is Unsustainable: Why We Need a Single-Payer Solution for All Americans. Friday Harbor, WA. Copernicus Healthcare, 2015.

**A list of books by Dr. John Geyman

  •  Health Care in America                                                 2002
  • The Corporate Transformation of Health Care               2004
  • Falling Through the Safety Net                                       2005
  • Shredding the Social Contract                                        2006
  • The Corrosion of Medicine                                              2008
  • Do Not Resuscitate                                                          2008
  • Hijacked                                                                           2010
  • Breaking Point                                                                  2011
  • The Cancer Generation                                                    2012
  • Health Care Wars                                                             2012
  • How Obamacare is Unsustainable                                   2015

To see Dr. Geyman’s biography and web site visit….… &

Service Model, Not Business Model

Jim Flower has written an excellent article in Hospitals & Health Networks stating, ”It’s time to Rebuild Health Care’s Business Model”. He nicely portrays the unworkable elements of our present system and concludes that there is no way of tweaking the model to make it work. As he says, “The health care system, payers and providers playing the Default Model Game, are delivering an unreliable, unguaranteed, financially and medically dangerous product to their real customers — the large purchasers and the consumers of health care. This is not stable.”  Unfortunately he runs out of steam when it comes to the solution. Admittedly, he is speaking to hospitals and health networks and not to individual patients, policy makers, CMS, legislators, etc. His recommendations to get out of the fee-for-service business as much as possible, drive down internal costs and bid actual prices are, again, just different ways of playing the same old game. They don’t alter the present underlying attitudes of treating health care as a commercial, for-profit business rather than as a humane service. We have to grasp the knowledge that health insurance is a no-value-added business, that the patent protected pharmaceutical industry is avaricious, hospital systems are bounced between profit-making and forced service and physicians are losing their sense of their profession as a “calling”. Reforming business models is not going to change these fundamental dynamics.  If we want affordable, accessible and universal health care we need to improve Medicare and expand it to cover everybody from the day they are born and finance it through a single payer, multiple provider system dedicated to health care reform.  

Health Care Waste-Administrative Costs

The recent paper by Jiwani et al  concerning medical administrative costs has attracted a lot of attention. This paper in BMC Health Services Research calculates the costs of billing and insurance related activities (BIR) in the United States. Using 2012 figures, the authors conclude that BIR costs were approximately $471 billion. “Added BIR” was the amount which was judged to exceed costs in systems with simplified requirements using the Canadian single payer system and U.S. Medicare figures for comparison.

BIR Costs graph                                    Graph from Jiwani et al. BMC Health Services Research (2014) 14:556 

Excessive costs due to administrative complexity is just one of the five areas of health care spending examined by Berwick and Hackbarth using 2011 figures. These authors calculated the costs of our administrative complexity as a range with a mid-point of $248 billion compared to the updated and refined figure of $337 billion provide by Jiwani et al. The 20ll study also included estimates of wasteful spending in the areas of failures of care delivery, failures of coordination, overtreatment, and pricing failures. The total was $734 billion with an added $177 billion lost in fraud and abuse.

Waste 2011 graph

Recent commentators, including Jiwani et al , have noted that simplifying our system and recovering that $337 billion of excess administrative costs would pay for the upgrading of our present coverage including adding the presently un-insured. In dollars amount that makes sense but adoption of a single payer system would not immediately capture those savings. Elimination of the excessive overhead of the insurance industry would be done quickly and could recover half of that waste. The rest would have to wait for the development of new payment and delivery systems. The physician overhead portion would be especially difficult because it is built into the staffing of multiple scenarios, e.g., solo, small and large clinic, single and multiple specialties, self- and other-employed. The staffing includes multiple employees serving multiple roles with overlapping clinical and administrative functions. The savings can be harvested only by reducing the payments to the physicians. The current fee-for-service payment system would make it difficult to calculate a workable and equitable phase-out plan. However the physicians’ portion of the added BIR is only 13% so the needed gradual development of an improved physician compensations system would still be workable. The change in payments to hospitals and other health services would be easier to conceptualize.

When one looks at the other categories of waste it is obvious that there is a large opportunity for savings that can be realized only by a single payer system.

Hospitals As Stakeholders

The desire for health care reform in the U.S. must lead us to examine the role that the various stakeholders play in the high costs and dysfunction of our system(s). Abuse, waste, and profiteering have been well documented in the pharmaceutical, medical appliance, and insurance industries. Fraud and mal-aligned payment incentives by and for physicians is, at least, being discussed. The hospital industry has been receiving a lot of attention because of the notoriety of the obscene charges and opaque charge-master protocol. But, so far the general public has had little instruction as to the destructive changes that have been occurring in the hospital industry over the last 20 years. With over half of U.S. hospitals being a part of a Health System we are now talking about much bigger and more powerful entities.

