Planning the Patient-Centered Health Plan for America

Current Issue:

Solo or small groups have the leanest healthcare


Nearly two-thirds of US office-based physicians work in practices of fewer than seven physicians. It is often assumed that larger practices provide better care, although there is little evidence for or against this assumption. What is the relationship between practice size – and other practice characteristics, such as ownership or use of medical home processes – and the quality of care?

We conducted a national survey of 1,045 primary care – based practices with nineteen or fewer physicians to determine practice characteristics. We used Medicare data to calculate practices’ rate of potentially preventable hospital admissions (ambulatory care – sensitive admissions). Compared to practices with 10-19 physicians, practices with 1-2 physicians had 33 percent fewer preventable admissions, and practices with 3-9 physicians had 27 percent fewer. Physician-owned practices had fewer preventable admissions than hospital-owned practices. In an era when health care reform appears to be driving physicians into larger organizations, it is important to measure the comparative performance of practices of all sizes, to learn more about how small practices provide patient care, and to learn more about the types of organizational structures – such as independent practice associations – that may make it possible for small practices to share resources that are useful for improving the quality of care.

Small Primary Care Physician Practices Have Low Rates Of Preventable Hospital Admissions

  1. Lawrence P. Casalino 1,*,
  2. Michael F. Pesko 2,
  3. Andrew M. Ryan 3,
  4. Jayme L. Mendelsohn 4,
  5. Kennon R. Copeland 5,
  6. Patricia Pamela Ramsay 6,
  7. Xuming Sun 7,
  8. Diane R. Rittenhouse 8 and
  9. Stephen M. Shortell 9

Author Affiliations

1. Lawrence P. Casalino ( is the Livingston Farrand Professor in the Department of Healthcare Policy and Research at Weill Cornell Medical College, in New York, New York.
2. Michael F. Pesko is an assistant professor in the Department of Healthcare Policy and Research, Weill Cornell Medical College.
3. Andrew M. Ryan is an associate professor in the Department of Healthcare Policy and Research, Weill Cornell Medical College.
4. Jayme L. Mendelsohn worked on this project as a research coordinator in the Department of Healthcare Policy and Research, Weill Cornell Medical College. She is currently a postbaccalaureate premedical student at Bryn Mawr.
5. Kennon R. Copeland is senior vice president and director in the Department of Statistics and Methodology, NORC at the University of Chicago, in Illinois.
6. Patricia Pamela Ramsay is a research specialist at the School of Public Health, University of California, Berkeley.
7. Xuming Sun worked on this project as a research biostatistician in the Department of Healthcare Policy and Research, Weill Cornell Medical College. She is currently working as a statistician in the New York City Department of Health and Mental Hygiene.
8. Diane R. Rittenhouse is an associate professor in the Department of Family and Community Medicine and Center for Excellence in Primary Care, University of California, San Francisco.
9. Stephen M. Shortell is the Blue Cross of California Distinguished Professor of Health Policy and Management at the School of Public Health, University of California, Berkeley.

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Previous Issue:

A Challenge

This year we were obligated to take on 250 ObamaCare patients. These were patients without insurance, on welfare, on Medicaid who were given HMO insurance. This was a more massive change in our practice than I could have anticipated in my wildest imagination. I had to promise my front office this was an obligation to the poor and disenfranchise to provide this care. We’ve always had 20 percent of our patients on Medicaid as our obligation. But this 20% had meshed with our private practice and handled themselves much like private patients. They made appointments, follow our recommendations, kept their return appointments, and presented themselves in a manner that didn’t disturb our private patients.

The first day when those 250 ObamaCare/Welfare/Medicaid patients were place in out HMO panel, we had rude awakening. My front desk was managed by my wife, Linda for the past decade or so. Normally when she arrived at my reception front desk, she would have three or four messages on the phone.  She would respond to these and then get on with her work.

She arrived at the usual time, and found 65 messages on the phone. It took her two hours to record these and another three hours to respond to them. We thought this was just the preliminary response from patients who may have been waiting to obtain care. However, this continued on a daily basis. This extra five hours of work on a daily basis would add up to and extra 25 hours per week or 100 hours per month. The going rate in our community is $30 per hour. One hundred hours at $30 per hour is an extra $3,000 per month of medical costs.

These calls didn’t come in during normal business hours but all hours of day and night. We quickly realized that these patients were not employed and hence were up at all hours of day and night. They all had cell phones and would call and leave lengthy messages at midnight or three o’clock in the morning.

