Healthcare Professionals for Healthcare Reform

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Our Letter to the editor Response in the Annals of Internal Medicine

We (the HPfHR writing group) were asked to formally reply to the letters they received about the original EMBRACE paper published in the Annals of Internal Medicine in April. We submitted it today and it is already on-line (see it here). The publication date has not yet been set.
Please encourage your friends and colleagues to visit the sites and get involved.
Take Care,

June 5, 2009 Posted by | Uncategorized | Leave a comment

My trip to Capitol Hill

I am writing this on the train heading back from Washington DC but will post it tomorrow (May 22nd). I took the Accela first thing this morning in time to make a noon appointment with Chris Murphy. Unfortunately, Murphy was at a vote (or actually a series of votes that included Cap & Trade, moves to censure Pelosi and even motions to adjourn), and I was not able to meet him until 12:45. While waiting in the office I got to talk to the receptionist who mentioned that the Congressman had had a slew of groups over the past couple of months coming through to discuss healthcare reform. She said she thought ¾ of all the visits in the past month have been for HCR. This set the tone for the rest of the day…

Chris Murphy and his legislative aide (Paul Kidwell) met me in an office next to the Energy and Commerce committee (of which he is a member) Conference room and had to get up a couple of times to vote. Despite all the distractions and very limited time, we did have a very detailed discussion on EMBRACE and healthcare reform in general.  Although he admitted that he had not read the paper, he claimed he understood the gist of our plan and felt that it was in essence a single payer system. I attempted to explain the differences (and that we had actually created it as a “not a single payer plan with the advantages of a single payer plan”) but in the end he felt that “it would still be perceived as a single payer system”.  I spent some time with Mr. Kidwell, when Murphy was voting, discussing some of the other features and he seemed genuinely interested in how we handled several political and financial issues. Then Murphy seemed to imply that for all intents-and-purposes the healthcare bill is mostly written, and from the gist of how he stated it, I suspect it will have a component of a privately subsidized public plan to compete with the private insurance companies.  Although they claim that there will be some provision to keep re-imbursement high for providers, we didn’t really have time to discuss any details.

It was what Murphy said when we ended our meeting that I think was most disturbing to me. He said that with the exception of the delegation from the ACP that came the day before, none of the doctors’ groups that have come by have actually wanted to discuss healthcare reform!!! They were more concerned with petty battles with other doctors/medical specialties than with reform!

All I could think was: we (doctors) blew it again: The ACP and I got here too late to influence the drafting of the legislation that seems to be all but written. I truly got the feeling, as we ended our session, that Murphy would have liked to have helped us, but it seems that other groups have been more consistent in their advocacy and united in their points.

John Larson was not available to meet with me but I did meet with his Legislative assistant, David Sitcovsky. He had read the EMBRACE article in the Annals (I sent all of the aides a copy before going down), and seemed to understand the gist of the plan. After listening to me explain the advantages of EMBRACE and taking down careful notes, he proceeded to tell me, in essence, that we are too late: he explained that “there will be a healthcare reform bill by July.” He seemed to confirm that it will contain the insurance reform that Murphy described. When I asked what kind of provisions there were to improve outcomes and reduce bureaucracy for the provider he mentioned the “Medical Home” model advocated by the ACP the day before. When I asked him how the primary care doctors, who would have to direct the Medical Home, would get reliable guidelines, he mentioned that there would be a department in HHS that would be responsible for developing guidelines. What mechanism this department/committee would use to develop the guidelines though is not clear.  

My final meeting was with Dodd’s staff. I was already informed that neither Dodd nor his healthcare aide, Jeremy Sharp, would be able to meet with me, but that I would be able to meet with Monica Feit and Rebecca Davidson. Ms. Feit is a PHD and a Public Health Fellow in Dodd’s office and Ms. Davidson is a Legislative Correspondent a year out of GW. They were both quite happy that two key pieces of legislations that Dodd held near and dear (the Credit card bill and tobacco regulation) had just been passed/promoted and it was clear that they were swamped with work. Neither had had the chance to read the material I sent so I spent a few minutes explaining EMBRACE. Unfortunately, before I could even finish explaining the plan (let alone discuss its assets), Ms. Feit was called away by Mr. Sharp for an important meeting. However, before she left, Ms. Feit told me that I would be happy to know that the Senate already has a bill being developed “that has many of the features of your plan”, but did not have time to go into the details. I spent the remaining time with Ms. Davidson discussing the advantages of EMBRACE.

