The Little Black Doctor Bag Circa 2016 and the Physician Gender Pay Gap

Last week was a truly memorable occasion in our family. My daughter entered medical school. The White Coat ceremony was lovely, joyful and dignified. I don’t often write about my personal life, but this one triggered a few thoughts that I would like to share, if you can indulge me.

So155358003_-university-little-rock-black-leather-nurse-doctor-metime in 2009, I began blogging about the promise of electronic patient records – all info, all the time, where you need it, when you need it at the point of care. What is most memorable about those early essays was developing the character Health System Ed, a little blue doctor holding an iPad.

In Ed’s first incarnation, he was holding a clipboard. And that just seemed so wrong. It was everything Ed was not about – static paper records stuck in a manila folder in a wall of files. So I went to an artist and we revised Ed and gave him an iPad. And yes, even though I wanted Ed to look gender, ethnically and racially neutral, I needed to give him a name, and “Ed” represented Health System Education.

Today, the iPad is an essential piece of medical equipment. Remember the little black doctor bag? Today, the little black doctor bag is a stylish black leather tote emblazoned with my daughter’s initials, just big enough to hold a MacAir and an iPad. With those tools, she’ll be able to know a lot about her patients, their labs, their vitals, their activity level. So I was just moved to see that we have come this far this fast, and that the little black doctor bag actually looks good with a little black dress, if necessary.

About Doctors in Little Black Dresses

Which leads me to my next point. We all know about the gender pay gap. Women have been railing about it for decades. Turns out that the gender pay gap is just as prevalent among physicians. This article today in FierceHealthcare states:

Reports of pay discrepancies based on physician gender have rolled in for years, as previously reported by FiercePracticeManagement. While the reason for the pay gap has long been in question, hard evidence has been virtually nonexistent, according to the current study. Researchers sought to adjust reimbursement data to account for the three primary theories accounting for the difference in pay: female physicians undervaluing their services, spending less time on the job or being less productive than their male counterparts.

As a basis for its report, the study used Medicare Fee-for-Service Provider Utilization and Payment Data Physician and Other Supplier Public Use File (PUF) data covering 13 specialties, which yielded an average pay gap of $34,125.68. Adjusting for hours worked, productivity and years of experience narrowed the gap to $18,677.23. While female physicians earned less across all specialties, two (hematology and medical oncology) showed statistically insignificant differentials. The largest gap occurred among nephrologists, at $16,688.96.

Cost and Passion is the Same for Women and Men

The cost of medical school is the same for men and women. The hard years of study, practice, relentless dedication to patients and the art of the science of medicine are the same for both sexes. If women can expect a 5 to 10 percent reduction in pay, that does not mean they will get a break on the high cost of pursuing their passion.

So with this little soapbox I’ve built over the years, let me add to the laundry list of policy issues this very critical issue of gender pay equality for physicians.

When that medical school tuition bill comes due, her bill will look the same as the next guy’s. It is both our hopes that her paycheck will look the same, too.

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A Yuuuuuuge Edition: Health Wonk Review Channels Inner Trump

donald-trump-health-wonk-reviewSteve Anderson at channels his inner Trump to bring us a yuuuuuge edition of Health Wonk Review. Thanks to Steve for a tremendous undertaking in the service to his fellow countrymen and countrywomen.


Posted in biotechnology, consumer health apps, electronic patient records, health economics, health insurance, health IT, health reform, healthcare change management, healthcare marketing, pharmaceutical marketing | Leave a comment

The Public Option or (ahem) Single-Payer: Solutions to a Growing Healthcare Monster?

Politically, I’ve been accused of being just a little to the right of Attila the Hun. That’s really not fair…to Attila.

I only open with that slight bit of hyperbole to underline the fact that this is not a corner of the world where you might expect to find a discussion about the value of the public option or a single-payer healthcare system as a solution to what is becoming a completely out-of-control sector of the economy. But in this political season, where vicious verbal spitballs are tossed at opponents with nary a care for veracity, perhaps it’s time for each of us to take a step back and look at point of view we haven’t really considered before. Just to set an example to the flamethrowers in Cleveland and Philadelphia, of course.