1   Hospital wars
The fight for survival and supremacy has affected profit and not-for-profit hospitals alike. Developing profit-making but duplicative services has contributed to the rising cost of medical care over the last two to three decades. CT scanners and MRI machines around every corner creates excess capacity that is met with increased prices, advertising and non-indicated use (often supported by conflicts of interest promoted by referring physicians).

Hospitals follow the latest high cost medical fads in order to capture a higher portion of the medical dollar. In the previous two decades this included first, the popular coronary bypass (CABG) programs. These include 301 new CABG programs within a 20 mile radius of an existing program and 80% of the new ones were within 5 miles of the old ones. These were built to capture the dollar, not to fill a medical need. And contrary to free-market dogma, the prices went up instead of down (the invisible hand?).

Fewer CABGsDuplicatice CABG

Following this was the expensive cardiac lab for inserting stents in coronary arteries. This procedure is now on the watch list for its overuse in patients who have never had a coronary related episode. Again, every hospital wants to have one-so they have to be used. This not only drives costs but it creates unnecessary surgical complications.

Inappropriate Heart Procedures
Controversy in the Cath Lab
Duplication of New PCI Programs
Competition, Not Need, Drives Hospital Cardiac Care Investment

One of the latest fads is robotic surgery, pushed by Intuitive Surgical, Inc. These instruments are extremely expensive and very costly to maintain. The company’s claims of reducing surgical times and reducing complications have not been proven. In fact many complications have occurred from their use. It will take a number of years to sort out the appropriate use of these complex and sophisticated machines.  In the meantime hospitals are jumping on the bandwagon. As reported in the Seattle Times in 2012, “Washington hospitals now have at least 37 surgical robots, and robotic surgeries — most to remove a uterus or prostate — have skyrocketed in recent years. Swedish Medical Center has seven robots, Sacred Heart in Spokane has three. Even tiny Pullman Regional Hospital, with 25 beds, bought one. It cost twice as much as the hospital netted in 2010.”

Use of surgical robots booming despite hefty cost
Robotic Surgery Complications Underreported

2.  Advertising & Lobbying
As with insurance companies, the hospital industry spends $1.5 billion dollars annually to sell their product. This often includes endorsements by medical people who have a financial interest. It is the patient who ultimately pays for these efforts to produce sales and income beyond what the hospitals can acquire by just doing their job. As one example, at St. Francis Medical Center in Missouri the ad budget amounts to nearly $46,000 per licensed hospital bed a year, or $130 a day per bed

3.  Marked increase in payroll costs for non-clinical salaries

     Generic managers & Executive Salaries
Kaiser Health News created a chart of executive compensation in the hospital industry for the year 2011. The highest compensation was at Kaiser Permanente ($7,936,510). It should be noted that many of the executives are what have been called “generic” managers.  Generic managers, that is leaders trained only to manage, but not experienced in what constitutes personal health care.  Managers and bureaucrats are increasingly numerous in health care, the former somewhat and the latter greatly out-numbering physicians.

A similar, but more surprising chart had been developed by KUOW an NPR radio station. This was for the Puget Sound area in Washington State in 2008. 21 of the top 62 administrators received $1 million or more (two over $5 million).

         Growth of non-clinical workforce
As Robert Kocher says in The Downside of Health Care Job Growth, “Over half of the $2.6 trillion spent on health care in the United States in 2010 was wages for health care workers.”   and, “today, for every doctor, only 6 of the 16 non-doctor workers have clinical roles, including registered nurses, allied health professionals, aides, care coordinators, and medical assistants. Surprisingly, 10 of the 16 non-doctor workers are purely administrative and management staff, receptionists and information clerks, and office clerks.”  Kocher points out that this non-clinical workforce has little to do with delivering better patient outcomes or lowering costs. So much of this is created by the multiple payer insurance system with hundreds (thousands) of payers and many thousands of billing codes, policies, rules, etc.

A good example of this bloat of medical bureaucracy comes from the 2008 testimony of Uwe Reinhardt, the economist, before the Senate Committee on Finance when he stated that at Duke Health Systems, where he served on the Board they had 900 clerks on the payroll for a 900 bed hospital.

Physicians vs Adm

4.  Acquisitions and Mergers
In 2012, 94 mergers or acquisitions took place in the hospital industry worth a total of $1.88 billion. See Mergers in 2012. In the first 6 months of 2013 there were 46 M&A’s and 98 for the year. In the first 6 months of 2014 there were 43. Additionally we are seeing various “affiliations”, “quality alliances”, “strategic alliances”, partnerships, and “Clinically Integrated Networks”, etc. Some of these acquisitions occurred because one of the participants was in financial difficulty but the large number of them is designed to increase market leverage and create increased reimbursements. The increased leverage in a geographical area also allows the new entity to dominate any kind of negotiation during physician hiring.