With all of these meetings, seeing that we missed the boat with EMBRACE, I pleaded that whatever legislation is passed must reduce the financial and bureaucratic burden on the healthcare provider and put in measures to improve the health of our patients.

Now as I sit on the train going back home, I have a feeling of regret that I/we did not make the trip earlier and a feeling of foreboding that what will be passed in Congress will not be healthcare reform as much as health-insurance reform; and that we providers (and our patients) will get screwed again. Unfortunately all we can do now is just sit back and see what we get!


May 22, 2009 Posted by | Uncategorized | Leave a comment

EMBRACE versus the Oregon Plan

Q: I agree with your approach.  There are hard ethical decisions to be made and that frightens many, especially politicians.  I understand that the Oregon Plan for Medicaid patients shortened a few political lives.  It was the right approach since it defined necessary from elective medical care.

May 6, 2009 Posted by | Uncategorized | Leave a comment

EMBRACE and Single Payer

Recently I had the opportunity to meet John Larson, a Representative from Connecticut who was recently elected as the Chairman of the Democratic caucus. He talked about what he was looking for in healthcare reform, and many of his stipulations sounded like they were right out of EMBRACE.
I met a few other people there including some physicians who seemed interested in learning more about the plan. They emailed me back and it seems had some issues with EMBRACE versus single payer plans. Below is my answer to them:

It was great to meet the two of you and I am honored that you took the time to read EMBRACE.
I will try to answer all the points that you both raised.
First a general statement: Setting aside the question/issue of healthcare being a right or a privilege, I do believe that in a perfect world any doctor that has taken the Hippocratic oath should be in favor of universal coverage for all services. In fact, many of the members of our group and even the members of the writing group of EMBRACE were (and some still are) members of PNHP. Many of us have been interested in healthcare reform even from before the Clinton debacle and have seen many plans come and go. The main problem is, as you point out, that the politicians tend to usurp healthcare policy away from those who tend to have patient and physician interests in mind, toward one that has a more fiscal based ideology. The problems, as I (and many of our group) have come to realize, is that we healthcare professionals have not been politically active (or savvy) enough and that we don’t live in a perfect world.
What we have attempted to do with EMBRACE (which was created in response to the above concerns) was to develop a plan that satisfied the basic tenets that all Americans should have free basic healthcare coverage, that the user (patient AND physician) friendly aspects of the current system (for those with insurance) be preserved, keep the practice of medicine in the hands of doctors and other healthcare professionals (rather than politicians and insurance companies) BUT also make it politically palatable/viable.
Your discussion on rationing and different types of healthcare systems is very much a discussion that we at HPfHR have had for most of our existence. What we have come to understand is that ALL healthcare systems have rationing; because there is no country (except maybe in the Persian Gulf) that can afford to cover all their countrymen for all medical care. In the US we have “irrational rationing” based on age, employment status, economic status and pre-existing conditions. In many European countries and even Canada, the rationing is much more rational, often based on medical evidence for effectiveness and cost (including cost to society). The problem for all these systems is that there are always going to be certain services, tests, medications and/or devices that can not be provided within the system. This means that there is ALWAYS at least a 2 tier system (as long as one does not outlaw the provision of these services outside the main system as occurs in Cuba). The existence of a tier that is not covered by the national insurance, invariably then creates opportunities for entrepreneurial creation of “private” insurance plans and even parallel medical delivery systems. Instead of helping the overall delivery of healthcare, this phenomenon almost always creates an unhealthy form of competition for resources and, worse, creates a system where a patient cannot go to the same provider for the different therapies and may even be dropped from the national plan (as happens in England). What is more, there are usually different physicians for different “tiers”, making the system more frustrating for the provider and more dangerous for the patient.

