Obamacare for idiots: The quest for "skin in the game"

At the end of the Monday 8 am presentation entitled, "Obamacare: Does it matter to me?" an audience member stepped to the microphone and said, "Thank you for this informative and petrifying presentation." Nervous laughter rose from the crowd, because we knew the cardiologist had located the pulse of this presentation aptly. Drs Jerome Hines and Frank Mikell of Illinois chaired today's session. The speakers included Michael Schroyer, RN, MSN, MBS, of St Vincent Heart of Indianapolis, Cathie Biga, president and CEO of CV management of Illinois, Suzette Jaskie, CEO of MedAxiom Consulting, and Michele Molden, executive VP and chief transformation officer for Piedmont Healthcare in Atlanta. These folks have a keen sense of what Obamacare really means to America, and they understand that a key component is to understand what Obamacare means to cardiologists, the keepers of the biggest DRG on the planet and the one that will either save or kill healthcare systems in the first wave of managed care. So, if you know all about Obamacare already, no need to read further. This is a real primer with several macros and a few specifics thrown in for good measure.

Obamacare for idiots, macro 1

Example: A "big East Coast" hospital has this actual scenario: The total Medicare reimbursement for heart failure was $4.2 million/year before Obamacare. Pay attention here! Based on its 30-day readmit rates, it incurred a 1% penalty on all Medicare receipts (not just CHF receipts, but all Medicare receipts). It incurred a $3.1-million dollar penalty for that year. Things didn't change, so the next year, it was penalized at 2%—losing $6.3 million in total Medicare receipts, making CHF patients an instant liability. In 2015 it is projected to lose 3%, which will total $9.4 million in revenue. After a long gestation and and even longer labor, born kicking and screaming will come palliative-care programs across the country—teams of doctors, nurses, and healthcare extenders, highly trained babysitters for the frail, the elderly, the noncompliant, and the frequent fliers, whose ultimate goal is to keep those patients at home.

Likes: It's not safe to be an inpatient in many hospitals across the country right now, so you are better off at home if you can manage it. Patients like staying out of the hospital for the most part, so satisfaction might improve with the "medical home." Per capita expenditures might go down.

Dislikes: Some patients who require admission will decline (become more ill, die, lose their independence, etc) because their inpatient needs may be marginalized by this approach. The patient must understand that although the goals of these programs have an altruistic component, their main purpose is to decrease expenditures for the system. If carefully managed though, the end can serve the means and vice versa.

Obamacare for idiots, macro 2

In 2015 COPD, CABG, and PCI penalties for readmits will likely be added. So, hospital systems had better "cut their teeth" on the CHF DRG.

Likes: Hospitals will begin to realize the importance of nurse callbacks for daily weights, sodium and fluid restriction, medication compliance, and follow-up. We will no longer turn up our noses because a certain measure fails to affect mortality. We will seek out measures that affect 30-day readmit rates.

Dislikes: For those who can't convince their care providers to put them in the hospital, they may actually be hurt by the very system devised to protect them. It will be up to the legal system to balance the issue when harm comes to patients. In extreme cases, the fear of malpractice and negligence suits may be all that balances the trend in our current healthcare system. It's a shame we don't have true risk management instead of offices that are "called" risk management.

Obamacare for idiots, macro 3

We all will bow to the "triple-aim paradigm"—otherwise known as the three-headed beast. This requirement is of biblical proportions. No system will succeed without heeding the call of each of the three components, which include: population health, per capita costs, and experience of care. OMGosh—where to start?

Per capita cost is the most concrete of the components. It can be measured, tweaked, tracked, mapped, and affected by robbing Peter to pay Paul. It's likely the easiest to understand but still difficult to contain. Suzette Jaskie said, "We've eliminated the investment income, and now we are trying to make it on operations. Though operating margins for all hospitals have ranged at around 7.1%, collectively we are happy to be doing around 5.5%, and for some systems, it's even a positive thing if it's a 2% to 3% margin."

In order to survive, system success will require heeding the basic tenants of resource management, non–labor-cost management, alignment of labor and productivity, purchase contracts, etc. Staying away from huge purchases and leaving behind our past affection for new bricks and mortar, land acquisition, chandeliers, brass fixtures, and the like will be paramount. "All the marble buildings, we are depreciating them today," Jaskie said.