Large scale mergers almost always lead to higher prices and there is no evidence that they improve quality of care. “Hospitals that face less competition charge substantially higher prices,” said Martin S. Gaynor, director of the F.T.C.’s bureau of economics price increases could be “as high as 40 percent to 50 percent.”

When Massachusetts General Hospital and Brigham and Women’s Hospital merged into Partners Health Care it drove up health care costs with no improvement in quality of care. Attempts to minimize the monopoly effect have been unsuccessful. As the New York Times stated in an editorial, “The experience in Massachusetts offers a cautionary tale to other states about the risks of big hospital mergers and the limits of antitrust law as a tool to break up a powerful market-dominating system once it is entrenched.”

5.  ACO’s
As hospitals try to position themselves in the world of Accountable Care Organizations the mergers and acquisitions noted above become part of the game plan. Kaiser Health News discusses this as a “Humongous Monopoly.” This leads into the latest trend of hospitals hiring physicians. So far there is no good evidence that these organizations can lower costs and no evidence that they can improve quality. In fact, hospitals dominate the governance of most of the existing ACO’s and any money saved is simply a shift of dollars from Medicare to the ACO’s, not the patients. Additionally, the hiring of primary care physicians reduces the number of physicians available to provide care in rural and distant suburban areas. When hospitals purchase medical practices and clinics the price goes up for everything from the office visit charge to electrocardiograms and other basic office procedures as well as the major procedures such as joint replacements and cardiac stents.

 6.  Religious influence
Dr. John Geyman has explained well the ill effects of the expansion of Catholic hospitals across the country.  This growth of religious influence on the quality and universality of medical care especially affects reproductive and end-of-life services. Ten of the biggest twenty-five health systems in the United States are Catholic. Merger Watch and the ACLU have teamed up to publish a definitive review of this phenomenon in “Miscarriage of Medicine: The Growth of Catholic Hospitals and the Threat to Reproductive Health Care.” In this report they state, ”Catholic hospitals have organized into large systems that behave like businesses – aggressively expanding to capture greater market share – but rely on public funding and use religious doctrine to compromise women’s health care.” In the process they are gobbling up both non-profit and for-profit entities. The only difference left between these categories is that the non-profits don’t pay taxes and they can solicit tax-free donations. Former quality differences have all but disappeared and the exceptional charity care has been swallowed up by the business model. More alarming is the threat posed to women’s reproductive health care and patient driven end-of-life care.

7.  Costs-Bitter Pill
In March, 2013, Time Magazine published the landmark article by Steven Brill, Bitter Pill: Why Medical Bills are Killing Us. The bizarre and obscene hospital charges that have become an all too familiar story are exposed as well as the rapacious “charge-master” billing system. These unbelievable bills will only get worse until hospitals are forced to live on a system of global payments for operations and tight certificates of need for capital improvements. This can not be accomplished with Obamacare or the free market.

8.  Fraud, Abuse, Fines
Hospital systems may increase their incomes by up-coding (raising diagnostic codes to a more severe level of illness) and thereby making their reimbursements higher and magnifying their risk-adjustment scores.         

Gaming the System
There are numerous other abuses such as (1)keeping patients in observation units for days instead of admitting them to the hospital is legal and profitable for the hospitals but inherently unethical, (2)charging huge mark-ups on cancer drugs, and (3)Aggressively pursuing collections at point-of-care from patients with medical emergencies.

The National Health Care Anti-Fraud Association figures that fraud annually accounts for tens of billions of loss. This would include fraud by other providers and medical services as well as hospitals. Hospitals are prevented by federal law from providing financial or in-kind compensation to physicians for less than fair market value. Nevertheless these practices continue. The Office of Inspector General has published a list of 34 settlements for violations by hospitals over the last 5½ years. These were all self-disclosed and just hint at the real numbers involved in these practices. For instance, in 2012 Freeman Hospital System paid $9.3 million for paying physicians for referrals. Of course this was a pittance compared to the $731.4 million penalty paid by HCA in the year 2000. That didn’t stop them however, and in 2007 they paid another claim at $16.5 million. The list goes on and on, e.g., Health Management Associates, Parkland Memorial, Adventist Health, etc. Since January, 2009 the Department of Justice has recovered over $7.4 billion in health care fraud prosecutions.  Not all of these were from hospitals but here is a list of representative fines:

St. Barnabas Hospitals —$265,000,000
First American Health Care of Georgia — $225,000,000
Staten Island University Hospital —$76,500,000
University of Washington —$35,000,000
University of Pennsylvania —$30,000,000
University of California Davis, San Francisco, Los Angeles, Irving andSan Diego — $22,500,000
Montefiore Hospital and Medical Center — $12,000,000
Catholic Healthcare West —$10,750,000
The Cleveland Clinic — $9,050,000
The Mayo Foundation —$6,500,000
San Diego Hospital Association —$6,200,000
Northwestern University —$5,500,000
Yale University School of Medicine— $5,500,000
New York Presbyterian Hospital —$4,880,000
Johns Hopkins University School of Medicine — $3,400,000
Harvard University and Beth Israel Hospitals — $2,400,000
University of Illinois College of Medicine and University of Chicago Hospitals $2,000,000
St. Louis University (a Tenet hospital) $1,800,000

