Volume 57, No. 2 February 2001

TRANSFORMATION

A new collaboration may herald a radical transformation in American medicine: "Hatchets buried, Newt Gingrich and Ira Magaziner agree that the Internet could help to solve some of the problems they battled over unsuccessfully in the past" (Rob Cunningham, Health Affairs Nov/Dec 2000).

Possible outcomes include top-down control through public- private partnerships (national or international fascism) -or an explosion in innovative free-market arrangements.

In a speech at the American Enterprise Institute on Nov 4, 2000, Gingrich said: "The current system is an historic accident with layers of protected inefficiencies and with basic flaws in the very design. I do not believe, theoretically, [that] you can take the current system and design a way for it to work, because I think it violates fundamental principles of how economics ... and human organizations work. I also want to suggest to you that the goal has to be transformation rather than modification, ... replacement rather than repair....

"I also think, frankly, you cannot make the Information Age medical system work if it is a doctor-centered system. I think it has to be a patient-centered system."

All great breakthroughs will come through "disruptive technology," Gingrich believes, citing Clayton Christensen's book The Innovator's Dilemma. Such technology is developed by people who don't get invited to Harvard and don't make sense to HCFA bureaucrats. Moreover, Aetna won't be able to figure out why to pay for it, Gingrich noted.

"You can't plan it; you have to live it," Gingrich said. "And to the degree that we bureaucratize and politicize the health system, we minimize the capacity for entrepreneurs to invent a better future." HCFA, with its 132,000 pages of regulations, is "the wrong model."

Gingrich believes that cost containment is an impossibility. We need a method to drastically reduce cost. That requires at least some direct customer responsibility to pay the bills.

Gingrich and Magaziner agree on the need for better customer access to information-and that the federal government has a major role to play, even if they disagree on the details. Magaziner wants to get to "consensus on universal coverage," and to "get the experience rating out of the system" (i.e. to abolish the business of insurance, which concerns the accurate pricing of risk). Gingrich favors a government-sponsored enterprise like Fannie Mae to "share the collective costs" of bad genes or other bad luck (i.e. socialist, coercive redistribution of wealth). Gingrich also believes that government has to take the lead to achieve standardization.

Gingrich at least realizes that "government can be powerful in blocking the future." However, while recognizing that vested interests will resist change, he doesn't acknowledge the importance of government in consolidating their power, or the dangers inherent in a public-private partnership.

In fact, massive information collection-demanded by the vested interests empowered by "administrative simplification" - serves the needs of bureaucratic central planning. Gingrich may call for outcomes monitoring; the reality is compliance monitoring of the "still highly fragmented physician office sector." Academic health centers and private firms-such as the Health Care Advisory Board and a coalition that includes Duke University, Vanderbilt, and EBMWeb-are busy devising "consensus- care pathways." The Federation of State Medical Boards, a highly influential private corporation founded in 1912, is working through licensure boards to root out non-consensus ("questionable and deceptive") practices. "Disruptive techology" can't thrive if "disruptive physicians" are delicensed.

In a skeptical counterpoint, J.D. Kleinke explains why "vaporware" is not going to fix problems that grow from hybrid public and private financing, cultural expectations of unlimited access, and third-party payers whose financial lifeblood is administrative inefficiency and the rules of the "float" (Health Affairs, op. cit.). Moreover, federal law, particularly the Stark and "anti-kickback" rules, stifles connectivity. Most importantly, "medicine really is an art," Kleinke says, that is "too complex to be digitized." This is one reason why it is not necessarily amenable to methods that work in aviation (Gingrich's favorite example) to reduce error.

Information technology, however, might fix those underlying problems-for the same reasons that it might thwart the social engineers' dreams of central control.

Information technology smashes the monopoly on knowledge heretofore held by academic centers and guilds. It empowers pati- ents, who are already voting with $27 billion out-of-pocket annually for non-consensus-based medicine-an amount that equals out-of-pocket expenditures for all physician visits. It can drastically reduce transaction costs. It can create a true marketplace by making cost information as well as clinical information widely available.