And they must be careful who the system purchases and what they do with their new laborers. Michele Molden said, "At Piedmont, we are a five-hospital system with two big physician companies, a primary-care and a heart institute. We can't ignore our primary-care brethren. The way to not fail in that business is to pay them on a revenue-expenses basis, treating them like they are still in private practice. They have high reimbursement but they are not incentivized for growth. We have calculated it takes seven primary-care physicians to support each cardiologist," a point I found interesting. "There is an inherent disconnect in that the specialty structure has an enormous thirst for growth. We need to consider how both of their compensations can come together, and I don't think many organizations have figured out how to rationalize compensation as an accelerant for change." She then added, "Time is not our friend. Our payments will be reduced."

So, think tanks had better fill up quickly and will require examination of both system and individual behaviors and practice patterns.

In addition, Cathie Biga asked, "Can we have quality in a payment reform world?" Then she explained, "Public reporting, physician compare, confidential feedback reports, payment adjustment, aka value modifiers—they will all impact compensation. Physicians will all be scrutinized on the 'green, red, and yellow report card,' where we will see our average cost per each Medicare beneficiary and then the total cost of care per CAD, COPD, DM, and HF patient." Whether integrated or not, this is for you unless you are in a rural health clinic, federally qualified health center, or critical access hospital. Then she said, "This is all very fluid. We don't really know how it's going to roll up."

Experience of care is where it seems some hospital systems have fallen down. Their focus has been so intent on getting their physicians purchased and their corporate folks lined up for the big Obamacare assault that they took their eye off the bouncing ball: the patient. Those who have felt orphaned by systems they've known or harmed by the system they entrusted their lives to for years are fleeing to other facilities, embracing care from total strangers, chancing their future on the unknown rather than continuing in a system that seems broken. Michele Molden made the point that we must focus on "service excellence," and it is imperative that each system develop a "culture of safety and reliability, increased quality, employee engagement, and community value." I couldn't agree more.

Now for the "Kraken."

We've covered two heads of the "triple-aim-paradigm" beast, but this last one is a monster, a veritable "Kraken" (the legendary giant squid with scores of tentacles), and it has its grasp firmly around the throat of every community, medical home, and healthcare system in the country. It is "population health," code for patient accountability, or what Michael Schroyer refers frequently to as "skin in the game." "Where is the skin in the game?" he asked rhetorically. "Where is the incentive for compliance? Somehow we have to put skin in the game for the American public to meet our goals."

The key to understanding population health is fourfold: The first consideration is the patient who is already ill. Since 50% of our population is noncompliant with medications, we have to motivate them with coddling, follow-ups, engaging families, etc. They have to have clinic access and phone access to avoid preventable readmissions.

The second consideration is for those who are not yet manifesting illness, ie, the 30-year-old moderately obese individuals, smokers, undiagnosed diabetics, the middle-aged hypertensives, and dyslipidemics. Those folks require some nudging by their third-party payers—ie, higher premiums and higher penalties. We must drive what we think is "primary prevention" when in fact for many, it's probably already secondary prevention that will require discussion of medical budgets and threats of out-of-pocket costs. (These same threats might work for some Medicaid folks, too.)

The third component is the redesign of health education in our elementary schools and high schools. Although it's totally fascinating to high schoolers to learn about STDs and how to use a condom properly, it won't keep them off the cath tables or out of the CHF clinics. Those types of topics are important to discuss at home and at school, but we need more nutrition programs, parental engagement, and participation in daily exercise programs, too. We need to teach our young the signs and symptoms of such things as appendicitis, gall-bladder disease, reflux, sleep apnea, heart disease, stroke, etc. They need to know the difference between a fat and a carb. It's more important than learning how to troubleshoot their laptop . . . really it is.