They were also very demanding, many insisting on being seen immediately. If we didn’t fit them in soon enough, they would call our HMO who assured them it was their policy that appointments were to be made in 24 to 48 hours. Then we received letters of reprimand for not providing prompt service. These complaints would then go to the state HMO program who would demand an explanation to be routed through our HMO.  We would then respond to our HMO and maybe it would then be dropped. However, some were appealed. Appeals through a state bureaucracy could be very time consuming with a serious loss of income. The harassment was a much larger emotional cost.

The operation of our reception area was devastated. Along with the changes in ObamaCare, Medicare and Medicaid placed numerous restrictions on care.  For forty years, I could write a prescription, or order a test or x—ray and the reception area would route the patient to the appropriate facility. This along with the billing and making further appointments fell in the range of 5 minutes of work.

This past month new Medicare restrictions implemented through our HMO required changes in the medications that the patient may have been on for a decade or two. They were upset that they were unable to get the medications they were used to obtaining.  The pharmacy would tell them “just have your doctor do a prior authorization” simply known as a PA. We did several of these and they took hours to finally obtain a medication that Medicare through our HMO covered. This could take hours of my office manager’s time over several days to process something that was covered. Medicare always demanded a listing of all the drugs that had been tried. Since, the trial process may have occurred a decade or two previously by another physician, this became an indeterminable process. My prescription writing time of a minute or two became 10 or 15 minutes after several rewrites.

As a pulmonologist who had treated respiratory failure for more than 40 years, this became a nightmare. For 40 years, after measuring the oxygen saturation, I would complete an oxygen prescription form, and my receptionist would fax this to the oxygen company. The oxygen would normal arrive at the patient’s home by the time they were home from my office. The first oxygen requisition I wrote after the new regulation, took several lengthy phone calls to the oxygen company. They range that must be written on the new Medicare forms. They required the low oxygen (hypoxia) documentation. After several phone calls, we fax the entire three page office visit documenting the low oxygen which we underline with heavy black ink that would transmit via fax. After hours, the lady at the oxygen company said the oxygen was in my own hand writing, not a printout from a machine. Most of us don’t have the multi-thousand dollar fancy hospital equipment and have always use the standard pulse oximeter that clamps on the finger. My first one cost me $350. The large Blood pressure, pulse, oxygen apparatus costs about $3500 and is no more accurate. I finally gave up on further phone calls. The first patient whose arterial oxygen was down to 78% from the normal of 98%,  (blue venous blood is 75%) was so short of breath I had to help her to the car. She declined to be hospitalized. She had to spend two months gasping for each breath before the oxygen could be approved. From a usual two hour wait to a two month wait. These types of costs, monetary (staff), time (hours to days to weeks etc.), patient increased risks (including dying in organ failure), increased suffering (shortness of breath – gasping for two month) never show up on a government or Medicare cost analysis even though they were doubled or tripled or quadrupled). Doctors or staff time is never measured. The pharmacists have similar increase in costs. Hospitals just hire more accountants, bookkeepers, insurance billers, Medicare, Medicaid experts and can usually recover costs including their significant increase because of government regulations.

(N.B. we once researched the reimbursement of our seeing a patient in lung failure on two tanks of oxygen in her home and the hospital reimbursement for a similar visit by their nurse or therapist. The hospital was able to charge more than 10 times what we were able to charge for the same work. Only we were the ones that were able to make the assessment and write orders that the hospital therapist would follow on his home visit. Normally they would call us to give them the oxygen and treatment orders which Medicare considers an irrelevant cost.)

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The Future of Health Care Has to Be Lean, Efficient and Personal.
Government health care costs are Time consuming, Bloated, Inefficient, and Impersonal.

Previous Issue:

Healthcare Mergers are not lean but are in a race to the bottom

I’ve been following the Lean Marketing column from Kevin Meyer’s “Superfactory” site for a decade or so. Medicine and Healthcare in General has a lot to learn from other industries. A recent posting by his associate, Bill Waddell, was very instructive. Mr Waddell states that he is “glad to have grown up in America before “InBev” existed – in a time when good beer was plentiful and cheap.”