Privacy concerns have impeded certain applications of information technology and are the pretext for a vastly expanded regulatory regime. The rules, contrary to their stated purpose, greatly increase access of government and its private partners to sensitive patient information. The occasion for such information gathering is the submission of a claim for third-party payment- the quid pro quo for surrendering privacy.

And that is the key to radical transformation. Empowered customers may ask: why is payment for medical services so different from paying for other necessities? Why should one have to file a claim subject to bureaucratic scrutiny? Why should one have to pay a third party's overhead, plus a sickness tax to cover other people's care, to buy a medical service?

Technology coveted by the minions of Big Brother could yet be the means for making his mission impossible.

Administrativectomy

In 1999, at the age of 41, with 6 years' experience in private practice, AAPS member Michael Harris, M.D., of Michigan, a solo urologist, had had enough. His patients were brainwashed into a "lotto mentality" and an "entitlement attitude." Insurance companies were hassling more, and paying less, while "trying to reduce medicine to high school cookbook formulas." Instead of complaining, Dr. Harris took out his knife and performed some radical surgery.

In early 1999, Dr. Harris departicipated from all private insurance plans, and in December, 2000, withdrew from his participation agreement with Medicare. Patients are provided with all necessary information and submit their own insurance claims, except for Medicare. Elective surgery is prepaid-by cash, check, or credit card. Local banks provide loans with just a phone call for those patients who prefer to finance their surgical charge: "I am not a low/no interest loan agency." The one patient who financed his surgery last year was paid in full by his insurance company 2 weeks later.

"When we submitted claims electronically," Dr. Harris writes, "patients were isolated from the hassles inflicted on me by their insurance companies.... It took 6 to 8 weeks to complete an uncomplicated insurance claim for companies with whom I did not participate. Companies with whom I did participate questioned my professional judgment and denied payment at will. When medical societies or individual physicians complain about payment hassles, nobody cares.... To my amazement, most patients are paid in full within 2 weeks of submitting their own claims and usually paid in full for my charges. I believe that insurance companies are more sensitive to policyholders than to doctors. The patients bought the insurance; therefore, the company has a duty to the insured. Doctors should never get in the middle of that relationship."

Patients are informed of the billing policy when they call for an appointment. Dr. Harris's rates are low; he cannot afford to hire a collection officer and must be paid for his time, all the time. He will care for the downtrodden free of charge but does not waste time or money submitting a useless Medicaid claim. Some patients are incensed because the doctor will not "honor" their insurance. That is fine with Dr. Harris: "This is a urology service, not a capitated/number game/health care avoidance scheme."

Dr. Harris reports that his overhead is down, and income up. He has never been happier practicing medicine.

Other cost-cutting measures include an simple electronic medical record and very efficient practice accounting. With a laptop computer in every room, Dr. Harris can keep detailed, typewritten notes without paying a 12-cent-per-line transcription charge. He took over the bookkeeping himself, after streamlining it with effective software, and saw accounting fees drop from $1,900 per month to $2,000 per year.

Dr. Harris's advice: "If you are unsure of the radical approach that I took, then start slowly, but with determination. Change for the better, against current thinking, is not always immediately satisfying. Look at your worst third-party payers and departicipate. If you lost 20% of your patients but made 20% more on half the remaining patients-and if your billing and collection headaches evaporated-you would have more income and more time. Imagine that! You could go sailing, golfing, or fishing. You could spend more time with your family.... You could see more patients who appreciate your time and effort. Now is the time to enjoy your practice!

Methodology for Change Agents

The GrantWatch section of Health Affairs outlines the thinking of the Robert Wood Johnson Foundation, one of the ten largest U.S. philanthropies, which controls about $7 billion in assets, including $4.4 billion in Johnson & Johnson stock.

The Nov/Dec issue looks at the RWJF's "end-of-life" projects, which began as the foundation was "making a greater effort to examine more strategically the factors leading to social change and how the tools of grantmakers might affect them."

