Monday, November 5, 2018

Book--Healthcare Financing

Posted by Stephen Weinberg, MD FACC FACP

There is a strong, renewed interest in a single payer system or "Medicare for All" as it has become known. I began to think about this subject in 2004 and after 3 years of research and writing, I completed my book "U.S. Healthcare on Life Support". It is 128 pages of heavily annotated research into the field of healthcare financing that is easy to read and comprehend.
The book details the entire healthcare delivery system and provides incites into how the system can be transformed financially, provide excellent healthcare for all, and save a significant amount of money for the entire country. Though the numbers in the book are from 2007, the information in the blogs has updated the numbers to the present.
The book can be purchased through Amazon:  U.S. Healthcare on Life Support
Below, you can find the Table of Contents and the Forward written by Professor Burns from The Wharton Graduate MBA Program.

Tuesday, March 27, 2018

Another look at a "single payer" system (Part 1)

Posted by Stephen Weinberg, MD FACC FACP

Let’s take another look at a single payer system. 
I have had numerous recent conversations with people regarding a single payer model. In an effort to bring additional clarity to the discussion and cut through the complicated math from the previous post, this post will attempt to simplify the issue.
As soon as one brings up the concept of a single payer health system, there is a great deal of pushback. The arguments include predominantly that this is socialism, the government cannot run any program of that size efficiently, it controls too much of the country’s economy, and the government cannot be trusted to do what is in the best interests of patients and will use this opportunity to ration healthcare similar to Canada and  the United Kingdom.  All of these ascertains may be true in theory, but it seems that, in reality, this is likely not the case.
From a very practical standpoint, Medicare is the largest single payer system in this country. Having been enacted in 1965, it has grown to cover about 55M people, or 1/6 of our population. I have practiced Cardiology since 1978 and I cannot recall a single patient who does not like Medicare. On the contrary, there is not a day that has gone by when a patient did not complain about their private health insurance carrier. These complaints range from lack of coverage, the need for referrals, inability to obtain necessary testing and treatments, rapidly escalating premiums, among others. I never hear that from Medicare patients.
Medicare is efficiently managed with an overhead of about 1.5% compared to private insurance overhead of about 15-20%. A huge difference.
The argument that the government would control a large part of the country’s economy cannot be denied. The US healthcare sector is about 1/6 of the total economy. Legislative controls and oversight could be applied similar to what exists now, which is controlling Medicare effectively; as compared to private insurers with premium increases of 20-30%, higher deductibles, higher copays and less coverage.
The argument that the government cannot be trusted to do what is in the patients’ best interests is also false. Once again, Medicare has always provided comprehensive care coverage since inception, unlike private health care insurance, as virtually anyone will attest who has private coverage.
The issue of rationing care is likewise untrue. This has never been the case with Medicare, as opposed to Canada and Great Britain. The difference between us and them is that the other countries have a fixed, capped budget for healthcare expenses so once the money runs out, care stops. This leads to long waiting periods for testing and care, as well as rationing. This is one of the mechanisms by which they can control costs. In the US, by contrast, there is no budgetary cap. The expenses are open-ended, so care is not rationed. Furthermore, the discussions regarding “death panels” that occurred when Obamacare was being legislated were totally false and were used only as scare tactics by opponents.
So, the arguments against a single payer are without merit. Since Medicare has been successful and extremely well accepted by senior citizens as well as the vast majority of the population, why not provide everyone with the same insurance coverage? As shown in the prior post, we are already spending more than enough money to insure everyone with comprehensive coverage and still save $260B annually
The next post will detail how to provide "Medicare for all".
Stay tuned.

Tuesday, February 6, 2018

The Case for a Single Payer System

Posted by Stephen Weinberg, MD FACC FACP

In an effort to discuss the healthcare system and options to finance it, this post will detail the costs associated with the delivery of care.
Each year the government publishes several large databases that detail the expenditures and revenues of the entire country. The data I will provide is for 2013, the year prior to the inception of “Obamacare” in an effort to simplify the analysis. The numbers are drawn directly from the databases. National Health Expenditure Accounts

# people
 in millions
Total personal HC costs
Govt Admin (Medicare and Medicaid) expenses
Private Health Insurance Admin expenses
Govt Public Health

