Offerings by George A. Sprecace M.D., J.D.:

MUSINGS ON THE RECENT BOARD RETREAT

GENERAL:

• Good attendance…a teachable moment?
• Good ideas
• Questions were fair, but could have been more probing and less repetitive.
• Too long for a sustained effort at that time of day.  Lost some control at the end.

SPECIFICS:

• Nearly all of the discussion was reactive, not pro-active.  Don’t cope; rather, Drive.  When Washington says “Jump”, don’t say “How High?”  Say “Sez Who?”.  We know better than the academicians regarding what is really needed in Health Reform.
• There was little or no discussion regarding PATIENTS, their needs, their expectations (rational and otherwise)…and their ultimate unique power to effect change (vs. we “health care providers”).
• The government interests and goals are all about COST CONTROL…at all cost, and much less about coverage.  The only ways to get cost control without provoking at least the passive aggression of health care providers are: Rationing / Prioritization, decided upon with broad public input and not imposed by the government through physicians; Medical Malpractice Reform to minimize the now substantial Defensive Medicine costs; end of life issues; motivating people, positively and negatively, regarding life-style changes that drive 50% of health care costs. 
• Coordination of Care, vital and to be performed by – and reimbursed to – any willing physician and not just “primary care” physicians.  “Specialists” now do a great deal of “primary care” and are often in a comparable position to effect coordination of care. 
• Physicians should be enlisted to help, and not demonized.  Ultimately, they are far from powerless. 
• The hospital must commit to a “WIN – WIN” game plan with their medical staff.  The alternative is only “LOSE – LOSE” !
• We cannot allow the marginalization of any of our Staff physicians, either by neglect or intent.  Again, they are far from powerless. 
• The hospital must encourage and not block the effective reorganization of the Organized Medical Staff that is in process with the development of the PAC, the re-alignment of the MEC, and their coordination as the eyes and ears of the Organized Medical Staff as the ultimate governance body. 
• There must be, in fact and in perception, a true Partnership between the Hospital Board – Administration and the Medical Staff.  And it must be realized and accepted as such by the Community we all serve.  That is not the current perception…and that is damaging.   

WE CAN DO ALL THIS !

George A. Sprecace, M.D./, J.D.

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HEALTH CARE REFORM:    ONCE MORE, WITH FEELING.

"ObamaCare", as enacted last year, is a Christmas Tree of wants, without dealing with true needs for health care reform.  And it is supposedly "paid for" through gimmicks and slights of hand.  What follows is a list of true needs for reform, from a practicing physician of 54 years experience...and counting. 
Are you ready for this? 

• Reject "capitation" as an unethical abrogation of a physician's fiduciary responsibility to his patient.  A perverse incentive if there ever was one, this method of payment places a patient's needs in direct conflict with the physician's.  It should be rejected as against Public Policy. 
• Enact effective Tort Reform, including Medical Mal-Practice Reform, in order to markedly reduce the practice of "defensive medicine", which now accounts for 20-30% of health care costs.  Specialized Health Courts, like those used in Bankruptcy, Patent and Construction controversies, would be the best way to go. 
• Encourage - and pay for - Coordination of Medical Care, by one physician for each patient, this function performed by primary care physicians or by properly inclined specialists.  
• Emphasize Health Care Accounts to restore patients' interest in the cost of their desired and needed medical care...and in their personal health and life-style. 
• Consider and approach physicians as part of the solution, and not as part of the problem...as is now the general attitude.  
• Encourage and reimburse physicians in the broad use of paraprofessionals in their practices and under their direct supervision.  
• Require that all members of the public carry a minimum amount of Health Care Insurance.  I expect that that provision of the current law will survive US Supreme Court scrutiny as being in accord with the public policy goal of covering all potential patients.  
• Distinguish between "the deserving underserved", between the honestly indigent and their lazy and greedy counterparts with regard to subsidized health care.
• Regulate drug costs, currently uncontrolled and abusive, while allowing sufficient return on company investments to promote good research...and not mainly shareholder profit.  
• Stop trying and expecting physicians to ration care, through various underhanded mechanisms - like "capitation" and "bundled payments".  A system of rationing and prioritization is needed, to separate health needs from wants, and to exclude "futile care".  But that is the purvue of public policy, arrived at through the political process and not by physician fiat, another example of abrogation of fiduciary responsibility.  
• At the same time, "futile care" as defined by two physicians in a given case, is neither obligatory or even permissive on the part of the treating physician.  Patients must be educated regarding this bedrock concept of the practice of Medicine.  
• Stop enacting and repeal rules and regulations that inevitably promote "gaming the system" in self-defense: Emergency Room practices that may be called "offensive medicine" in order to produce profit centers for hospitals so inclined; declaring as "Never Events" occurrences that are actually not under the reasonable control of the physicians and hospitals, but whose occurrence results in non-payment for the care; promoting through over-emphasis on electronic health records imaginative billing practices while ignoring the communication needs of physicians at the bedside and on the wards; a blizzard of regulations, sometimes internally contradictory, that promote an ever-increasing number of hospital administrators, each of whom has to justify his or her presence on the table of organization. 