Now for the specifics:
1) Q: Whether continuing the for-profit health insurance industry should be part of the new plan:
A: Although I agree with the sentiment, there is no way that we can outlaw private insurance in the US. Even with HR 676 (which is the PNHP plan that has been sitting in committee in Congress for 3 years), one can ban private insurance in the main system, but the insurance companies WILL have a presence for those who are not covered, and I suspect, that they will draw away many of the more healthy patients and put them in “for profit” clinics that will compete with the single payer providers. EMBRACE acknowledges this and allows private insurance to work WITHIN the system with only 2 stipulations: they cannot compete for Tier 1 patients (which we believe will not be an issue, since Tier 1 represents the greatest risk to profits for the insurance companies) and they must provide plans from a pre-determined (independently created) menu. By keeping the insurance companies within the system in this way we can a) regulate them b) make them compliment Tier 1 rather than compete against it, c) reduce the price of private insurance (because we reduce the risk to the insurance company and we increase competition -with the menu- that allows the costumer to compare prices), and d) make it more politically palatable and viable.
2) Q:The fatal flaw of the EMRACE proposal is that establishment of a so-called Tier 2 that funds “quality of life” care is a serious ethical problem for me. Health care is not like buying a car. Patients should not have to choose between a “Chevy or Cadillac.” Your future health care needs are unpredictable. You do not know if tomorrow you may be in an auto crash or develop diabetes. How does a Board decide what is “life-sustaining” versus “organ-sustaining” in this system? Does Tier 1 cover cataract surgery to restore vision only for those people who need to see well to perform their job, or a knee operation for a construction worker to continue his profession, or angioplasty for active people but not covered for non-active people?
A: First I should explain that the Board will decide what is covered by the different Tiers depending on best evidence (medical, ethical and economic). I also want to clarify that Tier 1 would include most chronic conditions such as diabetes, hypertension, high cholesterol and even obesity and smoking addiction. These are conditions that are life threatening and their treatment would be preventative so they would almost definitely be covered by Tier 1. Also, Tier 2 would be MUCH more affordable than private insurance is now (this is one thing that many in the US find hard to understand, but as in Germany and France -which you mentioned- the price is low because of less risk and more competition). A worker would almost definitely be able to have Tier 2 insurance that covers knee surgery, that is purchased by the employer (as a “perk”), the union or even the individual him/herself. Even if the individual is not insured, usually the price of Tier 2 operations are relatively low compared to treatment through Tier 1 and are almost always elective, allowing the patient to make a decision of whether he/she wants the procedure or to keep their money (or find a physician who may do it for less). There is NO moral problem here because there is never any denial of essential services or even for these “quality of life” services.
3) Q: By eliminating the for-profit health care insurance industry, money immediately flows into the health care delivery system. All economists agree that Medicare has a 4% overhead cost v. an average of 19% for the for-profit health care insurance industry. If, instead, we create a public funding option for people to purchase, this keeps the overhead costs down and eliminates the need for the for-profit industry.
A: EMBRACE eliminates all this overhead AND makes the system more streamlined. Almost all the overhead that private insurance has has to do with its interactions with the provider (and BTW, most of the statistics do not include the overhead for the providers for hiring billers and pre-certifiers and for the time spent on the phone…). EMBRACE removes all this for all concerned.