Personal Care costs Net of Expenses

Out of Pocket



Private Health Insurance

Other Indian, workers comp, etc



This chart shows total personal healthcare costs were about $2.7 Trillion with overhead of about $286B leaving net personal healthcare costs (the amount actually spent on care) of about $2.4Trillion.
Medicare overhead was about 1.5% of total expenditures (from the Medicare Trustee Report) or $160/person. As you can see, private insurance overhead was about $1,055/person, or approximately 6.6 times that of Medicare. (Remember the prior post regarding the excess costs of private insurers.) If private insurance overhead was the same as Medicare, the total private insurance overhead would be $160x165M people or $26.4B instead of $174B. The savings would be about $148B annually. Additionally, several studies, (Insurance driven overheadNEJM insurance overhead) have demonstrated that the excess overhead of hospitals, physicians offices, nursing homes, employers, clinical labs, and home care was about $172B in order to deal with the numerous private insurance companies. The total annual cost of excess overhead of our multipayer system was about $320B in 2013.
The real question is “what are we getting for this additional cost?” I would argue, nothing!

There is also a substantial amount of money being spent by individual states and the federal government in order to provide care for the uninsured, as outlined below.  (Also from 2013)

# people
Charity care from states, indigent clinics

Federal Govt

Other public money

Increased private insurance premiums*

Total Admin savings from 1.5% overhead

Total money available

*A study by Families USA demonstrated that private insurance premiums are increased by about $400/person per year as a result of providers (predominantly hospitals) obtaining higher reimbursements to offset the losses from Medicare, Medicaid, and the uninsured. Families USA, Hidden Tax

The cost to provide private insurance to all 45M uninsured (including children) was about $188B annually using the private insurance cost numbers from above. As you can see, there is about $449B available and currently being spent. If everyone had health insurance with a single payer at the current overhead of Medicare (1.5%), we would save about $449-$188 = $260B annually and everyone would have comprehensive health insurance
Seems like a good deal to me!
More to come.

Monday, December 18, 2017

The Upcoming Healthcare Debate: Universal and Single Payer, Get Ready

Posted by Stephen Weinberg, MD FACC FACP
With the changing political landscape in Washington and the dismantling of the Affordable Care Act (Obamacare, ACA), it is becoming clear that a significant portion of the population will again be without affordable, comprehensive healthcare. This will likely spark a serious national debate as to what steps should be taken to resolve this situation.
There are many ways to think about this, but I believe it is important to decide at the outset whether you believe comprehensive healthcare is a right or a privilege.
 If you believe it is a right, with altruism as your guide, then we need to determine what services should be included and how to pay it. If you believe it is a privilege, then the marketplace should decide what coverage you purchase and how much you will pay for it. It is important to note that the US is only 1 of 5 countries in the world that has not ratified the UN 1966 Covenant of Social and Cultural Rights which stipulates that each country will provide for “The creation of conditions which would assure all medical service and medical attention in the event of sickness”. We are in the company of Cuba and 3 other third world countries. Additionally, the lack of comprehensive healthcare is the third leading cause of death in the US in the age group 50-64, behind heart disease and cancer.
If you believe healthcare is a privilege, then you should consider your own self interest as a driving force regarding your decision as to how to proceed. If it can be shown that it is less costly to provide universal comprehensive care, then you should support it. I will address this issue in detail in future posts.
There is a difference between “universal” healthcare and a “single payer” system. “Universal” means that all the people in your society are covered with comprehensive healthcare. The mechanism of paying for it can be with private health insurance, a public/governmental plan, or a combination. All industrialized countries in the world provide for “universal” coverage of their citizens. The payment mechanisms vary, as noted above, from country to country. The benefit of “universal” coverage is that you have a large risk pool so you can spread the costs over more people making it less costly for everyone.
This “universal” coverage doctrine is very different from a “single payer” system.
A “single payer” system means that all costs are paid for by one entity, typically the government, except for a small amount of self pay for copays and deductibles. Bear in mind that a “single payer” system could allow for payment of certain healthcare expenses in addition to the basics covered by the system. An example would be costs for elective cosmetic surgery not related to an illness or injury. The benefit of a “single payer” is lowered overhead in that you would not have duplication of resources of each payer which would include the buildings, computers, marketing, management and their salaries, lawyers, accountants, actuaries, shareholder profits, and the corporate jet. Additionally, another benefit is that there would be one set or rules that providers (physicians, hospitals, home care nursing, etc.) would have to follow making it less costly and more easily managed.
It is important, therefore, to not confuse the terms “universal” and “single payer”.
In future posts, I will discuss in detail the costs associated with our current system and compare them to those of a “universal” system and a “single payer”. In an effort to participate in what I believe will be the upcoming national discussions regarding healthcare, you need to have the information necessary to speak with authority and I will provide it. I believe you will be surprised about the actual costs and what can be accomplished with the current amount we are spending on healthcare.