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HEALTH CARE REFORM – A PRIMER 

1. Many articles in recent months in NEJM, JAMA, WSJ
2. “The New Value On Provider “Value”, Treatise by Alice Gosfield in Health Law Handbook, 2011 edition.
3. “What Paul Ryan’s Critics Don’t Know About Health Economics”, by Alain Enthoven, WSJ June 3, 2011, pA15.
4. “Reforming Medicare – Toward A Modified Ryan Plan”, by Gail R. Wilensky, Ph.D., NEJM May 19, 2011 p1890.
5. Articles by GS, recently posted and also written and published since the 1970’s (www.asthma-drsprecace.com)

Letter to Tom Blum, GS

It's time for another update on your future health care.  This industry and the related professions are undergoing a revolution whose outcome is very much in doubt: for the ever - increasing number and severity of sick people, for the physicians and other health care workers who provide that care in return for progressively reduced reimbursement over the last twenty years,  and for the economic health of the Nation. 
Obama-Care is a Christmas Tree of "wants" without hardly any consideration of health reform "needs" that are begging to be addressed.  This is tantamount to returning to the "bleeding" treatment of the Middle Ages instead of the judicious use of antibiotics. 
To document some of the problem, I offer several readings:

• "Obama's Running Mate", Editorial of the WSJ Thursday, May 12, 2011, pA14;
• "WellPoint Shakes Up Hospital Payments", by Janet Adamy, WSJ Monday, May 16, 2011, pB1;
• "The Millionaire Retirees Next Door", by John Cogan, WSJ Thursday, May 12, 2011, pA15...an effort to promote generational strife, in my opinion.  What is the value of $500,000. contributed by and for an average worker over 30 or 40 years of gainful labor, and invested as a fiduciary on his promised behalf by the Federal Government over that time?  At least $1 Million. 
• "The Case Against Accountable Care Organizations (ACO)", by myself.  See below.

THE CASE AGAINST ACCOUNTABLE CARE ORGANIZATIONS

(ACO)

BY GEORGE A. SPRECACE, M.D., J.D.

APRIL 21, 2011

Three tiers of ACO’s have been described.   The following refers only to Tier lll, involving partial or full capitation.  A bibliography of supporting articles and data is available. 

A)     A QUESTION OF ETHICS.  Tier lll ACO’s, and any other system involving “capitation”, a form of health care payment wherein the provider agrees to provide all necessary health care for a patient for a period of time for a fixed and pre-determined fee – in effect becoming the insurer of that patient’s health or disease needs – is Unethical: 1) it is a breach of the physician’s fiduciary responsibility to the patient in that it is based upon an inherent conflict of interest that cannot be waived by the patient; 2) it properly undermines the critical trust of a patient in his or her physician; 3) it undermines the integrity of a learned profession and should therefore be considered as against public policy; 4) it is a blatant attempt on the part of the government to make the physician impose a rationing of health care, an action properly in the realm only of the public in a democracy; 5) it is an insane risk for any physician to take upon himself, given the fact that about 50% of all health care needs are life-style related, under no control of the physician.