4) Q: One alternative is to adopt a system such as in France or Germany , whereby they do have a tightly regulated minimally for-profit insurance system that exists along with public-financed health care. The difference is that these insurance companies do not waste money on marketing, obscene salaries, and layers of patient denials. The entire ludicrous notion of a “medical loss ratio” exists only in the warped delivery system in America .
B: This almost exactly describes the EMBRACE Tier 2 system but keeps it in one streamlined system. The insurance companies can still give their execs obscene salaries (if they choose), but at least the competition will make sure that these may be less.
5) Q: Congressman John Larson and the Democratic leadership are cowards. They know that a single-payer system is the morally right solution. By dismissing the PNHP proposal, he acknowledges that the Democrats are as much in the pockets of the insurance industry as the Republicans. To say that this is politically unworkable is untrue. Without even any fanfare or public awareness, John Conyers’ Hr 676 already has 72 co-sponsors in the 111th Congress. The 110th Congress had 93 co-sponsors before it died. By all physicians advocating for a single-payer system or creation of a minimally for-profit insurance entity to compete with the existing insurance industry, we can make it happen.
A: Without the name-calling, I would agree. HOWEVER, this is America and American politics. We physicians (and all in the healthcare delivery profession) should take great notice of what has happened and is still happening with HR 676 so that we don’t get screwed again!
HR 676 was first introduced by Conyers in February 2007 and quickly ignored in committee. It did, as you say get 72 co-sponsors by the end of the two-year session and has picked up some this session BUT there are 435 seats in the House. And, when I had the opportunity to ask the healthcare aides for Kennedy and Pulosi about the chances for the bill the Pulosi aide said “One degree north of zero”. When I asked them why, they both agreed that it is because of the insurance issue. When I talked to other Congressmen and politicos I was essentially told that it will be hard enough for the Democrats to convince the public (their constituency) that there should be some government control of health insurance (like expanded Medicare and/or Medicaid) that they cannot even begin to want to think about a single payer system. You can argue that that is because they have no guts but it won’t help OUR cause, namely to get meaningful healthcare reform that will be good for our patients and help us healthcare professionals provide that service to them.
Listening to Larson (who is now the Chair of the Democratic caucus!) I felt that EMBRACE pretty much fits in with his desires in healthcare reform. Because of this I think that EMBRACE has a much better chance of passing than HR 676 as long as we can show Congress there is support for this from healthcare professionals AND their constituency. So we must not only petition our Congressmen, we need to talk to our patients and have them urge their Congressmen to embrace EMBRACE.
6) Q: The key ingredient is to ensure that physicians remain in the system. The “Board” that sets reimbursement rates for physicians must set a reasonable fee schedule. As we all know, this is the greatest concern (and rightfully so) for physicians in crafting any new system.
A: I completely agree. In fact one of the upsides of the EMBRACE system is that providers will be in control of deciding reimbursement and will be able to manipulate these payments to push more important services like preventative care, and reduce the financial incentive to do more tests and/or procedures. With the increase in the number of “paying patients” with EMBRACE, all providers, no matter if they are primary care providers or sub-specialists will have enough “business” and there will be a significant reduction in overhead and bureaucracy in the system, which should also make life easier (and help retain providers in the profession and the system).