Further information will be forthcoming very shortly. Stay tuned.

Wednesday, May 7, 2014

Fee for Service Medicine is going to disappear

Posted by Stephen Weinberg, MD FACC FACP

Fee for service medicine may be a thing of the past, relatively soon.

The President and Congress have stated on multiple occasions that they believe fee for service medicine is the principle cause of the high cost of medical care. The theory is that physicians often order tests that are sometimes unnecessary in order to increase their income. Unfortunately, it is difficult if not impossible to be certain that these tests are, in fact, inappropriate. Studies that have tried to determine the usefulness tests ordered by physicians look at tests that were performed relative to the final diagnosis. However, the tests were performed in order to make the diagnosis. It is not surprising that some of the tests were not directly related to the final diagnosis, since the final diagnosis was unknown at the outset. Admittedly, a small percentage of physicians probably churn testing to enhance their incomes. On the other hand, the vast majority of physicians practice appropriate medicine and order tests they believe are necessary and follow appropriate guidelines.

So what does Washington propose to take the place of the current system? The programs being put in place are related to the Accountable Care Act (Obamacare). Physicians will be placed into Accountable Care Organizations (ACO's) which will pay them salaries based upon the financial performance of the organization. Simply put, if the ACO makes money, physician income will increase; and if the ACO loses money, physicians will earn less. My fundamental concern with this system is that there is a perverse incentive to do less for patients because of the very real financial "vice" physicians will be put into. I believe it is important that the patient has confidence in the physician doing what is best for the patient and not the physician. This new system will damage the physician-patient relationship and create uncertainty about whose interest the physician is truly serving.

Additionally, there is no good data to suggest that this type of system will be effective. Medicare has done several demonstration projects over the past 20 years in a effort to show that costs will decrease and quality will be enhanced in a non fee for service system where physicians and hospitals are at risk. These studies have not shown any significant benefit as reported by the Congressional Budget Office. Despite this failure, Medicare has now licensed more than 200 ACO's and more will be coming to a region near you. As pointed out in a prior post, the ACO is supposed to provide a letter to each patient indicating that they and their physician are in the ACO, but the letters do not point out the financial implications. It is one thing to be in the ACO with full disclosure and quite another to not know all the intricacies.

What is interesting is that none of the major medical centers that have had this staff model for years (Mayo, Cleveland, Geisinger, and others) has joined the ACO programs. One could argue that some of the motivation of groups to form these ACO's is that the handwriting is on the wall as to the direction of the government programs, there is perhaps money to be made, and the organizers can control large regional resources of physicians, hospitals and money, so why not do it. This does not seem to be an appropriate motivation.

So what is an alternative?
The easiest way to promote appropriate use is to have the physician office computers ramped up with some artificial intelligence to point out what is the best testing for the patient's symptoms and problems. This would not be very difficult with overlay software packages that can provide appropriate use criteria in real time. There would always be the ability to override the recommendations with good reasons. The problem is that by not planning ahead when practice computers were mandated by the government, there are so many platforms now that it would be a more difficult task, but not impossible. This is just another example of poor planning by Washington. They jump from one issue to another without long term thought as to the best approach. Instead of trying things out in a regional laboratory, they move ahead with draconian programs that can destroy the healthcare system. And when they try programs that do not work, as above, they embark on them anyway.

The current programs of healthcare delivery set forth in the Accountable Care Act are like throwing the baby out with the bath water. We will develop a system that few will like or trust with uncertain results.

The easiest way to control costs is to set a fixed annual budget for healthcare nationally and regionally and then you will have certainty as to cost. I do not think any consumer of healthcare wants this alternative; but, believe it or not, this proposition is also part of the ACA with ACO's taking the lead. By doing this you will have Canadian and European healthcare with all the problems associated with it. More about this in a later post.  

It is important that we all have knowledge about what is coming down the road with the ACA and speak out against policies that will be detrimental to our collective health.

Thursday, April 17, 2014

Less Money for your Care!!