The foundation began with a study of deaths in hospitals and has built a Last Acts coalition that now has 510 partners. RWJF has dispensed nearly $84 million in related grants. The bellwether train-the-trainer program, called Education for Physicians on End-of-Life Care (EPEC), began at the AMA. Multiple projects are designed to "improve the questions on licensing exams, support residency and faculty training, provide online curriculum modules, and influence the content of textbooks." Encouraging nurses to consider pain as the "fifth vital sign" is an RWJF initiative. RWJF cofunded the PBS series On Our Own Terms: Moyers on Dying, and the outreach program. The Last Acts campaign also aims at influencing entertainment television (such as ER), and sponsors panels at meetings of producers and directors.

Most people, notes RWJF, want a cure, rather than a "good death." The goal is to "help [them] understand that palliative care may be something they want"-and at an earlier point in the "chronic care continuum."

The overall objective can only be surmised. Linda Gorman of Colorado's Independence Institute writes: "Judging by its grants, the foundation's mission appears to be the promotion of policy initiatives that create the institutional framework required to replace private medicine with government-controlled managed care" (Foundation Watch, 11/00). Docile acceptance of rationing would facilitate that agenda.

Robert Moorhead, R.I.P.

Robert Moorhead, M.D., of Yazoo City, MS, died on Dec. 9, 2000, at the age of 92. He joined AAPS in 1948, served as President in 1961, and was an active member until just before his death. In his illustrious 47-year career practicing private medicine, he delivered thousands of babies, including Haley Barbour and Judge William Barbour. At the 1961 annual meeting, he explained, with great prescience, the pitfalls of the Relative Value Scale-the Marxist Labor Theory of Value (see AAPS News Nov 1987 and the pamphlet on the RBRVS.) He faithfully and lovingly served the people of the rural Mississippi Delta in the highest tradition of Hippocrates and also represented his profession in countless ways, including as President of the Mississippi State Medical Association and the Southern Medical Association.

AAPS Calendar

Feb. 3. AAPS Board of Directors, DFW Marriott North.

Feb. 8. Belden hearing (rescheduled), Milwaukee.

Feb. 9-10. Chaos in Medicine: an International Perspective, Oakland, CA. Contact: Dr. Vincent Cangello, (510) 834-4282, [email protected].

Feb. 20-21. Arizona chapter hosts Don Boudreaux of FEE.

Oct. 24-27. 58th annual meeting, Cincinnati, OH.

Organized Medicine for Universal Access

The AMA has given preliminary approval to a change in its Principles of Medical Ethics, adding an ethical obligation for physicians to "support access to care for all people." Dr. Herbert Rakatansky, chairman of the Council on Ethical and Judicial Affairs (CEJA), denies that this implies support for "single payer" or other specific delivery system.

The American Academy of Family Physicians (AAFP) is seeking member reaction to a draft proposal that declares health coverage is a "social good" in which participation must be mandatory (http://www.aafp.org/unicov ). Glen Dewberry, Jr., M.D., of Oklahoma City has supplied an analysis, which is available on request (800) 635-1196. The deadline is Feb. 28.

Correct Coding Fraud

As explained in the Sept/Oct issue of Now Hear This from the League of Physicians and Surgeons, HCFA, in its dual role of single payer and regulator of the Medicare system, is barred from implementing changes in physicians' billing practices without first obtaining input from the medical community. Accordingly, HCFA officials claim that policy on "correct coding combinations" (bundling) is developed by AdminiStar, a Part B contract agent, and then submitted to the AMA for distribution and input.

In the course of investigating carotid Doppler edits, which were the impetus for the carrier to vilify Dr. Lawrence Huntoon in letters circulated to his patients [see AAPS News May and July 2000], it was found that AdminiStar Federal is apparently just a smokescreen. It appears that HCFA develops the Correct Coding Initiative on its own through the National Technical Information Service, in secret. A call to the AMA revealed that there is a committee to review the bundling of codes, but its input is often overridden without explanation, reports Yvonne Archer. This, she claims, is illegal.