With the wave of mergers going on in our medical industry, we should be taking a lesson from the breweries. Hospitals are merging, as are healthcare insurance companies; physician groups are getting larger. There are cross mergers between hospital and physician groups; between insurance companies and hospitals. However, healthcare costs are going up and patient satisfaction is going down. These are reversions from a horizontal industry to a vertical integrated industry, the antithesis of what we are proposing to make healthcare more affordable. Where are the benefits to our clients, the patients we invested 12 to 16 years in training to serve? Why are we accepting this interference with our mission in life?

AB InBev is the Brazilian led, Belgium based outfit that is systematically buying and trashing the leading global beer brands.  An interesting article on Bloomberg Businessweek describes the unfolding debacle: Profits up, cash flow strong, but sales shrinking.  It is a step-by-step story of exactly how the short-term focus on profits, financial and marketing driven, disregard for the product and customer value approach takes place.

Beck’s was once a highly regarded German beer with a small but devoted core of American customers. Same with Bass, a British beer.  AB InBev bought them, started producing them in the USA, losing quality but at a lower cost, and sales are down.  It is a clear example of how focus on being the low cost producer is not a strategy for success, but merely a race to the bottom.

Selling Budweiser in the United States should be about as tough as selling sex on a troop ship, but AB InBev has demonstrated how to fail at it.  The high quality hops growers in Germany used to get an annual visit from August Busch III, but those days are long gone:

A former top AB InBev executive, who declined to be identified because he didn’t want to get in trouble with his old employer, tells a different story. He says the company saved about $55 million a year substituting cheaper hops in Budweiser and other U.S. beers for more expensive ones like Hallertauer Mittelfrüh. It is hard to say whether the average Bud drinker has noticed. But then, the average Bud drinker is not drinking as much beer.”

InBev is doing some leanish sort of cost management.  AB InBev CEO “Brito was just as ruthless when it came to the perks to which Anheuser-Busch employees had grown accustomed. He cut the number of BlackBerrys in half. Executives who once traveled in corporate jets now flew commercial. He removed the interior walls at One Busch Place in St. Louis and turned the office into an open-plan space. Everyone would work under the same Spartan conditions that Brito embraced. (In New York, Brito shares a large table with his head of sales and his finance chief.) ‘We always say the leaner the business, the more money we will have at the end of the year to share,’ he said in a speech at Stanford in 2008. ‘I don’t have a company car. I don’t care. I can buy my own car. I don’t need the company to give me beer. I can buy my own beer.’

It is a good idea to pick up pennies in the non-value adding areas like offices and cell phones.  The problem is that Brito doesn’t know the difference between expenses that add value for customers and those that don’t.  Costs are costs everywhere with equal enthusiasm in the minds of financially driven leaders who don’t really understand and appreciate the products and customers.

He laid off approximately 1,400 people, about 6 percent of the U.S. workforce. He sold $9.4 billion in assets, including Busch Gardens and SeaWorld. AB InBev also tried to save money on materials. It used smaller labels and thinner glass for its bottles. It tried weaker cardboard for its 12-packs and cases. The old Anheuser-Busch insisted on using whole grains of rice in its beer. AB InBev was fine with the broken kind.”

The results are predictable: “AB InBev’s CEO is a skilled financial engineer, but he has had trouble selling beer. The company’s shipments in the U.S. have declined 8 percent to 98 million barrels from 2008 to 2011, according to Beer Marketer’s Insights. Last year, Coors Light surpassed Budweiser to become America’s No. 2 beer.”

Of course AB InBev’s mismanagement opens doors for local and regional companies focused on the quality and value of their product; “The craft brewing industry grew 13% in 2011.  There haven’t been this many U.S.  breweries since before Prohibition“.  What InBev has done to beer is what so many companies have done in China in pursuit of a low cost strategy.  Without a keen understanding of value and mama bear-like defense of it, broad brush pursuit of low cost inevitably leads to low value, which can only lead to lost sales, either in fewer units or lower prices.  It is also a good example of the myth of mass markets and mass production.  Mass thinking is based on one-size-fits all products and they rarely delight many customers.

Read more postings at

Editor’s note: What AB InBev has done to beer, hospitals, HMOs, insurance carriers have done to medical care. They fail to understand the value of healthcare. Thus they have cheapened it for the masses with a broad brush pursuit of low cost which inevitably leads to low value. The serious beer drinker has noted that the lower cost has decreased the quality of beer and has spawned the craft brewing industry. Many patients have figured out the reason for the exorbitant cost of healthcare has also cheapened healthcare. They are now beginning to understand that by paying the average yearly costs of their healthcare out of their pocket and have major medical or high deductible health insurance to cover unexpected diseases, major surgery, trauma surgery, and other unexpected costs, has lowered their total health care costs. Americans are also observing that such insurance costs only half as much as their present policy. This also reduces overall healthcare costs significantly.