The fourth wave is where we as system and provider may need to concede some component of defeat. These are the frequent fliers: The brain-injured who smoke, the noncompliant schizophrenics, the homeless guy who keeps coming in with chest pain just to get warm, the smokers who, "by golly, want to exercise their constitutional right" to 14 angioplasties, or as one audience member put it today, "the ones still smoking while using their oxygen." There was much laughter as he quipped, "It's okay to keep doing that as long as they just get everyone else out of the house." And finally, but so heart wrenching, the fourth wave also includes those who are just so sick, no matter what they do or what we do, they just can't help those frequent returns. One option is to offer more outpatient services to herd some of these unfortunate individuals away from the inpatient sieve that drains so many resources for society. Palliation, hospice, adult day care, all may have some role in many of these very difficult issues.

The secret to our success in medical America will be the ability of each physician and hospital system to see its worth in driving community healthcare. As a team, we must reach out to the barbers and beauticians and put BP cuffs in their shops. We must send nutritionists out to groceries to lead healthy shopping sprees. We will shore up our PCI without surgery on-site programs to reduce the need for device therapy. We will go to legislators to convince them that school systems must "teach teachers how to teach" about impactful health issues, prevention, and therapy; we must provide the teaching curricula for mini–med schools or survival programs, so to speak. We must call our patients back on days 1, 2, 3, or whatever to make sure they not only received the proper discharge instruction but help them to follow it. We will go into factories and churches to offer prevention programs.

As physicians we will continue to do our part because most of us really got into this game for the love of it. We know how to diagnose and treat; that's the easy part. Systems will learn the rules and tweak the bottom line. In this new wave of healthcare, those are the easy parts.

The difficult part is understanding or perhaps accepting that Obamacare isn't just for the fortunate 32 million Americans who stand to gain healthcare coverage by the end of 2013 or only for those who have "skin in the game."

Obamacare is coming for everyone.