HCFA routinely trashes "guidelines and regulations ... designed to act as checks and balances against what otherwise becomes a runaway bureaucracy," states Mrs. Archer.

A court challenge to the CCI process may be feasible. "This could potentially destroy one of HCFA's most effective schemes to cheat physicians out of proper payment for work done," writes Dr. Huntoon.

Sanctions Worse Than They Admit

At a HCFA-sponsored conference call with provider advocates, OIG Chief Counsel "Mac" Thornton reportedly said that "inaccurate, excessive rhetoric is leading [physicians] into harmful behavior," such as undercoding, failing to return overpayments for fear of provoking an audit, or opting out of Medicare altogether (Medicare Compliance Alert 12/11/00). The OIG stated that "only" 21 physicians were convicted of criminal fraud in 1998 and 1999, and fewer than 25 had civil penalties imposed. In 1999, 1,078 providers were referred to the OIG by HCFA for fraud investigations, and 723 in 2000.

Convictions don't tell the whole story. Some attorneys say that Medicare's real weapons are threats of false claims suits and suspension of payments, which help to extract settlements. In FY 2000, the amount taken in health care fraud settlements reached an all-time high of $840 million. The number of excluded providers was 17,271 as of Nov, 1999, and 20,196 as of Nov, 2000).

While pressure might ease under the new Administration, don't count on it. Attorneys interviewed by Medicare Compliance Alert (1/1/01) predict more scrutiny of Evaluation and Management (E&M) codes; more searching for evidence of denial of care; and an increase in anti-kickback enforcement, which may emanate from compliance activities. Smaller physician practices may be prosecuted just to show that "no one is too small to escape notice." More asset freezes are likely, even in civil cases.

Star Chambers Make Coverage Decisions

According to a letter from Stephen Northup, Executive Director of the Medical Device Manufacturers Association (MDMA), HCFA should abolish Medicare work groups made up of contractor medical directors (CMDs), which he calls "latter-day Star Chambers."

CMD groups "are not specifically authorized by law or regulation, do not meet publicly, and are not required to disclose the nature of their deliberations or to justify their decisions. Nevertheless, the work of these CMD workgroups is the basis for hundreds of local medical review policies that determine what medical procedures and technologies are available to Medicare beneficiaries."

[See http://www.medicaldevices.org.]

Guidelines Don't Follow Guidelines

As pressure mounts to evaluate physicians for compliance with guidelines, the methodologic quality of clinical practice guidelines in the peer-reviewed medical literature is highly pertinent. Of 279 guidelines published from 1985 through 1997, mean overall adherence to standards was 43%, with no difference between guidelines developed by medical societies compared with government agencies. The biggest deficiency was in the identification and summary of evidence (JAMA 1999;281:1900-1905). Only 7.5% described formal methods to combine evidence and opinion. The evidence relied on by guideline developers was "modest in rigor, discordant, or nonexistent" (JAMA 1999;281;1950-1951). Few of the guidelines were evaluated in practice before dissemination.

On achieving consensus before back-up disks:

"As soon as Winston had dealt with each of the messages, he clipped his speakwritten corrections to the appropriate copy of the Times and pushed them into the pneumatic tube. Then, with a movement that was as nearly as possible unconscious, he crumpled up the original message and any notes that he ... had made, and dropped them into the memory hole to be devoured by the flames.