Almost all of the problems discussed here relate to the nature of our fragmented, profit-motivated medical system. They are caused by the system and can not be solved by the system. And we haven’t even discussed the huge problems of quality, affordability and access. Only a revolutionary change can have the muscle to change the basis of our medical care from profit-motive to a service ethic. Creating and moving to an Improved Medicare For All is such a change.

Please “like” me if you do.  Help me spread the word. You follow me and I’ll follow you.  Let’s talk about revolutionizing our medical care. If you want, I will come to your community organization and present a run-down on the arguments for single payer medicine.

Gilead thrives on Sovaldi

Gilead’s profits were up 246% in Q3.

As Becker’s Hospital CFO states, “The increased revenues were due to substantial product sales growth. Gilead’s product sales for the third quarter increased to $5.97 billion compared to $2.71 billion for the third quarter of last year.”

At this rate it won’t take long for Gilead to pay off the $11 Billion purchase price for Pharmasset and the hundreds of millions of dollars for clinical trials of Sovaldi, the $84,000 anti-hepatitis C drug.

Welcome to the free market.

Accountable Care Failure

Accountable Care Failure

Recent releases from CMS verify that 13 of the original 32 Pioneer ACO’s have quit even though year 3 isn’t even over yet.  Keep in mind that all 32 of these organizations are sophisticated EHR driven medical care systems. The reason for quitting is that they could not qualify for earned shared savings and many reported losses. Interestingly enough there are still no reports of what the start-up costs were for all these entities and, of course, we have no estimates of what the national start-up costs would be if ACO’s dominated Medicare reimbursement across the country. Many facilities lack sufficient EHR systems and staffing to comply with all of the regulations in the Pioneer ACO experiment. And what is it costing CMS to administer the program? Even worse, none of this applies to private and exchange insurance policies.

All of this nonsense could be stopped with the creation of a single payer system.

Can Physician Performance Be Measured?

In response to Comments in Becker Hospital Review I received these questions:

“Dr. Dave – I’d be interested in what outcomes you’d measure that really matter in the care of patients. And, what you’d suggest for a delivery and payment model(s).”

I submit the following answer:

I don’t know what background you are coming from. I’m a retired family doc with 27 years in private practice, 10 years working in and running a (salaried) rural health clinic and 7 years (salaried) doing urgent care in a >200 docs physician owned medical clinic and 6 years part-time in a low income clinic.

When talking about “measuring outcomes” remember the old saying (falsely attributed to Einstein) “Not everything that counts can be counted, and not everything that can be counted counts.”  What are outcomes;  mortality rate, days of pain free existence, avoidance of bankruptcy, peace of mind, years of life lost due to premature mortality (YLLs), years lived with disability (YLDs), healthy life expectancy (HALE) ?  And to whom do we attribute increase and decrease; the patient, which doctor, an institution, the system, society?  And, again, can numbers represent compassionate, concerned, competent care?  So what does it mean to “measure”?

There are numerous problems with current pay for performance problems. One of the biggest problems is thinking that any sense can made of the current Rube Goldberg system of Obamacare plus >2000 insurance carriers. Any real solutions need to benefit every single person in our country. Pretending to measure performance in medical care is a political diversion of both CMS and the insurance companies.

As far as I’m concerned putting all physicians on salary with reasonable negotiations is the only way to help gain control of medical costs and create the leverage for improving quality by eliminating incentives for cursory encounters and unnecessary medical procedures.

Pay-for-Performance is a poisonous concept whose unintended consequences are far greater that any conceivable benefits. System improvement and re-development of the culture of a medical “calling” and ethos of peer responsibility are essential. So-called P4P and quality improvement efforts cannot begin to deal with the multitude of problems that face us.

We can’t (and shouldn’t) go back to a Dr. Welby picture but we don’t have to keep going in the wrong direction.

I’m in favor of a single payer system (improved Medicare for All). I’m also in favor of starting that improvement now.  And I’m in favor of medical care reform in many areas (physician, hospitals, pharmaceuticals, medical appliances, costs, integrity, transparency, etc.)  A single-payer system would require a tremendous amount of work to create the needed reforms  but it’s the only system that can have the muscle to overcome the self-interest of the powerful stakeholders and ensure compassionate, competent, and cost-effective care for  everybody.

I invite you to visit my blog site (HC-Reform) and “Like” what you like. For our present discussion I would start with Pay-For-Performance (

Dr. Dave