Thanks again for your interest. Please let me know if you have any more concerns.


May 5, 2009 Posted by | Uncategorized | Leave a comment

A Conversation Comparing EMBRACE with Emanuel/Fuchs Plans

I have been having a “conversation” on Facebook (in the group called Doctors for America) with a Dr. John Lee about the relative merits of the EMBRACE plan compared with the Emanuel/Fuchs Plan. Here are some of the highlights of the exchange:

… “single payer” seems DOA in the Senate. (Conyers valiantly labors on in the House.) So, apparently, we have to get behind something that Susan Collins will support. Ezekiel Emanuel, Rahm’s brother, has a plan that might serve as a compromise. He supports vouchers and advocates turning all insurance companies into HMO’s. Susan Collins might go for that. He was just appointed special advisor to the director of the White House Office of Management and Budget for health policy.


Our group, Healthcare Professionals for Healthcare Reform (, realized a couple of years ago that even though we believe that a single payer plan may be best for the health of the country, it would never make it politically in this country. We just published our proposal called EMBRACE in the Annals of Internal Medicine . We would be interested in your thoughts.

I’ve been seriously studying your article and re-reading the Emanuel/Fuchs Plan which I mentioned in my last post.
Your article differentiates yourself from “single-payer”, but, in a major sense, you both cling to the same, familiar fee-for-service payment system. In contrast, the Emanuel/Fuchs Plan is capitated, which goes beyond “centralized billing “ to no billing. Just take your voucher to any insurance company/ HMO. Capitated payment could most easily be applied to your basic Tier One benefits, well defined entities in an unselected actuarial pool (no cherry-picking allowed, but some risk-adjustment—voucher worth more– for sicker patients). Think of the huge savings in overhead if we stop itemizing and billing for actuarially predictable events? And should we not encourage Tier One benefits be delivered within an HMO system of primary care anyway? The other major advantage, which the all-important fiscally conservative Senators will like, is a capped, global budget that will force a rationalization of the current chaos.

I don’t mind the concept of Tier 3. It is a free country; buy whatever extras you want. But the definition of “quality of life”, which will distinguish Tier 2 interventions from Tier 1, makes me a little uncomfortable. Emanuel/Fuchs give the Federal Employee Benefits to everyone. What Congressmen get. We are all in this together. Social solidarity, which is language politicians from Britain to Switzerland use when discussing their very different solutions.

Re-read the goals of your plan in your conclusion section. Then read the Emanuel/Fuchs Plan and see if they don’t come closer.

HPfHR was specifically established by healthcare providers to address healthcare reform from the provider’s point of view. We wanted a system that was both effective in improving everyone’s health while being user friendly to physicians and patients alike. We also were looking for a system that would be politically viable and easily understandable to the public (including physicians!)
I am familiar with the Emanuel/Fuchs plan and I know that since Ezekiel Emanuel is Rahm’s brother it is likely it will have the ear of the President. As you point out, there are several similarities between their plan and the EMBRACE plan promoted by our group. There is a central Healthcare Board and there is universal coverage, and frankly this would be better than the current system and better than most of the plans that are now actively being considered in Congress.
However, there are important differences:
• 1) In the Emanuel/Fuchs plan the role of the Healthcare Board seems to be mostly limited to the “business” management of the system. Its only method of improving healthcare is by “recommending best practices to health care providers and organizations based on (the Board’s) evaluations.” In truth, this Board will have no effective power to dictate what best practice is. In addition the “monitoring compliance industry-wide” and “monitoring the quality of health care delivery industry-wide” that they advocate will be a bureaucratic nightmare on the level of the worse managed HMOs around today.In contrast, the evidence based tiers in EMBRACE predetermines “best practice” services within the system with minimal bureaucratic oversight, yet allows the provider to offer, and the patient to request “unapproved” services (but the patient may have to pay for it if he/she does not have insurance).
• 2) Because physician participation in the voucher plan is optional and there are other forms of coverage, the Emanuel/Fuchs plan will most likely lead to a system where there are one set of doctors for the “voucher patient” and another for the others. Although the “voucher patient” most likely will have good care, the truth is that as a provider, I would never want to have to decide if I am going to be one type of doctor or another.
• 3) The voucher system in Emanuel/Fuchs, although steering away from an employer based system, will not be universally portable. EMBRACE will do both: eliminate employer based basic coverage AND all insurance, whether public or private will be fully portable.
• 4) In the Emanuel/Fuchs system, the price of the Private insurance is set (no competition). The consumer must negotiate with the insurance company for the content of the plan. This assumes that the average American knows all the nuances of health insurance coverage and may understand what he/she may need in the future. In EMBRACE, the Board decides on the content of the plans and the insurance companies compete on price, deductibles, additional features etc. that the consumer is much more likely to understand.

The details of regulation would have to be negotiated and fine tuned. Any system that attacks cost, as only capitation can, would involve some provider hassles, I grant. But think of the money we’d save if we stopped itemized billing!! That would buy a lot of primary care.

By the way, with respect to “best practices” did you notice that “The president’s Federal Coordinating Council for Comparative Effectiveness Research, formed last month, includes Ezekiel Emanuel, brother of White House Chief of Staff Rahm Emanuel, to oversee the studies. The council’s first report to Obama and Congress, containing recommendations of what treatments should be studied, is due June 30” And the hiring of new lobbyists is showing the “…..drug industry’s resolve to stop Obama from using comparisons of medical treatments to force cuts in health costs. More than half of medical care may be based on insufficient evidence of effectiveness, the Congressional Budget Office said in March.”