Posted by Stephen Weinberg, MD FACC FACP
In October, 2012, Medicare established a program to reduce the frequency of hospital readmissions that occur within 30 days of discharge for 3 illnesses. Hospitals are being financially penalized for readmissions that are more than the predicted by Medicare. 2225 hospitals will be penalized a total of $227M this year. Since this money will  come out of their operating budgets, less money will be available for patient care, your care.
Hospitals caring for the poor were more likely to be penalized than those that did not. 77% of indigent hospitals vs. 36% of non-indigent hospitals are having money withheld. Medicare does not take into account the socioeconomic profile of hospitals. 87% of academic teaching hospitals, which care for a disproportionate number of indigent patients, are being fined. These reductions are in addition to the fact that the hospitals do not get paid for that readmission as well. These institutions typically provide sophisticated  tertiary care services to a large segment of the population and can ill afford reduced reimbursements.
These reductions are in addition to the increased expenditures for social workers, discharge nurses and more intense post hospital care paid for by these hospitals. It should also be noted that the government penalizes hospitals for keeping patients in the hospital longer than predicted. Premature discharge contributes to re-hospitalizations. So if you keep patients too long, you get penalized. If you discharge them prematurely, they have a higher chance of readmission. Seems like perfection is the only answer.
Whose fault is it if the patient cannot afford medications (hospitals often provide drugs for several days at home), appropriate dietary components such as a low salt diet for congestive heart failure, unable to truly understand what it takes to stay well despite extensive written and verbal instructions? Many patients just do not care or cannot comprehend the complexities of their own care.
The % hold back (2% now) will be increasing over the next couple of years and additional diagnoses will be added to the list of readmission penalties.
What is important to know is that the government is withholding significant money from many hospitals. This reduced reimbursement will impact your care!

Monday, April 7, 2014

"I have Medicare" or "I have good private insurance, so what do I care about the upcoming changes with Obamacare" Well, think again . . .

Posted by Stephen Weinberg, MD FACC FACP
The Accountable Care Act, better known as Obamacare, has, as part of the program, the imposition of Accountable Care Organizations. These are relatively large organizations comprised of hospitals, physicians and in some instances insurance companies. The goal is to provide a better coordinated healthcare delivery experience for the patient. The end result is to improve the quality of care and reduce costs. I outlined some of the issues in a prior post.
That's the easy part. The more difficult issues involve who's working for who.

First, when your primary care physician joins an ACO, you will likely receive a letter from the parent organization introducing itself and that your physician is part of it. An example is this letter from Partners Healthcare in Boston.
What is important to note is that you need to "opt-out" if you so desire. You will otherwise be part of the ACO if you do nothing!

Second, the type of ACO matters as to how your care may be provided. Briefly, ACO's are being designed with various levels of financial risk. Some will have upside risk, meaning bonuses will be paid for reducing costs and maintaining certain quality standards. The other large type is both upside and downside risk where the organization may lose money if costs are in excess of revenues. These losses will filter down to physicians as well as the hospitals. So how might this affect you? Savings can occur by reducing costs through standardizing hospital purchases of equipment, drugs and disposables; standardizing protocols of care; better sharing of information; and coordination of the various aspects of care. Other cost saving measures consist of reducing readmissions to the hospital, reducing the use of expensive testing and therapies (MRI, CAT scans, cardiac cath, PET scans, surgeries, pacemakers, defibrillators, etc.). These are all laudable goals except if they produce harm to patients. Quality indicators are being designed to determine if care is substandard. Unfortunately, these measures are very imprecise indicators and on an individual basis, they are not very helpful. As a patient, you may be injured as a result of withholding care. The financial incentives may be too great to allow for protection of individual patients. It may be that the quest for cost savings may lead to harm of some individual patients. I believe this highly likely. When I was writing my book on healthcare financing several years ago, I performed a non-scientific survey of many of my patients to see if they would accept somewhat less care if the cost savings benefited the country as a whole. Not one patent was willing to accept any change in care! They all wanted to know that their physician had their welfare as the only issue. I feel the same way and as a physician, I do not want an incentive program to influence my decisions regarding care. The pressure to withhold testing and therapy could be so great that patients may suffer, individually. Putting in place purchasing and protocols makes sense, but incentives that may withhold care are dangerous.

So what are the messages that you need to understand?
You may be in an ACO and do not know it.
Your care may be influenced by the policies of the ACO and you may not know it.