Your comments

	Obamacare for idiots: The quest for "skin in the game"
	# 1 of 20	March 12, 2013 12:57 (EDT)
	Ken Phillips	Re: Re-admissions, 'Never' events, and 'Quality.' 1) Do re-admission rates (for each disease/DRG/APACHE or other severity score prior to 'penalties' exist for each Hospital? How are re re-admision rates for each Hospital set (at what rate of re-admissions does the penalty start)? 2) Does CMS, etc. have a 'baseline' for 'Never Events'? A unit of the NIH hospital had a 'mini-epidemic' of multi-resistant K. pneumoniae. If this hospital had a 'never' event, how are community hospitals judged? 3) Here in the USA, we seem to vacillate between 'process' measures (e.g. MD/Hospital 'Quality' measures and 'outcome' measures (e.g. 'disproportionate' hospital re-admission rates, even if all 'Quality' measures were met). How can we physicians work to change the focus or standards, including defining 'Quality' measures for each patient, a level of 'never' events (perhaps a standard baseline of 'nosocomial morbidities for each DRG (Apache or other severity of illnes scale) at presentation? Author's disclosure (Mar 12, 2013) My focus: The unique, individual patients whom I treat.
	# 2 of 20	March 14, 2013 02:15 (EDT)
	Tina Abell	Comments from a cardiology research nurse Dr. Walton-Shirley, You make excellent points, as usual. I read your blog often. Not only do we need to boost preventive health measures for the community, we also have a critical need for decent jobs for the low-middle class. I was behind a family at the grocery store. They had 6 loaves of white bread, 8-10 2-liter bottles of store brand soda, and packaged meats. The mom made the comment that the food had to last two weeks! The truth is, people are suffering in this country. The United States as a super power is in a sad state of affairs. The average person is unhealthy, uneducated and unhappy. Author's disclosure (Mar 14, 2013) I have no relevant disclosures to make in connection with this topic.
	# 3 of 20	March 16, 2013 05:29 (EDT)
	Melissa Walton-Shirley	Ken and Tina Thanks so much for your posts. Tina, that is a heart breaking experience. I took a drive in a small bedroom town just outside our city: paint peeling, side walks chipping, shutters banging in the breeze and for sale signs everywhere. We have to pray and work hard to get out of this recession and preach prevention Prevention PREVENTION to help out patients stay out of our hospitals in crisis at this time in medical history. Author's disclosure (Mar 16, 2013) I have no relevant disclosures to make in connection with this topic.
	# 4 of 20	March 20, 2013 04:16 (EDT)
	william reichert	the plan Maybe the goal is to make medical practice so distasteful, so much a task impossible to succeed at that physicians quit, driving down access thus reducing medical visits thus reducing costs. Author's disclosure (Mar 20, 2013) I have no relevant disclosures to make in connection with this topic.
	# 5 of 20	March 21, 2013 05:27 (EDT)
	becky christianson	My penny's worth (even that's not worth as much as before!) Where to begin...(I've read this several times, trying to formulate thoughts that appropriate to say here)...Ken, readmission rates are calculated by claims to Medicare. They encompass EVERY admissions for 30 days--soon to be all-cause. Go to hospitalcompare.gov (I think it's gov) and you can put any hospital you want to see what its rate is. As far as what is measured (process vs outcomes) there is now such a thing as Value Based Purchasing and that is a really complex item to explain. You'd be better served going to the federal registers and searching for I believe it's the 2010 IPPS rule. There is about 40 pages on VBP there. Wonderful bathroom reading. ACCA (Obamacare) is now over 20,000 (yes--20 thousand) pages written by non-elected officials. Gee, Christmas Eve 2010 it was "only" 2300+ pages in length and none of us could read it before it was rammed through and passed. Now there are so many waivers and exemptions that it is very hard to tell who is going to be impacted and who isn't---except for us middle income people..... It is no longer about the patient....it is about how much the government refuses to pay for care. If you have end-stage anything you are supposed to stay home and die, because EVERYONE knows that in your last 6 months of life the government spends more on your care than it did over the last several years combined, and you "just aren't worth it anymore".Now, Medicare Spending Per Beneficiary is being measured and compared.....so the huge university hospitals get compared with the small community/county hospital and here come the penalties. Most likely for each: the university hospital gets the train-wrecks and the AMI's so they get the saves with the CABG's and "approrpiate AMI care". And the small community hospital gets the "ding" for my 99-year-old gramma who doesn't WANT to go to the city--I want to have Dr. Jones take care of me--he KNOWS me! And so, gramma peacefully dies in the little hospital from her AMI and the hospital eats the cost because gramma didn't get cath'd or tPA'd, or got her LVEF measured before she died. BUT--gosh darn it, she got to die with dignity in her hometown! That doesn't count to the bean-counters..... I've been reading about these medical homes....not so sure that is the way to go either...it's a continuum of care that is being looked at now--home, hospital, nursing home, home. And we may soon get to split that precious reimbursement between us all. Keeping pts home with possibly outpt clinic care might work, but so many of those are now being headed up by NP's and PA's---so where do the docs get to practice???? Hospitalists---talk about