Your other points:
• “I would never want to have to decide if I am going to be one type of (voucher) doctor or another”. Don’t see why private practice doctors couldn’t continue with a mix of patients, as they do now. What percent would opt out of the constraints of a no-frills voucher plan? Don’t know, but MediCare cost is about 22% out-of-pocket & National Health in Britain looses about 12% to the private sector. So I’d guess vouchers would cover 80-90% of care. Is it the monolithic aspect of this that worries you?
• Don’t understand why Emanuel/Fuchs wouldn’t be just as portable.
• With Emanuel/Fuchs the consumer would have a choice among many different plans which would compete on variations of benefits, deductibles and co-pays. As I recall, they would make sure each region had a half-dozen plans to choose from.

You asked about my background. I suppose I am a fan of capitation because our county hospital system, the Contra County Health Plan, was the first federally-qualified, government-run HMO in the country (1972). Our resulting primary-care clinic system is second to none in the national public sector. Happily, I’ve been spared the hassles and inefficiencies of itemized billing. Capitation puts the outpatient system is in the driver’s seat, not the hospital. We are also a teaching hospital (Family Practice, Martinez, Ca) affiliated with the UC Davis Network. What is your background?

I am a cardiologist who has been in 4 different types of practices in my 20+ years since finishing my fellowship. I have been in a busy inner-city “public” hospital in NYC; in a full time hospital based private practice; in an office based private practice group and am now the director of non-invasive cardiology and associate director of a cardiology fellowship program in Connecticut (i.e. in academics). I am also a council member in the CT chapter if the ACC and have been in DC lobbying (too) many times.
In my travels I have learned that 1) politicians will listen to you, but unless you either have money or a large measure of support of their constituency, they will not help you; 2) most doctors want change but feel that someone else who knows more and has more time should do the work (I know because I was one); 3) most doctors and patients hate the words “capitation” and “HMO” and 4) the more complex something is (like a healthcare plan), the more likely it will be opposed, and destroyed by people who can easily claim faults (mostly untrue or major exaggerations) or dire predictions. The reason for the latter is that the more complex something is, the less people (including politicians and doctors!) are able to reason for themselves what is true or not, and rely on “experts” or pundits to interpret it for them.
I think that my background and my experience led me to seek others who felt like me, and this is how we ended up with HPfHR and the EMBRACE plan. EMBRACE is simple in structure and keeps everything transparent. It has all the benefits of a single payer system, but allows participation of private insurers. It eliminates the bureaucratic nightmares for practitioners and patients and allows freedom of choice for both groups (doctors to choose any test/procedure/therapy he/she feels is needed and patients to choose among doctors and hospitals).
Back to our discussion:
1) Don’t understand why Emanuel/Fuchs wouldn’t be just as portable: The portability of a system depends on the uniformity of plans that are available. In the Emanuel/Fuchs plan, there will be multiple plans to choose in each region and no oversight that these plans will be the same if you get it in NY or in CO. So if you move to a new state you have to get a new plan. In EMBRACE you have a menu of the Tier 2 (private) plans (predetermined by the Board) that assure that the plan you purchase is complete and is identical no matter if you purchase it from Aetna or from Blue Cross. Because of this and because Tier 1 is identical all over the country, you are covered no matter what job you have or where you travel in the US (and even abroad!)
2) With Emanuel/Fuchs the consumer would have a choice among many different plans which would compete on variations of benefits, deductibles and co-pays. As I recall, they would make sure each region had a half-dozen plans to choose from: As we saw in Medicare D, consumers don’t do well when they have lots of choices of items, the content of which they may not really understand. How many people actually know all the details of the healthcare plan that they are covered by? I would guess next to none (except those in the business). However, I agree that for financial concepts like price, deductibles and co-pays, the consumer can understand this better. In EMBRACE the private insurance plans are predetermined but the price, deductibles and co-pays are not; allowing for “free market’ like competition on an even and transparent playing field.
3) What percent would opt out of the constraints of a no-frills voucher plan? Don’t know, but Medicare cost is about 22% out-of-pocket & National Health in Britain looses about 12% to the private sector. So I’d guess vouchers would cover 80-90% of care. Is it the monolithic aspect of this that worries you?: Many things worry me about this. One thing is that the US is not Britain or even Canada. There is a history of free enterprise (for the insurers) and private practice (for the docs). As we have seen with Medicare, which was once a straight “publicly funded” system, when private insurers are allowed to participate within the system, it inherently establishes competition between private and public sectors, to the detriment of both (but more to the public sector). This is well demonstrated with Medicare Advantage (or “Managed Medicare”) where privatized Medicare has managed to leach the low risk patients, leaving the higher risk, more expensive patients to “public Medicare”. So I fear that having vouchers compete with private insurance will recreate this scenario. What EMBRACE has done is separate public insurance from private, allowing private insurance to compete with itself (which I believe is fairer).
4) Any system that attacks cost, as only capitation can, would involve some provider hassles, I grant. But think of the money we’d save if we stopped itemized billing!! That would buy a lot of primary care.: As mentioned above, “capitation” is anathema to both providers AND patients (and patients tend to be both Democrats and Republicans and they vote in large numbers). The problem for docs is obvious: you have to negotiate (if the system allows negotiations) a per-patient fee for care and hope that you don’t get one or two hypochondriacs or even worse, really sick patients in your practice. This clearly is worse for the smaller practices and/or solo practitioners, and will lead, in the long run to large HMO like practices (with better risk pooling). For the patient there is the knowledge that your doctor is being paid by volume rather than service or quality. If this is the case, and the patient has a chance to go to a doctor who does not have to practice under these constraints, then the patient will switch doctors. EMBRACE will allow doctors/providers to itemize but still have NO overhead (due to the free internet based Universal Billing Form). In addition, there is no need for capitation to save cost. If something is not in Tier 1 it will not be covered by Public insurance! And yet, you can still go to the same doctor and get the same service even if you go “outside” the public system.
5) More than half of medical care may be based on insufficient evidence of effectiveness, the Congressional Budget Office said in March.: I totally agree and that is why we believe that there should be an independent Board to oversee the commission of studies to get these data. The Federal Coordinating Council for Comparative Effectiveness Research is an excellent first step but unless it is overseen by a Federal Reserve like board, as we advocate in EMBRACE, there will be no clear direction with these studies.