B)       FINANCES. 

• A Loser.
• A clear invitation and expectation for “bait and switch” tactics by the payor.
• “Price Transparency” can lead to anti-competitive practices and even to increased prices.
• Implementation can easily impact the following laws: Stark Laws; Anti-Trust laws; Civil Fraud Legislation; Fraud and Abuse statutes and their attendant “Qui Tam” actions. 
• Great limitations of data and indices used by the government in setting payment levels and other rules.

C)      ACO DEMONSTRATION PROJECTS AND ANALYSES SO FAR….

D)      THE GOOD NEWS ABOUT U.S. HEALTH CARE

E)       THE REAL NEEDS (vs WANTS) FOR HEALTH CARE REFORM.  Please see my articles and analyses dating back to the 1970’s, to be found on www.asthma-drsprecace.com

F)       ONE OF THE BASIC NEEDS IS COORDINATION OF CARE AMONG A PATIENT’S MULTIPLE PHYSICIANS…SOMETHING TOO OFTEN LACKING IN THE MEDICAL PRACTICE OF TODAY, AND SOMETHING THAT CAN BE UNDERTAKEN BY ANY ONE OF THOSE PHYSICIANS, REGARDLESS OF SPECIALTY. 

GS

February 19, 2009 - And now to the greatest preoccupation of the new Administration after the Economy: "Health Care Reform".  Here, the best we can hope for is efforts at the margins of what really needs to be discussed and resolved; electronic health records, the least important but the most and most easily discussed; too much health care, a veritable buffet requiring priorities and rationing of needs vs wants; forced mediation of malpractice disputes instead of litigation...a lose-lose exercise for everyone except the lawyers; promote heavily Health Savings Accounts, thereby finally including the demanding/needing patient in the decision-making process, instead of systematically undermining that vital option; bring abusive managed care organizations to heel; emphasize patient responsibility, while half of Americans' illnesses are directly life-style related; emphasize and pay for coordination of care, whether by the primary care physician or by a caring specialist; promote and encourage the activities of "physician extenders", under the direct supervision of physicians; and reach out to physicians and other health care providers for a partnership in the process...instead of reaching out with the stick for the favorite pinata.  And wouldn't that be a breath of fresh air.  Meanwhile, don't hold your breath.

Managing Managed Care, GS

What is the Doctor-Patient Relationship?, GS

Two articles in a recent edition of the New England Journal of Medicine discuss "new developments": "Large Employers' New Strategies In Health Care" (NEJM, Vol 347, No 12, Sept. 19, 2002, p939); and "Changing Health Insurance Trends" (ibid, p 956).  The latter article even reports the finding that 'on average, insured persons seek medical attention less often when they have to pay a portion of the cost out of pocket'.  Imagine that!  All such disclosures should be compared with the contents of my article published in the New London Day, May 27, 1978, and entitled "Don't Blame The Doctors For Rising Medical Costs."  Some things never change; and some people never learn.

See, "Lawrence & Memorial Needs New Vision For The Future", by Robert A Linden, M.D., The Day, Tuesday, May 10, 2005, Commentary, pA9

"Managing to Survive...an Internist's Story," Anonymous

"Getting Uncle Sam To Cover Your Massage", the Wall Street Journal, Tues, Nov 5, 2002, JKPersonal Journal, Sec. D1.

"Rationing Health Care: Does it work?" The Pharos,  Summer 2002, pp. 13-19

"You Can Make Them Pay: new ways to appeal make it easier to take on health insurers and win", the Wall street Journal, Personal Journal, Sept. 17, 2002,  D1.