Not Just Too Expensive, But Too Complicated

The loud political rants about healthcare focus on the exorbitant costs of hospitals, nursing homes, drugs, doctor’s salaries – if you are reading this you are already familiar with the litany of complaints. Drugs running more than $100,000 a year are hitting the pharmacy shelves with increasing frequency.  Health insurance premiums are skyrocketing  to pay for it, with patients bearing much higher deductibles just so they can feel a bit of the consequence of their choices – both in taking responsibility for maintaining their health and for the treatments they select. 

Within the last year, I’ve seen a proposal that patients be allowed to take out what amounts to a mortgage to pay for some of the higher-priced treatments. That means as you begin to pay off your college debt sometime around the age of 50, you can start to look forward to assuming another big bill to stay on this side of the grass. Ouch!

Patients aren’t the only ones feeling the pinch. Health insurance companies are sinking under the weight of regulations and requirements so onerous that they can no longer operate under a legitimate business model – meaning one that might result in a profit. (“Heaven forfend any private entity make a profit,” – thus spoke Attila’s little sister sarcastically.) Instead, we saddle the insurance companies with so many competing requirements (medical loss ratios and basic plan standards, for example) that not even Houdini could get out alive.

Since I have spent much of my career consulting in the pharmaceutical industry, I might let this particular sleeping dog lie. Suffice to say, patients and other payers in the United States pay the brunt of the cost of drugs mostly because we can. We just can’t for much longer. In most of the rest of the world, drug prices are capped or some places are just so poor the drug companies give it to them. Expect that to change as the economic balance in the world shifts. It’s an industry that is shifting its business model because the old one is not sustainable.

Let’s Talk Complicated

If you couldn’t sink our healthcare system with ridiculous costs, including more indigent patients, you might be able to poke the last hole in the boat by saddling all the stakeholders with an increasing amount of paperwork and regulation. At some point, the players just give up.

Doctors, hospitals, health plans, patients, biopharmaceutical and device manufacturers all now live under so many regulations and requirements to do business, that doing business in a rational way is becoming increasingly impossible.

That is not hyperbole. That is reality. Think Meaningful Use.

At tax time, patients have to prove they have health insurance or pay a penalty.

Physicians are required to prove they meet quality measures which change all the time, are incomplete or just plain un-meetable. In order for physicians and hospitals to qualify to be paid by Medicare and Medicaid, they have to meet so many constantly changing rules, regulations and requirements with shifting deadlines that some have thrown up their hands and want to opt out of taking public money completely. But not so fast. If you are a physician or a hospital, most of your patients are over 65 and have Medicare or are indigent, disabled or in some way unable to work and are on Medicaid. It isn’t that easy to just opt out.

I’ve already discussed the difficult rock and hard place in which health insurance companies find themselves.

Would Single Payer Just Be Easier?

What does all this have to do with the public option or a single payer system? A lot. At some point, the focus needs to return to a simple transaction between a patient and a healthcare provider where the only issue on the table is the patient’s health. Perhaps the only way to make that happen is to remove business from the business of healthcare and provide a universal option. Because simply, if government needs to regulate business to the point where it is almost impossible to conduct it in a rational way, perhaps it’s time to get out of the business altogether and just concentrate on providing healthcare where payment is off the table completely for most patients.

Attila’s little sister could argue against that previous paragraph all day long because every word comes with a caveat. None of the aforementioned is as simple as I’ve stated it, but in the end, it seemed important enough to look at how other people see the problem. The problem is getting healthcare to people who need it, and a lot of effort and money is spent doing anything but getting doctors and patients together in the interest of the patient’s well-being.

I really do invite all kinds of comments and disputes to my facts and my reasoning. It’s a political season, and it seems like a good time to look at a political solution to a growing monstrosity of a problem high on the agenda of both parties.





