George A. Sprecace M.D.,
J.D., F.A.C.P. and Allergy Associates of New
Health Law Topics
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Response for SUNDAY, April 6,
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Response for TUESDAY, February 18,
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Response for SUNDAY, October 5 and 6, 2012
PERSONAL SUMMARY, THE L&M
LEADERSHIP RETREAT, OCT. 2012
The following are based upon the speaker's presentation, my
contemporaneous comments, a review of his slides and my
comments are presented in italics.
- "Transition away from episodic
fee-for-service reimbursment and toward accountable forms of risk-based
payment, involving case managers or population
managers". Risk-Based is based
upon perverse incentives and conflict
of interest between "Providers" and patients...inherently
Unethical. Case and population managing can be performed now with
patient and provider incentives and dis-incentives.
Competition". I've been doing that for 55
- 1% withhold starting now,
based upon a) 70% Process Measures...Good,
based upon hard research; and 2)
30% based on patient surveys...overweighted, soft and
subject to manipulation.
- Penalty for re-admission
rates: progressively 1-3%, even re-admissions for totally different
diagnoses from the original admission...CRAZY.
- All about Cost
Containment. For example, L&M estimates that it must reduce
its costs by $35 Million over the next 5 years. At what cost in
quality and in availablitry of care? A cynical
and cowardly effort by our national "leaders"
to force the Medical Profession into being Rationers of Care - a worthy
principle that should be decided broadly by the public and by public
policy. It is done by placing MD incentives opposite to patient
needs: Unethical, undermining a learned Profession and thus
against Public Policy. This must be litigated right up to the
- "Hospital and MD Allignment is
Critical". YOU BET!! Hospitals had better
take care of their physicians, especially now when
they could "stick it to them" in the short-term. We are in a 5-8
year Transition period, full of uncertainties, with MD's in a weak
bargaining position. Then will follow a long period of MD
ascendency...based entirely on MD shortages and population
demographics. A word to the wise.
- How to reduce patient and
provider utilization? We need patient
motivation: passive in the form of HSA's and
increased self-payment; and in the form of active penalties for
continuing to pursue unhealthy life-styles. And we need to reduce
the 20-25% of health care costs that physicians produce because of
DEFENSIVE MEDICINE in the current litigious malpractice climate.
Madical Mal-practice reform is crucial, changing perhaps to Health
- "What are the main market
movers? And what do they want?" Of the
payors, Employers should get out of the business,
certainly abandoning "Defined Benefit" for "Defined Contribution"
plans, with prominent patient-employee contribution. Insurers
will survive and thrive as Wall Street does: by expanding into markets
that approximate Las Vegas activities. And what about physicians?
They want to provide quality care with adequate reimbuserment and
little hassle. Patients have long wish lists - as long as someone
else pays for them, and as long as they don't have to change their
ways. Enough of That!
- Currently great
uncertainty. Great expansion of Medicaid, with little concept of
who will pay for it, Changes in Medicare. The Election: a
referendum on "Entitlement" spending. A very difficult pending
budget debate right after the Election. And there will be no
clear winner, resulting in the losers being enraged - more
grid-lock. All the more reason for
"deciders" in the Heath Care Industry to base their
current decisions not only on the transition period of the next few
years, but especially on the subsequent decades - a different paradigm.
- This is a Penalty program, not
a Reward program. The deck is marked.
- Physicians programs, willingly
assisted now by venture capitalists, may be better than Hospital /
Physician programs. PHYSICIANS: YOU ARE
PLAYERS, NOT VICTIMS,,,if you don't "sell your soul
to the company sto" during this Transition period.
- In some programs, consumers
(patients) are being Paid to pick the lowest cost providers! "Caveat
Emptor"...and don't expect medical malpractice lawyers to get you out
of this one. Your Choice got you in trouble.
- Coordination of Health Care is
the vital missiong link in this scenario. This
can be done by "any willing provider"...primary care
or specialist...with proper financial support. It should also be
provided by Home Care (both transitional and permanent), by
para-professionals (physician extenders, very valuable), by sharing
resources and expenses through smart alignments, and by providing
perceived quality and convenience to patients. Regarding the last
point, every in-patient in a hospital needs an advocate / ombudsman to
negotiate the day-to-day uncertainties of the hospital experience and
- Finally, this "Crisis" is truly
one comprising both danger and opportunity, This hospital should
carfefully nurture its rerlationship with its Medical Staff, providing
a true "Win-Win" situation...short-term and long-term. And it
should continue to develop itself as "sui generis" in this locale and
region...and not try to follow the methods of larger, distant and
different areas, which will likely be totally inappropriate to our
needs and opportunities.
I have been speaking and writing on this subject - Health
Delivery - since the mid- 1970s. Several of these
available on this website (www.asthma-drsprecace.com). And any one of
be re-published with very little change at this time. So:
"Now is the time for all good men to come to the aid of
George A. Sprecace, M.D., J.D.