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The Future of Health Care Has to Be Lean, Efficient and Personal.

Previous Issue:

The Most Energetic Area of Lean Practice

James Womack: The Lean Movement

With the current activity to increase the minimum wage, we need to review what James Womack said in 2008 when he was reflecting on the progress of the Lean Movement: “One critical indicator is our success in extending lean thinking to new industries and activities. In recent years I have been greatly encouraged that lean thinking is moving far beyond its origins in manufacturing to distribution, retailing, maintenance and overhaul, consumer services, construction, and – perhaps most striking – healthcare. Indeed, the latter may be the most energetic area of lean practice today.”

“There is much consolidation going on in the health care industry. Groups are merging; Hospitals are merging, ancillary facilities are merging; all in the name of efficiency. What is over looked, is that no value is created with like firms merge.  These actions quickly shift wealth from customers, employees, suppliers, and former owners to the new owners. This may do more good than harm, because otherwise the firm in question may completely fail. But it is often unclear that any additional value has been created in the sense of better satisfying customer needs with a given amount of human effort and capital investment. And, from society’s standpoint, the only way to increase living standards is to change the ratio of human effort and capital going into firms to the amount of value coming out. Otherwise the outcome is basically zero- sum, with some winners and some losers.

“By contrast, the objective of a lean transformation is to analyze the core value creating processes of organizations in light of customer needs (which may have changed), then figure out how to create more value with the same resources so the organizations can grow and society can prosper. It’s the difference between shifting wealth from one party to another and creating more value, ideally value that can be shared with customers, employees, suppliers and owners.”

(Note that Womack never uses the term “adding value” because this is an accounting convention for the difference between the input costs of a firm and its output prices. Often Womack finds that only cost is added by the firm as inputs are converted to outputs, not value from the customer’s [or patient’s] standpoint.)

Managers (and owners) will try anything that is quick and easy even if it doesn’t work before they try anything long and hard that does work (e.g. intense process analysis linked to customer needs to create more value from the same resources.)

We thank James Womack for keeping us informed of the lean enterprise goals and will follow through with relevance to health care, which he feels is one of the “more energetic areas of lean practice today.”

Please peruse the Lean Enterprise Institute, at

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Previous Issue:

A Medical Correlative

Many patients never learn or even suspect that the CT examination, the echocardiogram, or the magnetic resonance imaging study that they underwent was neither necessary nor indicated.

Chaos in the Cockpit

Herbert L. Fred, MD, MACP
Tex Heart Inst J. 2012; 39(5): 614. PMCID: PMC3461665

On 1 June 2009, Air France Flight 447, an Airbus A330 en route to Paris from Rio de Janeiro, plunged into the south Atlantic, killing all 228 people aboard. French authorities finally concluded that the plane’s 3 pilots had not been trained adequately to fly the aircraft manually in the event of equipment failure or a stall at high altitude.

According to a report issued on 5 July 2012,1 the Bureau of Investigation and Analysis found that ice crystals had misled the plane’s airspeed sensors and that the autopilot had disconnected. Confusion heightened when faulty instructions emerged from an automated navigational aid called the “flight director.” Amid a barrage of alarms, the crew struggled to control the plane manually, but they never understood that the aircraft was in a stall and never undertook the appropriate recovery maneuvers. In fact, they followed the flight director’s instructions and went into a climb instead of into a dive, as they should have to correct a stall.

William Voss, president of the Flight Safety Foundation in Alexandria, Virginia, offered the following comment on the accident: “We are seeing a situation where we have pilots that can’t understand what the airplane is doing unless a computer interprets it for them. This isn’t a problem that is unique to Airbus or unique to Air France. It’s a new training challenge that the whole industry has to face.”

The whole healthcare industry faces training challenges that are eerily similar to those now evident in the airline industry. Indeed, we continue to graduate physicians who lack sufficient clinical skills to render good patient care without routinely reverting to and relying upon computers and other technologically advanced devices.2 In contrast to commercial aircraft accidents that typically injure or kill many people at once—and in spectacular fashion—medical misfortunes rarely make headlines. No one, for example, ever hears about the absolute halting of patient-care activities when the hospital’s computed tomographic (CT) scanner breaks down.3,4 And many patients never learn or even suspect that the CT examination, the echocardiogram, or the magnetic resonance imaging study that they underwent was neither necessary nor indicated.