Posted in biotechnology, electronic patient records, health economics, health insurance, health IT, health policy, health reform, healthcare marketing, pharmaceutical marketing | 1 Comment

A Pot Luck Health Wonk Review – Breathe This In


Chris Fleming has posted A Pot Luck Health Wonk Review at Health Affairs Blog.  Many thanks to Chris & crew for hosting a great edition – we all greatly value Health Affairs ongoing participation!

As Chris said in his post, “Despite the absence of a post on medical marijuana, we’ll call this a “Pot Luck” edition of the Health Wonk Review.”

So breathe deeply, or as some contemporary presidents have preferred, don’t inhale, and ingest this panoply of wonkery.

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Human Nucleus: Your Analyzed Individual Genome is the Basis for Population Health In Extremis

diamandis and HLI Human Nucleus (2)

You can know and affect your health future now. Human Longevity Institute is launching Human Nucleus, a place where you can have your genome completely analyzed into its millions of component pieces of information. That information is actionable immediately, and remains as part of a learning database from which you continue to benefit.

The first cohort of 200 participants is through the pilot phase, and the program is now opening to a wider audience on his email list, explained Peter Diamandis MD, co-founder of Human Longevity Institute  and the force behind this transformation of the way we think about healthcare. Dr. Diamandis is a leading futurist, Chairman and CEO of the XPRIZE Foundation and the co-founder of Singularity University.

To participate, you can fill out an application for the team to determine if you fit the criteria. If you make  the cut, you spend a day in LaJolla, CA with some of the sharpest and most forward-looking healthcare minds on the planet for a new level of a full medical workup. The cost? $25,000 buys you the chance to be part of a massive initiative to move healthcare into a future.

Manage Your Health Portfolio

Dr. Diamandis envisions that patients in the future will be able to “manage your health information the way that you currently manage your wealth portfolio,” he said during a Google Hangout  on Saturday afternoon with HLI’s Chief Medical Officer Clay Perkins. HLI’s stated goal to help move healthcare from Sick Care to a true healthcare system.

“Over time, we’ll see more emphasis on this time of care and less hospital beds,” Dr. Perkins said.

Exciting? Just a little. And by the way, if you wait a few years, the price of the genome sequencing is expected to drop to about $3,000. What is the price of waiting? You may save $22,000 by waiting for the commercial rollout or, like at least one participant in the first 200, if you spend the $25,000 today you may save your life by finding something that would not have been discovered until it was much more advanced and fatal.

If they find something amiss, they work with your physician to immediately find a top specialist to take action. Already, the team has found serious issues in about one-third of participants – issues that were able to be proactively addressed – and now the team is already getting thank you notes from a few people whose lives have been saved.

Population Health In Extremis

The idea of medicine being this personalized almost runs counter to the notion of population health, but actually it is population health in extremis.  Your highly secure information is first analyzed for your personalized health risk assessment and individual care plan around the assessment. Then you data is aggregated and analyzed along with all the other de-identified data resulting in ongoing machine learning insights. “The more data we have, the more we learn about you.” Participants are learning more about themselves as Human Nucleus learns more about the pool of participants.

The studies are being conducted in tightly controlled experiments that will be published in peer-reviewed journals.

“It’s a fundamental concept. If we can determine based on your genomics, [we can determine] what you are likely to die from. . .Your genome is your health future and it give you the probabilities, mixed in with nurture and your style…it tells us what to look for early on. . . it’s as fundamental as it gets,” Dr. Diamandis said.

The long view on the project is to find the secret to aging well by studying people who are healthy into their 90s and beyond. For details, check out Human Longevity Institute here and click on the Health Nucleus video on the home page.

“This is an early prototype of what human health will look like,” Dr. Perkins said.


Posted in biotechnology, consumer health apps, electronic patient records, health economics, health insurance, health IT, health policy, health reform, healthcare change management | 2 Comments

Health Wonk Review, The Musical


And now, for your dancing and listening pleasure, Health Wonk Review, the musical

David Harlow of HealthBlawg’s Health Wonk Review is Bustin’ Out All Over. Hat tip to Rogers and Hammerstein. Listen here.