NOT having a continuum of care! It MIGHT save some of those middle of the night calls---BUT gramma doesn't want to tell a perfect stranger all about her "past"....Dr. Jones KNOWs her! WHERE IS HE/SHE????? I think it is getting near where that ounce of prevention may end up costing as much as the pound of cure....but it's the way to go. Get the neighborhood gardens set up in the blighted areas, get those BP monitors in the barber/beauty shops and churches (how about seeing if the shop would let you come in once a week or twice a week to see people.....or in the church basement have monthly meetings to discuss medicines, life-style changes, etc? How about forcing the legislators to make drugs be available in generic form earlier and get pharma to quit charging just the US for all the R&D in what we pay for medications? I think William (or whoever said it in a different blog post of yours) has it right---we are all talking to the choir, and our only hope is that somehow someone can "thump some heads" and get this trainwreck stopped before it's too late! Thank you as always for letting me rant..... Author's disclosure (Mar 21, 2013) I am a clinical data analyst--core measure abstractor--for a small rural hospital. Daily I get to see how these new measures effect the pts, drs, and hospitals.
	# 6 of 20	March 21, 2013 09:06 (EDT)
	Melissa Walton-Shirley	Becky Good to hear from you. It's therapy indeed! William, it's getting more and more distasteful all the time, even more so if "power"and "money" are the focus rather than the result of good medical care in a community. That's where many are living now. Author's disclosure (Mar 16, 2013) I have no relevant disclosures to make in connection with this topic.
	# 7 of 20	March 22, 2013 10:56 (EDT)
	Jon Whitney	Not about health care--about medical cost containment! The problem is that, as Dr. Andrew Weil has now publicly stated, we don't have a health care system, we have a disease management system in the U. S. When the medical profession and those it treats wake up to what we are ingesting and what it does to our bodies, including beverages, food and pharmaceuticals, then we'll start on the road to health care! Author's disclosure (Mar 22, 2013) I have no relevant disclosures to make in connection with this topic.
	# 8 of 20	March 22, 2013 12:03 (EDT)
	william reichert	the plan... continued Last month my hospital was sited for not giving ASA to a patient with an MI . A huge penalty could be the result just like the example in the post about the early readmission for CHF. When we reviewed the case it was seen that the patient actually did not have an MI. However Medicare refused to debate this point despite hours of communication. Finally the lawyers have been called in. This game is serious and will turn out to be VERY EXPENSIVE. to play. The amount of money required to be COMPLIANT with the regs is certainly going to kill hospitals. This is the point. Medicine is " tooo expensive". The money is not there. The politicians do not have the courage or the power to cut out the expenses needed to bring the system back to fiscal. health. The plan is to drive providers out of business because they delivered an "inferior" product, not a too expensive one. In the end some hospitals in markets with many providers will be forced to close or radically reduce the scale of their mission. This will reduce costs. The government will be able to fill in the gap with a federally funded and managed facility if they choose to do so.This is the way the Feds will take over medicine. This scheme is an unfortuneatly necessary step to control costs. Some members of the public have been successfully conned into believing doctors.can and should be held accountable for the nations life style choices as the post above by Jon demonstrates. When the Feds take over it will be interesting to see what. steps they take to control life style choices. Maybe Bloomberg will become LIFE STYLE CZAR. Dont get me wrong A federally comtrolled system may work out well considering the need to control costs. Maybe it will be better for Harry Reid and his allies to decide proper " outcomes" and therefore the proper goals of the healthcare system. As Stalin demonstrated a truly centralized system can more quickly. and effectively enforce the changes the elite decide is needed. are res onsible itals ital Author's disclosure (Mar 20, 2013) I have no relevant disclosures to make in connection with this topic.
	# 9 of 20	March 22, 2013 12:26 (EDT)
	Molly Ciliberti	Why don't you call it by it's real name? Affordable Care Act Every time you call this good law Obama Care you are putting it down. That is a swipe at our president by Republican morons who would have the poor and the working poor go without medical care. It makes you sound like a tea party dimwit. This is an imperfect law but it helps millions of Americans get healthcare. As physicians (my husband is an Emergency Medicine physician and I am an ICU nurse) you should want to make sure everyone has healthcare. We need a healthy, intelligent, educated population to work and pay taxes so we all benefit from their good health. Author's disclosure (Mar 22, 2013) I have no relevant disclosures to make in connection with this topic.
	# 10 of 20	March 22, 2013 02:07 (EDT)