October 7, 2012
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CARE REFORM: A PRIMER
As a practicing physician for 55 years, and as
attorney practicing and studying Health Care Law for the last 28 years,
been writing and publishing on this subject for decades.
of this production is available on relevant sections of my web
In fact, an early publication, dating back to
be re-published with only minor revision…reflecting how little progress
society has made in addressing the real issues of Health Care Reform.
The “Accountable Care Act” (aka ACA and
ObamaCare) is a
Christmas Tree of “wants” that gives short shrift to the real needs
health care reform. As such, that ode to
political expediency needs to be repealed and replaced.
“With what”, you say.
Alright: ONCE MORE, WITH FEELING.
- Nearly half of health care
expenditures in this country are directly life-style related:
obesity, tobacco use, alcohol abuse, illicit drug use, irresponsible
motor vehicle practices, the governmental support of unhealthy personal
practices like abortion, children out of wed-lock, defending failed
schooling, etc. These practices should be
heavily taxed and otherwise discouraged instead of being supported as
- A large percentage of health
care costs incurred by individuals and by society occur during the last
6 months of a person’s life. This,
while a strong majority of adults support Advanced Directives…and a
small minority of them actually have such “personal choice”
instructions to guide their loved ones and their physicians. Furthermore, physicians should recognize that
they have an ethical obligation to refrain from offering “futile care”.
- At least 20% of health care
costs represent “Defensive Medicine”, defined as actions taken by
health care providers predominantly to protect themselves from
allegations of “medical mal-practice” adjudicated in a lucrative and
unnecessarily adversarial system. The
current practices should be replaced by Health Care Courts similar to
Patent Courts and Bankruptcy Courts. Only
in that way can Justice be achieved and defensive medicine minimized.
- The great need in the existing
system of health care delivery is Coordination of Care among the
increasing number of medical specialists and other health care
providers involved in much if not most of current patient care. Such services are time-consuming and require a
broad - based knowledge of Medicine to be effective.
They can be provided by any one of a patient’s physicians
who is willing and who has the necessary level of insight and expertise. And they must be paid for adequately!
- There must be established and
enforced – by society as a whole and not by the Medical Profession – a
system of Prioritization (Rationing!) -
among the many services and potential recipients of those services. Coverage of cosmetic surgery and of Viagra
does not rise to the level in importance of immunizations.
Right now, cynical efforts are being made to force
physicians to make such decisions through unethical mechanisms such as
“accountable care organizations” which place a physician’s
self-interest in direct opposition to the interests of his or her
- Payment for all medical care,
subject to clearly defined exceptions for indigence and serious medical
necessity, should require at a 20% co-pay by the patient. The patient must be a serious first
decision-maker in his quest for medical care. For,
once a patient enters a physician’s office, the cost is generated and
the service is provided. The physician
cannot and will not be the arbiter of the “need” for the care requested
– or demanded.
A comment about the much-discussed “Electronic
Records”. These have been given a
very high priority and much pressure by our “leaders”…not because they
important, but because they are the easiest of the above issues to
address. Easiest, but not in-expensive
and definitely disruptive of the vital eye-to-eye physician / patient
physician / physician relationships on which all good medical care
so, what is the prognosis of the
above 6 vital areas of reform being addressed and implemented any time
soon? Poor to Grim.
Meanwhile, actions in the direction of
ObamaCare and of “Universal Health Care” will produce the opposite of
goals: lower quality, higher cost, and reduced access.
Folks, it’s your choice…and your life
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ON THE RECENT BOARD RETREAT
- 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
- 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
WE CAN DO ALL THIS !
George A. Sprecace, M.D./, J.D.
November 1, 2011
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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
54 years experience...and counting.
Are you ready for this?
famous the phrase " Ah feel yo pain". Physicians have been
trying to shield their patients from the pain of the last 25 year of
"health care reform", with poor results. It is time for
patients and the public to feel their own pain in order finally to
motivated toward their own self-help and against the often craven and
self-serving actions of their elected leaders. The alternative,
course we have already begun with "ObamaCare", is lower quality, less
access, and higher cost.
- 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
- 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
- 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
- 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
- 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
- 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.
The choice is yours, folks.
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IF HE ADDS
MEANINGFUL MEDICAL MALPRACTICE TORT REFORM - RESPONSIBLE FOR 25% OF ALL
CARE EXPENDITURES - TO THE PLAN, PAUL RYAN GETS A BIG SLOPPY KISS FROM
See also my writings going back to the mid 1970's.
Ryan's strong antidote to Obama health care
10/05/2011 12:00 AM
10/04/2011 11:40 PM
say they want to "repeal and replace" the health care law President
Barack Obama signed last year, but they are a lot more specific about
the first half than the second. Rep. Paul Ryan wants to bring some
balance to the slogan.
Sept. 27 speech to the Hoover Institution at Stanford University, the
Republican chairman of the House Budget Committee supplied an Obamacare
alternative of his own. Ryan has the right diagnosis of what's wrong
with federal health care policy, and the right prescription, too. He
just needs to adjust the dosage.
in large part to Ryan's efforts, congressional Republicans have already
embraced two of the ideas in his speech. They want the federal
government to give states a fixed amount of money to run Medicaid,
instead of paying for half of whatever the states decide to cover for
the poor. And they want to replace Medicare with "premium support" for
future senior citizens, who would purchase private insurance using
capped federal subsidies.