Although computers and like devices offer tremendous advantages, they have important drawbacks as well. They occasionally malfunction, are not always available, and produce findings that can be misinterpreted. They have no judgment, common sense, or understanding. And they cannot reason, overcome their deficiencies, or show concern for the welfare of human beings. A well-trained doctor—or a well-trained pilot—can.5

Go to:


Address for reprints: Herbert L. Fred, MD, MACP, 8181 Fannin St., Suite 316, Houston, TX 77054
Author information ► Copyright and License information ►
1. Clark N. Report on ’09 Air France crash cites conflicting data in cockpit [Internet]
2. Fred HL. Hyposkillia: deficiency of clinical skills. Tex Heart Inst J 2005;32(3):255–7.[PMC free article] [PubMed]
3. Fred HL. The downside of medical progress: the mourning of a medical dinosaur. Tex Heart Inst J 2009;36(1):4–7. [PMC free article] [PubMed]
4. Fred HL. C.T. scanner dies. Hosp Pract (Minneap) 2001;36(1):23. [PubMed]
5. Fred HL. Gimmicks. South Med J 1983;76(8):953.

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Previous Issue:

Every industry is getting lean; we no longer have a choice

David J. Gibson, M.D.
Director, Clearway Health Solutions

You may have missed reading a thought provoking article from Thomas Freedman in the NYT yesterday.  The article entitled Average Is Over (see attached below), is particularly relevant as it relates to the political debate that is evolving with a trajectory that is progressively being divorced from reality.  All the politicians are promising jobs, jobs, jobs.  Obama wants more government spending to bring back jobs as demonstrated in his SOTU speech last night.  The Republicans are promising that the market will return jobs if the government is downsized and taxes are lowered.  What happens when both are proven to be wrong which will become evident soon after the election later this year?  It is not a pretty picture to contemplate.

The following are a couple of excerpts from Freedman’s article: “In the 10 years ending in 2009, [U.S.] factories shed workers so fast that they erased almost all the gains of the previous 70 years; roughly one out of every three manufacturing jobs — about 6 million in total — disappeared.”

Most of the current job creation is now focused in the relative low paying and previously non-exportable service sector.  Hospitality jobs such as waiters and waitresses are an example.   Now, these jobs can be exported to the IT sector.  Consider the following”

Last April, Annie Lowrey of Slate wrote about a start-up called “E la Carte” that is out to shrink the need for waiters and waitresses: The company “has produced a kind of souped-up iPad that lets you order and pay right at your table. The brainchild of a bunch of M.I.T. engineers, the nifty invention, known as the Presto, might be found at a restaurant near you soon. … You select what you want to eat and add items to a cart. Depending on the restaurant’s preferences, the console could show you nutritional information, ingredients lists and photographs. You can make special requests, like ‘dressing on the side’ or ‘quintuple bacon.’ When you’re done, the order zings over to the kitchen, and the Presto tells you how long it will take for your items to come out. … Bored with your companions? Play games on the machine. When you’re through with your meal, you pay on the console, splitting the bill item by item if you wish and paying however you want. And you can have your receipt e-mailed to you. … Each console goes for $100 per month. If a restaurant serves meals eight hours a day, seven days a week, it works out to 42 cents per hour per table — making the Presto cheaper than even the very cheapest waiter.”

This is relevant within the context of our unleashing market forces within the health care sector of the economy.  Informed consumers, as has been demonstrated in every other sector of the economy, will predictably reform the industry and drive creative destruction that has been avoided in the past for all the reasons we have previously discussed.  The provider cost per unit of service will be quickly reduced in order to compete in a competitive market.  The use of IT to increase productivity will become an imperative.  The resulting loss of HC jobs and the reduction in compensation will be an assault on one of the last relatively affluent job option within today’s U.S. economy.

This message is not intended to argue against our introducing available market consumer forces into the HC industry.  This will occur with or without our involvement.  Rather, I am speculating on the collateral unintended effect that this fundamental shift in the industry’s structure and organization will have on the general economy.

David J. Gibson, M.D.
Clearway Health Solutions

By THOMAS L. FRIEDMAN, NYT | January 24, 2012

In an essay, entitled “Making It in America,” in the latest issue of The Atlantic, the author Adam Davidson relates a joke from cotton country about just how much a modern textile mill has been automated: The average mill has only two employees today, “a man and a dog. The man is there to feed the dog, and the dog is there to keep the man away from the machines.”