"What happened in the unseen labyrinth to which the pneumatic tubes led, he did not know in detail, but he did know in general terms. As soon as all the corrections ... had been assembled and collated, that number of the Times would be reprinted, the original copy destroyed, and the corrected copy placed in the files in its stead.... In this way every prediction made by the Party could be shown by documentary evidence to have been correct; nor was any item of news, or any expression of opinion, which conflicted with the needs of the moment, ever allowed to remain on record."
George Orwell, 1984

Members' Page

The Motive. Our hospital brought in an attorney to give a presentation that was supposed to "scare all of us real good" so that we would become better documenters and more compliant with government regulations. He apparently talked with an FBI agent in Buffalo recently and was told that four or five more FBI agents had been added in this area for the sole purpose of investigating health care fraud. The main reason is not that there is necessarily a lot of fraud, but that health care is a major part of the economy in western New York State. In other words, there is a lot of money that the government feels it can get its hands on.
Lawrence R. Huntoon, M.D., Ph.D., Jamestown, NY

Spending Levels. Who is to say what the "right" level of spending is for a given purpose? The U.S. spends much less on food as a percent of GDP than many other nations. Does that mean that we are starving? We spend a lot more on entertainment than most ($495 billion). So what? Who cares?

If we look only at government (involuntary, coerced) spending on "health care," the U.S. is at about the same level as other developed countries. The rest is voluntary, private spending that we choose over other uses of our money. Who dares to say that we should be forbidden to spend our own money for medical care-other than the World Health Organization, of course?
Greg Scandlen, National Center for Policy Analysis

Where Bills Come From. Many Republicans were surprised to find language in nearly every health care reform bill passed since 1994 that is identical to provisions of the Clinton health plan, which failed in 1994. When confronted with that fact, members responded that they didn't read the bill.

The bill came from the computer files of staff members. The party of the committee chairman may have changed; but the language in the computers didn't.
Ernest J. White, Alexandria, VA

Ritalin Abuse. Congratulations to AAPS for the articles on drug abuse, Ritalin, and ADHD [see AAPS News Jan 2001]. You bring out a very serious public health problem that has been largely ignored by physicians and the public. The scientific validity of ADHD has been taken for granted. So has the need for Ritalin and other psychotropic drugs for young children whose school behavior is considered pathological. Perhaps the worst part is that the state, with all its enforcement powers, is behind the whole operation....

Note that the use of the term (Mental) Illness is inconsis- tent with the DSM classification of the APA, which speaks of "disorder" (the last "d" in ADHD)....Medical student Winston Chiong has written an important reminder that the use of the term "disease" should be reassessed (MS-JAMA, 1/3/01, p. 89). Diagnoses are often given too liberally without regard to the social and economic consequences [to the patient]....
Nelson Borelli, M.D., Northwestern Univ. Medical School

Peer Review Abuse. AAPS is the only organization I know of, except for the Semmelweis Society, that has ever taken any interest in the terrible problem of sham physician peer review. I am dismayed that there is virtually no avenue of redress for the physician targeted for bad-faith peer review. By the time the process is well underway, he is probably doomed. I suggest that at the first hint of an attack on a physician's staff privileges or medical license, he should go into a state of general alarm and spare no expense or effort at immediately attacking the process. Waiting and hoping that things may not be so bad after all seals the doctor's fate-just as delay in the use of potent antibiotics in the face of a serious bacterial infection leads to sepsis and death.
Edwin Day, M.D., Lafayette, LA
www.semmelweissociety.org

MSAs Catch on Slowly. Within my 20-employee company, we implemented an MSA option in 1997. An employee can pick the $500 deductible "traditional" plan or the MSA. Initially, I was only able to persuade half to pick the MSA, but as the MSA enrollees have experienced significant accumulations and better coverage, all but one have converted to MSA.

Proposals that require the employer to pick one or the other plan, but not both, create too much tension. Not wanting to rock the boat, the employer picks the traditional plan. Giving the employee the option enhances the market penetration of MSAs.
Art Jetter, Jr., Omaha, NE

A Corrupt System. I belong to the Christian Brotherhood Newsletter, a group of people who agree to donate a certain amount each month to help other members pay real medical bills. It is not insurance, so we are considered self-pay. One member broke her hip, incurring $40,000 in hospital bills. The financial department said the best they could do was a 10% discount. She balked, knowing that HMOs or Medicare would never pay that much. They encouraged her to apply for "charity" care. Here is the zinger: "We would prefer government payment to your cash, so we will qualify for more government aid in the future."