At the very least, it is important to provide full disclosure to all patients regarding the parameters of the ACO they are enrolled in. The government should mandate this. The Partners letter is incomplete and needs further details about the positive and negative incentives of the program. With this information, you can then have a conversation with your physician decide what you want to do. If you do not think the ACO policies are something you can accept, you have the option of opting out and changing your physicians.

The more you know, the better off you are!

Thursday, March 27, 2014

The Myth about Life Expectancy

Posted by Stephen Weinberg, MD FACC FACP
Much has been made of the fact that the life expectancy in the US is lower than other industrialized nations. This fact has been touted over and over again as proof that the healthcare system in the US is inferior to other countries. But merely saying this, does not make it true. It is important to explore the issues a bit more to understand the data.
It is true that we, as a society, have a lower life expectancy. Information from the OECD ( Organization for Economic Co-operation and Development) indicates that for 2011 (the last year compiled) the best life expectancy was in Switzerland at 82.8 yrs. The average of the 34 reporting countries in the OECD was 80.0 and we were 78.7. We were 26th out of the 34. Not a particularly good showing.
Anyway, let's look at these numbers. Why are we so low? Research has shown that patients on Medicaid (the health program for the poor) have a life expectancy 10 years less than people with standard insurance. Furthermore, people who are uninsured also have a decreased life expectancy which is about the same as the Medicaid population. There are 50M people on Medicaid and 50M uninsured in the country. Let's assume that the people with standard insurance have the same life expectancy as Switzerland (82.8 years) and the others have 72.8 years (10 years less). The people with the lower expectancy make up 33% of the population of 300M. Taking a simple weighted average of both populations yields a predicted average life expectancy in the US of 78.6 years which is almost precisely what was found in the OECD data. So, this indicates that those of us who have had a lifetime of standard health coverage have the same life expectancy as the best country in the world. Unfortunately, the other 33% of us have a value lower than Slovenia (80.1 years).
So why do we have this huge disparity despite spending all this money?
The answer is complex and that is where the pundits and legislators fail to truly address the situation.
We have one of the highest rates of traumatic deaths in the world, including vehicular, murder, suicide, accidents. Our death rates from HIV/AIDS, mental illness, Alzheimers are also one of the highest in the industrialized world.These illnesses do not lend themselves well to preventive medical care. On the other hand, cancer and hardening of the arteries, (ischemic diseases) have death rates much below average. These illnesses are cared for and prevented by good medical programs.
We don't have the benefit of a relatively homogeneous genetic pool, like most countries, where certain diseases are much less common. An example is Japan where ischemic heart disease is fairly uncommon.
We have great societal differences as it relates to obesity, which leads to diabetes, compared to other countries.
Additionally, we have a significant population in the US (100M people or 1/3 of our population) that has not had comprehensive health insurance coverage and access to care so they are, in general, less compliant with taking medication, obtaining timely medical care, eating properly, and having checkups, and taking care of themselves. As a result, they develop serious illnesses at a young age that then require emergency care at great expense and die prematurely.
"So what", you say. "All of this is just a bunch of numbers that really don't have any meaning for me". Well, not so fast. One of the major arguments set forth to justify radical changes in our healthcare delivery system is that our life expectancy is lower than it should be compared to other industrialized countries. (The other issue is cost which will be addressed in a future post.) That is true for the 1/3 of our population without private health insurance, but it is not true for the 2/3 of us that have such coverage. With changes designed to affect everyone, without good scientific evidence that they will be effective, it may mean that the vast majority of us living full lives may suffer as a result. Money may be diverted, physicians and hospitals may be incentivized to ration care. We certainly need to develop programs that will improve the health of those disadvantaged, but not harm others.
It is vital that all of these discussions and issues are transparent and that major changes to our system are not made in the absence of convincing evidence they will work and not cause unanticipated problems.