Davidson’s article is one of a number of pieces that have recently appeared making the point that the reason we have such stubbornly high unemployment and sagging middle-class incomes today is largely because of the big drop in demand because of the Great Recession, but it is also because of the quantum advances in both globalization and the information technology revolution, which are more rapidly than ever replacing labor with machines or foreign workers.

In the past, workers with average skills, doing an average job, could earn an average lifestyle. But, today, average is officially over. Being average just won’t earn you what it used to. It can’t when so many more employers have so much more access to so much more above average cheap foreign labor, cheap robotics, cheap software, cheap automation and cheap genius. Therefore, everyone needs to find their extra — their unique value contribution that makes them stand out in whatever is their field of employment. Average is over. . .

What the iPad won’t do in an above average way a Chinese worker will. Consider this paragraph from Sunday’s terrific article in The Times by Charles Duhigg and Keith Bradsher about why Apple does so much of its manufacturing in China: “Apple had redesigned the iPhone’s screen at the last minute, forcing an assembly-line overhaul. New screens began arriving at the [Chinese] plant near midnight. A foreman immediately roused 8,000 workers inside the company’s dormitories, according to the executive. Each employee was given a biscuit and a cup of tea, guided to a workstation and within half an hour started a 12-hour shift fitting glass screens into beveled frames. Within 96 hours, the plant was producing over 10,000 iPhones a day. ‘The speed and flexibility is breathtaking,’ the executive said. ‘There’s no American plant that can match that.’ ” . . .

Read the entire article at the NYTimes . . .
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Past Issue:

Lean HealthCare requires defunding ObamaCare

Viewpoints: ObamaCare should be defunded – now
Sally Pipes – Special to THE BEE – Friday, Apr. 01, 2011

Last week, the Obama administration’s top lawyer, acting Solicitor General Neal Katyal, asked the Supreme Court not to honor Virginia Attorney General Ken Cuccinelli’s request to fast-track his state’s constitutional challenge to the federal health care law. Katyal argued that there was “ample time before 2014” – the year by which all Americans must have health insurance – so the high court need not rush to hear the case.

Unfortunately, between now and then, the majority of the Patient Protection and Affordable Care Act’s other provisions will take effect. Implementing those provisions will require billions of dollars – money that could be for naught if the Supreme Court invalidates the law.

With this year’s budget deficit near $1.4 trillion, that’s also money we don’t have. Now is the time to defund the law – not just because the law’s fate is uncertain, but because we can’t afford to implement it.
At least 44 states and the District of Columbia are facing deficits that total $112 billion over the next year. They may welcome the initial seed money that Obamacare provides to expand Medicaid – the joint federal-state health insurance program for the poor – and fulfill other provisions of the law. But they’ll be left holding the bag in just a few years, when the federal subsidies run out.

A report commissioned by Sens. Orrin Hatch, R-Utah, and Fred Upton, R-Mich., projects that Obamacare “will cost state taxpayers at least $118.04 billion through 2023” thanks to the required expansion of Medicaid. When it passed, the health care reform law contained $105 billion in approved funding through 2019. This year, the legislation is set to spend $23 billion.

Congress could put a stop to these expenditures. Republicans have professed their opposition to the law, but they appear to be balking at the prospect of actually cutting off funding.

That’s too bad, as several of Obamacare’s newly established programs have no business drawing on taxpayer funds. . .

In the past, Berwick has expressed admiration for government-run, single-payer health care systems – which control costs by rationing care. American patients accustomed to receiving the world’s most advanced care should hope that the Center for Innovation doesn’t deem single-payer a payment model worth testing.

Another reform worthy of the chopping block is the minimum medical loss ratio, which requires that health insurance firms spend 80 percent of premiums in the individual and small-group markets – and 85 percent of premiums in the large-group markets – on medical claims.

Minimum medical loss ratios will cripple competition by forcing smaller insurers that don’t have the economies of scale needed to comply with the rules from the marketplace. Indeed, research from PricewaterhouseCoopers has shown that residents of states with minimum loss ratios face lower levels of competition – and higher prices – than their counterparts in states without them. . .

Absent action, the nonpartisan Congressional Budget Office projects that from 2014 to 2023, America will spend $2 trillion – a little over 14 percent of the national debt – on the president’s health care reform effort.