For more Harlowfun, tune in every other Tuesday to Health Wonk Review On Air with David Harlow. Click here to listen or participate on Blab.

Posted in biotechnology, consumer health apps, elearning, electronic patient records, health economics, health insurance, health IT, health policy, health reform | Leave a comment

HIT, LGBT and ACA: Health Wonk Review from Tinker Ready

untitledTinker Ready of Boston Health News delivered a wide range of health policy thought for this edition of Health Wonk Review.

Read it here just in time to study for David Harlow’s Health Wonk Review Blab today at 1 p.m. Eastern. Catch him and join in the conversation. Just click on this link.

Photo: Great hospital design! Tinker Ready offers a little color from the former home of the Hospital de la Santa Creu i Sant Pau in Barcelona.

Browser alert: I found that Chrome worked best to get full functionality of Blab. With Edge and my Android browser, I could see and hear David but couldn’t speak to him. So if you want to chat with David, try Chrome.

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A Single Payer Movement: Physicians, Politicians, Policymakers Drive Efforts

In the US, a single-payer or national health plan is usually regarded as politically unfeasible. It may not be the politicians who lead the charge, however. It is the people working in the system, specifically physicians, who are being squeezed by the increasing number of rules, concurrent reductions in income and patients who can’t afford them, that are looking for solutions.

A group of Harvard Medical School physicians wrote an editorial for the American Journal of Public Health  advocating a national health plan, one that simplifies payment for healthcare providers and organizations and opens access to care for all. The authors suggest creating a seamless system with multiple points of access largely financed with public funds

In a critique of the Accountable Care Act, the authors say that the ACA has fallen well short of its promise to make healthcare affordable.

“A decade from now, according to the Congressional Budget Office, 27 million Americans will remain uninsured despite full implementation of the law. Many more are underinsured or constrained by “narrow networks” of providers that limit choice and rupture longstanding therapeutic relationships. Doctors and nurses contend with growing requirements for mind-numbing electronic documentation1b in a health care marketplace increasingly tilted toward giant insurers and hospital conglomerates that amass power through consolidation. Finally, the system’s administrative complexity, which robs patients and providers of time, money, and morale, was further fueled by the ACA.”

The authors write for a group of 2,000 physicians who are advocating for a national health plan, the Physicians for a National Health Program (PNHP).

The ACA moves the country in the direction of some elements of single payer by incrementally driving providers to bundled payments. The country’s healthcare bill is increasingly covered by the government as the number of people covered by private, employer coverage falls. The government – federal, state, local – now funds about 50% of care, and that percentage has continued to grow over the last 20 years. The people who crafted the ACA legislation created a reimbursement system that edges the US closer to single payer, and makes payment justification through documentation requirements so unwieldy as to interfere with the practice of medicine.

Another report released last week showed that hospitals with higher revenue did not perform better on a group of outcomes. This study of several hundred California hospitals supports the idea that pricey healthcare is not better healthcare.

These two unrelated studies move toward the idea that a simple, low-cost system focused on patient care might better serve patients and the economy. Healthcare is close to accounting for 20% of GDP in the US, and that is a mighty engine for growth but also a very dangerous place because it encourages a lot of entrenched interests to preserve their piece of the pie. From a broader perspective, healthcare may also be siphoning resources that could be used to bolster other industry sectors to create a more balanced and resilient national economy.

In a post from the last Health Wonk Review, Health Access blogger Anthony Wright crafted a well-reasoned case for ways to move the single payer discussion forward in politics. Wright, as the Executive Director of Health Access California, plays in political waters every day to move forward broad visions within political realities. Single payer, as he points out, is a term to describe a healthcare system that is “more universal, progressively financed, cost-effective, streamlined and efficient, comprehensive, and prevention-oriented.”

Those goals are all achievable, over time, incrementally. But they require buy-in from an entrenched sector of the economy whose lifeblood is dependent on a massive influx of dollars from all participants to keep it alive.