	Timothy Sullivan	Skin to win! I'm afraid things are going to get worse before they get better in healthcare. Health insurance has been financed by government and business for so long that people have come to look on it as a "right". Health insurance is the means by which people "finance" their future health expenditures. As with any insurance, the actuaries calculate the amount of money it should cost that average person (like the policy holder) spends on covered health care in a year, adds a markup to it, and bills a premium for the services. Currently, government mandates both Federal and State have added SO many contingencies to this calculation, that the cost of these additional services has risen steadily. Add to this the fact that Americans have become more sedentary and gluttonous to the equation and you'll naturally see premiums skyrocket! Because government (Medicare and Medicaid) and businesses pay the lions share of these premiums, the average person does not "feel the pain" of the actual costs of healthcare. For millions of Americans this will change in January 2014, when they are not only required to carry their own Health insurance policies, but some will be forced to pay for the entire premium by themselves after their employers drop coverage in favor of paying the penalty tax instead! The transition is going to cause a great deal of financial pain for a lot of people! Author's disclosure (Mar 22, 2013) I am a Wellness proponent who feels that America can solve the healthcare crisis with better attention to diet, exercise and habits rather than overly relying on the Medical profession and Government to solve it.
	# 11 of 20	March 22, 2013 02:54 (EDT)
	Kathleen Lynch	AMEN Molly! Molly, what a thoughtful and accurate assessment of the ACA. I could not have expressed my opinion any clearer! Here is the bottom line: Until we have a meaningful discussion about tort reform and change the U.S. healthcare model from one focused on diagnosis and treatment to one focused on PREVENTION, health care costs will continue to climb. Period. Author's disclosure (Mar 22, 2013) I have no relevant disclosures to make in connection with this topic.
	# 12 of 20	March 22, 2013 07:12 (EDT)
	william reichert	The big prevention myth I wish what you say about prevention were true Kathleen. Alas, it is not. More focus on prevention is not the answer to the high cost of medical care in the U,S. See: NEJM 2008 358 661-663. Author's disclosure (Mar 20, 2013) I have no relevant disclosures to make in connection with this topic.
	# 13 of 20	March 22, 2013 07:33 (EDT)
	Eric Tiblier	Man-up to a brave new world (1984?) Shirley, Great job reporting on the ACA, aka "Obamacare"; I can't agree with you more on your analysis. Between congressional reimbursement cuts over 10+ years (Republican and Democratic) and now the ACA, the federal government is allowing giant hospital-based systems to become the dominant force in the country. Now I don't believe the "black helicopters" are coming (Alex Jones)but the Feds are trying to kill private practice. I don't feel sorry for the "big East Coast" hospital losing millions of dollars in fines. As a solo cardiologist, I would be out of business in 90 days if I could not find a solution to a similar losing scenario. However, I am not too big to fail and my private practice would collapse. The East Coast hospital also gets tens of millions of dollars now that their employed cardiologists have been imaging all of their patients at their hospital with "facility fees" for the last 2 years producing huge profit margins for the "East Coast" hospital. So getting hit with the 2-3% penalties on hundreds of Millions $ of budget/revenue suggests they need to get their act together and fix 30 day readmission rates. Depending on their revenue, it may be a drop in the bucket. Maybe they should reduce the multi-million dollar salaries of the administrators if they don't know how to arrive at a solution. Or better yet, why don't the hospitals have doctors managing operations and solving readmission problems. That would be too much common sense ! Rock On Shirley! Author's disclosure (Mar 22, 2013) I have no relevant disclosures to make in connection with this topic.
	# 14 of 20	March 23, 2013 09:58 (EDT)
	Winston Smith	The Unaffordable Care Act Just keep focused on the complete lives theory of managing healthcare resources. No need to concentrate on that man behind the curtain! Author's disclosure (Mar 23, 2013) I have no relevant disclosures to make in connection with this topic.
	# 15 of 20	March 24, 2013 02:32 (EDT)
	Cat Santori	Random thoughts Well one of the things you can do is admit people under observation status. The insurance could increase liability requiring additionan charges to be rendered by the people who smoke or do not get their medications refilled. We could subsidize the farmers who grow fruits and vegetables making healthy choices the most affordable. I like the idea of making health education holistic, I did not know that had changed. Offering healthy choices including fruits, vegetables, and water in vending machines at schools is another thing that is happening. Healthcare should be available to everyone. Still, if people refuse to take life preserving medication or smoke, should they remain our continued responsibility? It may be cruel yet their hospital admissions are using up money one of us may need in the future. Like Shirley's idea to slash administration. Administration cuts caregivers to save money and expect perfection from understaffed units. Perhaps they are the ones who need to work understaffed and meet their own expectations since they are so highly paid and well educated it should not be a problem for them to meet expectations. Patients are becoming so in charge of their own care because we have to keep them satisfied. They are not agreeing to follow the evidence based practice recommendations. They have their own plans. If we disagree they are dissatisfied and when things don't work out well because they are forming their own plan of care without listening to reason? They are dissatisfied. Health care is increasingly frustrating. Still, people are living longer and better with scientific evidence. Author's disclosure (Mar 24, 2013) I have no relevant disclosures to make in connection with this topic.