Simply put, the American people can’t afford Obamacare – and would like a defund.

To read the entire OpEd by Sally Pipes . . .
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Past Issue:

Douglas Farrago MD, Editor, Creator & Founder


The mission of Authentic Medicine is to rediscover how much the art of medicine means and allow us to reconnect to our roots once again. It is about fighting back against those things that are taking us away from the direct care of patients while still pointing out the lunacy and hypocrisy of this job. Be part of the movement that will take back the healthcare system from the idiots who are ruining it.

Why we are moving to an era of Industrialized Medicine

The Quality Movement and why it is a scam

The ever expanding Medical Axis of Evil

Medical Dogma and the Alphabet Soup (JC, HIPAA,etc)

Bureaucratic Drag and the distractions from treating patients

Burnout and depression amongst healthcare professionals

Humor in caring for the patient and the caretaker



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  • Entrepreneur-Country. Julie Meyer, CEO of Ariadne Capital, (Sorry about the nepotism, but her message is important) recently launched Entrepreneur Country. Read their manifesto for information: 3. The bigger the State grows, the weaker the people become – big government creates dependency . . .   No real, sustainable wealth creation through entrepreneurship ever owed its success to government . . .  11. The triple play of the internet, entrepreneurship, and individual capitalism is an unstoppable force around the world, and that Individual Capitalism is the force that will shape the 21st Century . . .  Read the entire  manifesto  . . .
  • Americans for Tax Reform,, Grover Norquist, President, keeps us apprised of the Cost of Government Day® Report, Calendar Year 2014. Cost of Government Day (COGD) is the date of the calendar year on which the average American worker has earned enough gross income to pay off his or her share of spending and regulatory burdens imposed by government on the federal, state and local levels. Cost of Government Day for 2014 was July 6th a ten-day increase above last year’s revised date of July 16th. With July 6th as the COGD, working people must toil on average 186 days out of the year just to meet all the costs imposed by government. In other words, the cost of government consumes 53 percent of national income. If we were to put health care into the public trough, the additional 17 percent of GDP that healthcare costs, would allow the government to control 70 percent or nearly three-fourths of our productivity and destroy our health care in the process. We would have almost no discretionary income.
  • National Taxpayer’s Union,, Duane Parde, President, keeps us apprised of all the taxation challenges our elected officials are trying to foist on us throughout the United States. To find the organization in your state that’s trying to keep sanity in our taxation system, click on your state at On August 13, you can start working for yourself. It takes nearly 8 months of hard work for every American to pay for the cost of government. Read more . . .
  • Citizens Against Government Waste,, America’s Taxpayer’s Watch Dog.

Since 1984, Citizens Against Government Waste has been the resource that policymakers, media, and the taxpaying public rely on for the bottom line behind today’s headlines. Waste News is the first stop for reporters covering government spending. Members of the Media visit our media page to sign up for email updates or to set up interviews with CAGW policy experts.

Porker of the Month will introduce you to some of government’s worst pork-barrel offenders.

“To advocate an efficient, sound, honest government is neither left-wing nor right-wing, it is just plain right.” –J . Peter Grace, CAGW Co-Founder

  • Evolving Excellence—Lean Enterprise Leadership. Kevin Meyer, CEO of Superfactory, (Sorry about the nepotism, but his message is important) has started a newsletter which impacts health care in many aspects. Join his evolving excellence blog . . . Excellence is every physician’s middle name and thus a natural affinity for all of us.  This month read The Customer is the Boss at FAVI “I came in the day after I became CEO, and gathered the people. I told them tomorrow when you come to work, you do not work for me or for a boss. You work for your customer. I don’t pay you. They do. . . . You do what is needed for the customer.” And with that single stroke, he eliminated the central control: personnel, product development, purchasing…all gone. Looks like something we should import into our hospitals. I believe every RN, given the opportunity, could manage her ward of patients or customers in similar lean and efficient fashion.
  • FIRM: Freedom and Individual Rights in Medicine,, Lin Zinser, JD, Founder, researches and studies the work of scholars and policy experts in the areas of health care, law, philosophy, and economics to inform and to foster public debate on the causes and potential solutions of rising costs of health care and health insurance .

Ayn Rand, a Philosophy for Living on Earth,, is a veritable storehouse of common sense economics to help us live on earth. To review the current series of Op-Ed articles, some of which you and I may disagree on, go to

For other issues, please visit our archives