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Health Wonk Review: Pivoting Toward the General Election

“The long national nightmare is going full throttle.” – Anonymous Health Wonk Review Commenter






DonaldThe Donald…quacking.




For the best in presidential pictorials, and health policy thrown in to make it palatable, you don’t want to miss Brad Wright’s Health Wonk Review roundup at Wright on Health. Let the games begin!

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Under the New “Budget Neutral” MACRA Physician Payment System, Some Will Lose To Pay the Winners

She came to the urgent care center with a sprained ankle. The primary care provider gave her excellent care, expertly applying evidence-based evaluation guidelines to her situation, and, thereby, avoiding unnecessary x-rays. By all measures, the provider’s care was excellent, but the interaction still ended up reducing his salary. You see, that patient’s only medical interaction that year was for this ankle sprain, and the provider was therefore held accountable for all of her primary care needs. Since she had not received a mammogram that year, or received a diabetes screening, he incurred an end-of-the-year penalty for failing to meet these quality standards.

-Peter Ubel, MD from

In an article entitled MACRA-economics 101: Prepare today for tomorrow’s outcomes in Healthcare IT News, author Arien Marec gives one of the cleanest and most concise roundups of the new quality-driven, outcomes-based value reimbursement system that came out of the Medicare Access and CHIP Reauthorization Act of 2015. Under MACRA, providers will be taking on risk for patient outcomes. Marec tells us that providers who aren’t ready to provide data showing their patients are being treated according to guidelines, have good patient satisfaction scores and an effective electronic health record system are going into the new payment world ill-equipped to survive.

After the final MACRA rules were issued on Monday (May 2), the Medical Group Management Association senior vice president of government affairs, Anders Gilberg, warned that solo practitioners and physicians in small groups of 24 or less probably will be on the downside of the risk scale. He said only those in larger groups stand to get bonuses in this payment scheme designed to be “budget neutral” – that is government-speak for the losers will pay the winners.

In MACRA-economics 101, Marec advises physicians to do a few things to get ready now.

Get ready: Prepare with education, analytics and a focus on quality:

  1. Educate. Providers need a firm understanding of their population health approach, robust productivity strategy, and an awareness that use of certified EHR technology is written into legislation.
  2. Incorporate data & analytics. Annually, the amount of healthcare data grows by 48 percent. Clinicians need to think about how they are acquiring and aggregating the data they need to get the full view and manage the whole patient. 
  3. Preplan and refocus on clinical quality. If not already part of an ACO, providers should put together an application for one of the CMS models. If you already have strong analytics, identify the areas you need to improve.

Be Ready Now

And, by the way, all this needs to be ready to go now.  Future reimbursements starting in 2019 will be based on physician performance in 2017 – a mere 7 months away.

The chances that anyone is really ready to play according to these rules is about as good as the chances that anyone was really prepared to get those tasty little Meaningful Use incentives. While MU technically goes away with these changes, the broad parameters regulating use of electronic patient records have made it into the MACRA rules.

Already, we are seeing some pushback from sectors in the provider community that felt they weren’t treated fairly under the Hospital Compare star rating system, delaying release of those ratings a few months while CMS reassesses its calculations. I’m just taking a guess that as these reimbursement rates are announced, other providers who end up on the losing side of the risk equation are going to assert a challenge to the way physician payments are calculated.

Already, some are saying pay-for-performance initiatives are set up to fail as reported in the last Health Wonk Review  because of the many and conflicting metrics. While HHS’ National Coordinator for Health IT Karen DeSalvo and AHRQ President Marilyn Tavenner held a joint presser discussing streamlining of quality metrics that you can read here, right now the urgency is on and providers are running hither and yon unsure which outcome to chase.

My prediction: prepare for legal challenges. The electronic health records needed to support stringent rules backing something as serious as payment are just not where they need to be. Without the solid data, clear benchmarking and reasonable outcomes that take into account the reality of caregiving in widely diverse regions with wildly diverse patient populations, quality- and outcomes-based payment just isn’t ready for prime time.

Posted in electronic patient records, health economics, health insurance, health IT, health policy, health reform | 1 Comment