We will pay the bill, but not until we make some big waves. We will negotiate a better discount for cash.
Alieta Eck, M.D., Somerset, NJ

Legislative Alert

President-Elect George W. Bush presented the American people with a strong and remarkably detailed policy agenda, ranging from substantial reform of Social Security and Medicare to ambitious education and tax-reduction initiatives. His Cabinet choices-from General Colin Powell and Donald Rumsfeld to Governor Tommy Thompson and John Ashcroft -demonstrate that he is serious and that he understands a crucial fact: Personnel is Policy. You can't get a solid agenda for change enacted unless you have capable and committed people to promote it.

When the President-Elect met with Congressional leaders on December 2, 2000, he said: "I'm going to remind both the Speaker and the leadership about the agenda that I've talked about. I feel one of the reasons why I'm sitting here is because of the agenda, and it was a clear agenda" (Washington Post 12/14/00). Likewise, Ari Fleisher, the President-Elect's transition spokesman, also told The Post, "The governor is committed to the programs on which he ran. The ability to govern and enact an agenda derive more from the actions of the officeholder than the margins of an election." The President- Elect's Cabinet choices reinforce his commitment to honor the promises he made to the American people.

Advice from Opponents

The newly elected President will be deluged with advice on how to "hit the ground running"; how to manage the government; whom to appoint; whom not to appoint; what is and is not in his best political interest or the national interest. He will be counseled on how to exercise the time-honored political virtue of "prudence," the need for "temperance" and "restraint" in the pursuit of his policy objectives, and the wisdom of accepting lower expectations. Remarkably, he will be given "friendly" and ample advice and counsel from policy analysts, foundation representatives, journalists, and politicians who, feigning good will toward the incoming Bush Administration, deeply regret that he has been elected to the Office of the Presidency in the first place. The new President realizes, of course, and so should his advisors, that such counselors can also be relied upon to wish him little or no success in making major policy changes, particularly in domestic policy.

While "bipartisanship" in a closely divided government is often a political necessity, it is equally true that the spirit of bipartisanship can only remain vital within the contours of the new President's promises-his public trust-to the electorate. In their solid and candid assessment, the editors observe, "Mr. Bush's main campaign promises remain anathema to many Democrats, and the things Democrats like least about them tend to be precisely those that many Republicans like most" (Washington Post 12/19/00).

The Presidential nomination and clearance of Cabinet officials is complete. The burden of quick confirmation should rest with the Senate. It appears that Senator John Ashcroft, nominee for Attorney General; Gale Norton, nominee for Interior: and Linda Chavez, nominee for Labor will all run into left-wing opposition. Wisconsin Governor Tommy Thompson can also be expected to generate at least some heat: the hard Left will never forgive him for welfare reform, and the abortionists' lobby is not known for its moderation.

Left-wing groups and their allies on Capitol Hill are girding for battle. While nobody yet seriously thinks that the congressional Left will be able to defeat these Cabinet nominees, nobody seriously thinks that the Left is simply going to fold. And, of course, don't expect Washington's liberal leaders to offer avuncular advice to NARAL et al to defer to the recently heady spirit of bipartisanship. In official Washington, one is quickly educated to the fact that this thing called "bipartisanship" is a one-way proposition: it means that Bush should surrender and refrain from pushing either his conservative agenda on tax cuts, for example, or nominating conservatives to carry out conservative policies.

Recruiting the Lieutenants

Moving a major agenda for change-including a rollback of excessive taxation, promoting accountability and performance in America's educational system, and improvement in the pension and medical coverage for the next generation of retirees-will not only depend on the ability of the President to work cooperatively with Members of Congress, building alliances across party lines and accommodating the legitimate interests of competing factions in a closely divided national legislature. It will also depend on the quality and commitment of his own political appointees below the Cabinet level-the Assistant Secretaries, the Deputy Assistant Secretaries, and the non-career senior executives and program managers.