April 18, 2009 Posted by | Uncategorized | Leave a comment

A response to an “Annals dialogue” comment

Before the Annals published EMBRACE, it had an on-line “dialogue” which I joined. There were a couple of entries that I thought might be of interest that the Annals did not keep after publication. Here is one comment and my reply:

Umesh stated: I fear that the focus on ‘universal coverage’ and the consequent debate almost completely ingores another very important priniple that should be an integral part of the current health care reform effort: a 
single payer system. The massive chunk of health care dollars (abuot 30%) being siphoned off by for-profit intermediaries is almost enough to pay for all uninsured Americans (about 18%). Is the academic health care establihment so weakened that they cannot withstand the vested interests?  

My response:

There IS a “single payer” proposal that has been making the rounds for over 6 years and has been stuck in Congress for over 4 years. It is called H.R. 676 and it is based on the 2003 JAMA white paperby a group called PNHP. It has garnered a fair amount of support by healthcare professionals, especially academicians, who understand that a single payer model that preserves some autonomy for doctors will be more effective in improving the health of the country than the current system (even if the current system is expanded to achieve universal coverage).  


The problem is that HR 676 and all single payer plans are not POLITICALLY viable.  


On both sides of the aisle, from John McCain to Ted Kennedy, from John Boehner to Nancy Pelosi, all agree that “Single Payer” is dead in the water. The reasons are many, but the most important is that the insurance (and pharmaceutical) lobby is one of the strongest in Washington and getting stronger. It is very telling that when President Obama had his White House Health Care summit, only the representatives of PNHP were not invited (it took huge effort with a last minute phone-in campaign to get a representative to finally be admitted).  