Republicans have had less to say about the uninsured, or the majority
of Americans who are eligible for neither Medicaid nor Medicare. They
have advocated tort reform and the creation of an interstate market for
the purchase of individual insurance, both of which might make coverage
a little bit more affordable. But as Ryan acknowledges, that's not
believes that we should change the way the tax code treats health
insurance. Employer-provided coverage is not taxed on par with wages,
and thus the federal government encourages companies to offer coverage
rather than provide higher wages and let employees buy coverage. The
more expensive the coverage, the more the tax break is worth. The
fundamental flaw of Obamacare, as Ryan sees it, is that it leaves the
inflationary incentives of current policy in place.
Ryan's proposal, the tax break would become a credit available equally
to those who get coverage from their employers and those who buy it
themselves. Anyone who wanted to buy coverage that costs more than the
credit would have to pay the difference themselves. The expectation is
that people would buy less expensive coverage and more often pay for
routine expenses out-of-pocket. The new cost pressures thus created
would, together with competition, drive prices down.
would have more control because they would be more likely to own their
insurance policies rather than rely on their employers. Over time, the
problem of people who can't get insurance because of pre-existing
conditions would diminish, because people would have to change
insurance less often. "This is the 21st century," Ryan tells me.
"People do not have the same jobs for their entire careers. The tax
benefit should be attached to the worker, not to the job."
John McCain, an Arizona Republican, made a similar proposal during the
2008 campaign, and the Obama campaign attacked it relentlessly as a new
tax on employer-provided coverage. (Within two years, Obama had enacted
his own new tax on employer-provided coverage as part of his
health-care overhaul.) The McCain experience does not faze Ryan. "He
did a very, very poor job of defending the idea," he says. "This is not
taking away a tax benefit, it is improving a tax benefit for people."
People making low incomes, he points out, would get a larger tax
benefit under his proposal than they do now.
to explain his colleagues' reluctance to embrace this reform, Ryan
says, "I think people are just politically risk averse. As you know, I
am just more of a policy risk-taker."
may be that voters, too, are more risk averse than Ryan.
have repeatedly demonstrated a preference for the health-insurance
arrangements they have today, faults included, over politicians'
visions of some better system. That was one of the major political
obstacles to Obama's health legislation - and the reason he kept
insisting that it would allow everyone who liked their existing
coverage to keep it.
colleagues have shied away from his reform because they fear the
voters' fear - especially because they already think they took enough
risks on Medicare. Modifying his plan may be a prerequisite for getting
Republicans on board as well as the public.
important caveat aside, however, Ryan is on the right track. A credible
conservative alternative to Obamacare has to involve changing the tax
code. And without a credible alternative, Republicans won't be able to
repeal it, let alone replace it.
Ponnuru is a Bloomberg View columnist and a senior editor at National
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HEALTH CARE REFORM – A
- Many articles in recent months in
NEJM, JAMA, WSJ
- “The New Value On Provider
“Value”, Treatise by Alice Gosfield in Health Law Handbook, 2011
- “What Paul Ryan’s Critics
Don’t Know About Health Economics”, by Alain Enthoven, WSJ June 3,
- “Reforming Medicare – Toward A
Modified Ryan Plan”, by Gail R. Wilensky, Ph.D., NEJM May 19, 2011
- Articles by GS, recently posted
and also written and published since the 1970’s (www.asthma-drsprecace.com)
to Tom Blum, GS
Musings – gleaned from Readings, 2010 and 2011, GS
Health Care Future, GS
and Consequences, GS
Wanna Fix Health Care? Stop Hiding The Cost!,
W. Jenkins Jr. (WSJ Oct. 13, 2004, Opinion, pA17).
also my articles written in 1978 and
in 1998. It's "de ja vu" all over
or rather...unchanged. Quick advice: No health
Get thee to an HSA.
More on Medical
More Relevant Offerings:
"Why Not A Smallpox Choice", the
Wall Street Journal, Tues. Oct 29, 2002, Opinion, A22.
"Getting Uncle Sam To Cover Your Massage", the
Wall Street Journal, Tues, Nov 5, 2002, JKPersonal Journal, Sec. D1.
"War, Modern Dilemmas Shape Court's New Term", USA
Today, Friday, Oct. 4, 2002, 4A.
"Rationing Health Care: Does it work?" The
Pharos, Summer 2002, pp. 13-19
Medical Savings Accounts:
An idea so good for patients and for health care delivery that it has
kept under wraps by the Health Insurance Industry for fifteen years, as
long as I have been espousing it.
Gives its OK for Consumer-Directed Health Care Plans", AMA News,
29, 2002, Government and Medicine', p. 5, 7
"Health Plan That Puts Employees in Charge of
Catches On," the Wall Street
Journal, January 8, 2002, Section B
See also, "Managed
See also, "Greedy
Lawyers Driving Doctors Out of Business", The Day, August 10, 2002,
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