	# 16 of 20	March 24, 2013 03:34 (EDT)
	Melissa Walton-Shirley	Molly I attended a session at the ACC entitled "OBAMACARE-does it matter to me?". That's where I took the title from. Author's disclosure (Mar 16, 2013) I have no relevant disclosures to make in connection with this topic.
	# 17 of 20	March 25, 2013 11:41 (EDT)
	Paul Wilson	If I remember correctly In the not to distant past this column was used for a vigorous defense of obamacare. At the time a number of posters spoke in a "careful what you ask for you just might get it" vein. So now you (and the rest of us, except of course, for select politicians)are getting the first peek into this burgeoning disaster. And a peek it is. The full understanding of this mess has yet to be revealed and I expect as we go forward the howls and wails will grow most strongly from the former and future former supporters as they are progressively hoisted on their own petards. Author's disclosure (Mar 25, 2013) I have no relevant disclosures to make in connection with this topic.
	# 18 of 20	March 25, 2013 04:50 (EDT)
	Molly Ciliberti	time to be in the health "business" We need to stop being in the healthcare business and change the focus on keeping people healthy through good prenatal care, well baby care, good pediatric care and immunization, mental health care and preventative medicine throughout life. We keep playing catch-up and we are losing. Pay physicians for providing preventative medicine including those needed discussions on all aspects of health (mental health is included) and not on doing procedures or interventions. When we get to that point where we need procedures and interventions, we have "failed" in our mission to keep people healthy. We can’t totally prevent accidents and illness, but we can do a hell of a lot better. We need to better educate our population on how to take better care of themselves and to take responsibility for their own health. Time to get the lawyers out of it, unless there is real malpractice and give them $350 or a set fee and not this 1/3 of the settlement (and we are surprised when they sue for enormous sums.) But we must not penalize someone for being poor or the working poor (without benefits) or for being mentally ill or for having a pre-existing condition (a condition totally made up by health insurance companies whose only real job seems to be managing your money into their pockets) and provide healthcare to all, single payer as part of our taxes. Time to step up and get smart. If we have a healthy educated population that can be productive and pay taxes we all benefit. How can anyone be against that? Author's disclosure (Mar 22, 2013) I have no relevant disclosures to make in connection with this topic.
	# 19 of 20	March 25, 2013 09:37 (EDT)
	Melissa Walton-Shirley	Paul I'm just covering OC,the good, the bad and the ugly. The entire piece was in the context of information presented by five speakers who covered different aspects of it in a scheduled conference at the ACC. I still defend the good, bemoan the bad and rail against the ugly! Author's disclosure (Mar 16, 2013) I have no relevant disclosures to make in connection with this topic.
	# 20 of 20	March 28, 2013 12:16 (EDT)
	becky christianson	Molli, Please don't call people 'morons' and 'dimwits'. That is demeaning and disrespectful. There's room for disagreements here; we've had them before, and will have them again. Your second post here has many of the suggestions we all had together many years here. Prevention indeed is the way to go, education of all people to better care for themselves and their families, and insisting on adults taking responsibility for their action or inaction. Unfortunately, it seems that in in the last 35 years of medical/nursing care, it has all been disease driven. Healthcare was an art/scienc, not a business. It is now a business. It is not the actual health care that is "bad" it's the cost. HIPAA initially was about "HEALTH INSURANCE PORTABILITY" not 'privacy", and it was said that you could take the insurance you wanted from job to job.....that never materialized. Now we have this behemoth act that is radiclly changing the way healthcare is given and paid for----why should I carry my adult children on my insurance until they are 26 years old? And their children? This went from a 2300+ page document passed throughthe legilature late at night with no one getting the chance to read it. It is now over 20,000 pages long and is being written by unelected government employees! just how affordable is that? If I owned a business, I would probably elect to pay the fine, since paying that fine (so far) is MUCH cheaper than forking out the thousands of dollars of premiums for my employees. And how about all those waivers??? I really truly wish that the prevention/education portion would just take off and become reality. And THEN get the malpractice suits under control----I love your idea of giving the lawyers a set fee, but I think $350 is too much! (my sister's a lawyer, so I just gave her a salary decrease!!) It's all about power....the legislature and the insurance companies and AARP and the like are all vying for power and we are pawns in this, both as providers and consumers. The revealing is not going to be pretty. Author's disclosure (Mar 21, 2013) I am a clinical data analyst--core measure abstractor--for a small rural hospital. Daily I get to see how these new measures effect the pts, drs, and hospitals.

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