That is why we at Healthcare Professionals for Healthcare Reform (HPfHR) developed the EMBRACEplan that is published on-line here. In it you will find that we have all the benefits of a single payer system (universal free coverage for all “basic” healthcare needs), while including a more transparent and portable private insurance system. We have also attempted to preserve all the benefits of the present system (such as access to all providers and easy availability of testing and therapy etc).  


This fight is not going to be won by the academic health establishment; it needs the input and support of all who are involved in healthcare. Please review the EMBRACE planand consider it versus the alternatives. There is a limited time to get involved and get our voices heard. If you want more information about HPfHR please visit our website: or email me:



April 7, 2009 Posted by | Uncategorized | Leave a comment

PhRMA: Health Reform Could Wreck ‘Uniquely American’ System

There is an interesting item in the New Republic about Pharma and healthcare reform. I think this is very much on target about how Pharma is quietly working behind the scenes. In many ways this is also true regarding the insurance industry, except that they have been working behind the scenes to make sure what is introduced in Congress includes them.

March 25, 2009 Posted by | Uncategorized | Leave a comment

EMBRACE Published: The Conversation Has Begun!

EMBRACE has been published in the Annals of Internal Medicine (on-line ahead of April 7th publication)!!

The Annals has added two new features: Instant letters with “rapid responses”  and a Join the dialogue on the Early Release Articles (which is effectively a blog). Both these venues have comments directed to EMBRACE and we have responded. Please visit and consider joining the conversation.

March 11, 2009 Posted by | Uncategorized | Leave a comment

Campaign Against Health Reform is Run By Notorious Conservative PR Firm

A new group called Conservatives for Patients Rights (CPR) is about to launch the opening salvoin the fight to sink President Obama’s health care plan.

CPR is running TV, radio, and web ads that attempt to stoke irrational fears of “a central national board” in charge of medical decision-making, asking Americans to envision a world where “bureaucrats decide the treatments you receive, the drugs you take, even the doctors you see.” Of course, that vision has nothing to do with the president’s health care plan, but the truth shouldn’t be an impediment to CPR’s dream of killing health care reform.

After all, the group has hired Creative Response Concepts, the same PR firm that represented the Swift Boat Veterans for Truth during the 2004 presidential race. The “media relations” contact number listed on CPR’s website, (703) 683-5004, is the same phone number as Creative Response Concepts.

Creative Response’s past clients also include the Christian Coalition, the right-leaning National Taxpayers Union, and USANext, the front group that led George W. Bush’s failed push to privatize Social Security. Hilariously, Politico could only bring itself to observethat CPR has hired “veteran Republican consultants” for its new anti-Obama effort.

What is clear is that this misinformation is already out there and it seems to be working:

Today I got into a conversation with another physician who told me that Tom Daschle specifically stated that he envisaged that ‘a central national board’ will be needed to ‘ration’ care to patients. It was almost a verbatim regurgitation of this group’s “talking points”. This is particularly disturbing because I read Tom Daschle’s book and have heard him talk  and I know he said nothing of the kind. It’s also disturbing because this doctor seems to be working against the interests of patients and the interest of the health care system as a whole.

This time around, we health care professionals need to stand up against this misinformation. Just remember how we (and our patients) got screwed before by these guys…


March 4, 2009 Posted by | Uncategorized | Leave a comment

The Obama Budget and the EMBRACE Healthcare Reform Plan

It is very telling, and in that respect so different than the Clinton healthcare initiative, that in his budget Obama has put aside a $634 billion reserve fund for health care reform and left it up to the Congress to come up with a plan. He has outlined a set of guidelines and has left it up to Congress to hash out the details. He has stipulated that the plan should ensure that coverage be universal, affordable, portable and there should be investments in prevention and improved quality of care.

Although there are many proposals out in Congress, EMBRACE  fits these criteria and comes at  a good time, especially since it looks like we will need a compromise.


February 28, 2009 Posted by | Uncategorized | Leave a comment