Wednesday, March 26, 2014

The Dangers of Profit and Loss

Posted by Stephen Weinberg, MD FACC FACP
Gain-sharing is an incentive program in which physicians are compensated for putting forth extra time and energy in an effort to save the hospital, in which they work, money. This could be by standardizing equipment used in the OR, ER, pacemakers, suture material, and other disposables that will reduce costs. It can also occur by developing and adhering to protocols that will make care more efficient and thereby keep costs low. I have participated in these programs and spent endless hours on committees coming up mechanisms to reduce expenses and then implementing them. The time spent is compensated by physicians sharing in the savings, if any, generated by the hospital. These are all laudable endeavors and should be encouraged in all programs.
I have concerns however when physicians get compensated for reducing or withholding care. Once a physician is in the employment of a hospital or is financially aligned with a hospital  and his salary is dependent upon the profit or loss of the hospital, the pressure on the doctor to admit or not admit a patient to the hospital or discharge a patient too early is greater than I believe it should be. With shrinking physician and hospital reimbursements, both entities are being placed in a situation where the need to wring every last wasted dollar out the system is becoming overwhelming. As a result, people can get hurt.
I believe there needs to be a firewall between physician income and hospital profit and loss to avoid rationing of care. There is nothing wrong with developing care protocols, streamlining flow, reducing waste from duplication of effort, developing purchasing power by decreasing the numbers of vendors in the hospital, using quality control measures in the hospital so that physicians get feedback as to their style of practice in terms of quality and cost, and other mechanisms to improve quality and efficient care.
There needs to be a mechanism by which each new improvement program is evaluated as to whether it crosses the line and whether it can potentially put patients at risk. The melding of physician income and hospital profit as a consequence of withholding "appropriate" care should not be permitted. The problem is that determining where that barrier should be erected is difficult, but I believe we should err on the side of caution. It is likely that our current quality measures will not detect these shortcomings unless they are egregious and therefore, individuals will likely be hurt. An example of this is the existing Medicare rule (since October, 2012 under the Accountable Care Act) that penalizes hospitals where the 30 day readmission rate for certain diagnoses (heart attack, heart failure and pneumonia) is above a level set by Medicare. The penalty is 2% and will rise to 3% next year. If a patient comes to the ER with recurrent symptoms of heart failure and is within the 30 day window, he might be sent home to avoid the penalty even if his best interests would have been served by readmission. Currently over 2000 hospitals in 49 states are being penalized a total of $280M this year. More about this program later.
The push by the ACA (Obamacare) to have physicians employed by hospitals, adopt Accountable Care Organizations, global payment risk models, and other profit and loss sharing programs, the more physicians will be integrated into a global financial model and the more patients should be concerned that this could lead to rationed care.
At the end of the day, patients want their doctor to be their advocate and ultimately do what is in the best interest of the patient and not the hospital, insurance company or other entity.

Monday, March 10, 2014

Where are Obama and Obamacare Headed?

Posted by Stephen E Weinberg, MD FACC FACP
I believe President Obama made his feelings known during the 2008 Presidential campaign. He stated over and over that he felt physicians should be salaried and there should be an end to fee for service medical care. He believed then and now that the fee for service system breeds increased costs by incentivizing physicians to order more tests and procedures. He stated in a July, 2009 press conference: “You come in and you've got a bad sore throat, or your child has a bad sore throat or has repeated sore throats. The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out.’”
The implication was that a pediatrician would decide to remove the tonsils of his patient (which could never occur) or that there was some kickback from the surgeon to the pediatrician (which would not occur). Additional references have often been made about the overuse of CAT scans and MRI’s as well as other imaging procedures by general practitioners is as a result of financial gain. They do not own or receive payments from imaging centers. It is clear that the President sees a large part of the medical system as one large conspiracy of kickbacks and self-interest. Many members of Congress have stated similar opinions.
As a result of this conspiracy theory, the President would like to see all physicians in salaried roles similar to the Mayo Clinic and Cleveland Clinic. He believes this would solve our healthcare economic problems by reducing costs. There really is no data to show that this is the case.
In fact, Medicare performed several studies and demonstration projects in the past 10 years to try to prove that incentivizing hospitals and large group practices to create plans to reduce costs would actually be effective.  The CBO, in 2012, evaluated these studies and found that one project involving cardiac bypass surgery did save about 10% over standard care, but the other 3 studies showed no financial benefit, including the 10 group study of about 6,000 salaried physicians. A Feb. 26, 2014 study in JAMA involving 32 practices in Pennsylvania demonstrated no quality improvement or cost savings over 3 years involving the Medical Home concept which has been touted to be the best model for primary care. In an accompanying editorial, the Dean of the University of Nevada School of Medicine pointed out that often things which appear obviously true do not stand up to scientific scrutiny.

So where does this leave us? President Obama is creating a situation where he is pushing physicians into salaried positions with his Medicare reimbursement policies (more about that later) based upon his assumption that this will reduce costs and improve quality of care without any evidence that this is so. He is willing to dismantle the entire healthcare system in the absence of knowing what the end result will be.