The new President must make a serious determination on the number of political appointees he will need. Obviously, no President can advance his agenda with a small handful of staffers in the White House or the federal departments. His political opponents on Capitol Hill and elsewhere, of course, understand this, and hostility to the Administration will sometimes take the form of Congressional attempts to limit his appointing power. Likewise, the new President should expect that any increase he makes in the number of political appointees will draw fire from opponents in Congress, liberal foundations, and the "public administration community," who will complain that he is "politicizing the civil service". The new President should be prepared for this kind of self-serving propaganda, recognize it for what it is, and remain undeterred by it. He needs a full cadre of personnel, personally loyal to him and fully committed to his agenda, in the federal agencies that execute the details of national policy. Once again, appointing a sufficient number of political appointees to staff key agencies and subunits in the agencies and departments will enable the new President to suffuse his authority throughout the executive branch of the government, enhance cooperation among political appointees in the agencies, promote teamwork among his appointees, and prevent their isolation.

Depending on the Career Civil Service-to a Point

Career staff in the federal departments and agencies also have a civic duty. They must give new political appointees solid information concerning not only of the issues requiring immediate attention, but also of current policies, priorities, and programs. In this respect, briefing books can be an invaluable tool, and an excellent point of reference over time. These volumes can provide detail on the history of these programs, how they work, and why they are structured the way they are. They may prove truly enlightening. More importantly, they can provoke the right questions from political appointees. New political appointees are likely to find out that agency priorities, or the way programs are organized, reflect the political agenda of the outgoing Administration.

Clinton Administration loyalists, not universally known for their own bipartisan spirit, understand this. Upon taking office, President Clinton quickly, by executive order, reversed many of the first Bush Administration policies in the first days and weeks of the Clinton Administration. It was change-big time. Mr. Seth Harris, a policy advisor for President Clinton at the Department of Labor, in a remarkably candid article kindly advised Mr. Bush to rely more on the advice of career staff and dispense with the bulky briefing books: "Forging early and close relationships between each department's new political leadership and its career staff will moderate any ideologically driven agendas and produce a better functioning government. The briefing books will hardly be missed" (Washington Post 12/20/00). Translation: Look, you dim Republicans, don't you worry your little brains about all that hard, dull, dry-as-dust and mind- numbingly detailed program and policy stuff; we'll tell you what you need to know." Can't you see it now; the old gang over at HCFA telling all those newly arrived conservative health policy team coming into HHS to just, well, relax and take it easy. Don't worry. Be happy.

Wanted: A Tough and Loyal Team

Political appointees are in the spotlight all of the time. They must be constantly aware of how a Presidential initiative will play in the media. They must understand this in the formulation and the implementation of policy. The price of failure in this respect can be high. So it is essential that among the criteria for selection of executive appointees should be their experience in dealing with the media, including television. It would certainly help the President and his team if the men and women who are expected to speak on behalf of the Administration, especially on controversial issues, be given the appropriate media training for doing so.

A serious agenda for change is always difficult, and nowhere more so than in official Washington. The new President should realize that many attractive candidates, for all of their fine personal and professional qualities, education, and experience, may not fill senior positions well where they are charged with being agents of change. Such a role inevitably invites conflict, on Capitol Hill and in the media, and it requires personal perseverance, stamina, and, as the occasion demands, raw political courage. Some otherwise highly qualified candidates are simply not cut out for that kind of role. In the past, there have been cases of political appointees "going native" in the federal bureaucracy or enriching their resume, while losing sight of their primary mission and the very reason for their appointment: the advancement of the President's agenda, rather than their own future career prospects or the institutional interests of their departments or agencies. It is an old, and sad, Washington story.

Secretary Thompson at HHS

The nomination of Wisconsin Governor Tommy Thompson is the appointment of a strong leader in what is shaping up to be a very strong Cabinet. Elected three times by comfortable majorities in a state historically cool to conservative politicians, Thompson brings strong political skills with his well-established administrative ability. At HHS, he will need both. The point to remember: HHS is a huge bureaucratic Empire with many kingdoms-including HCFA and its financially troubled Medicare and Medicaid portfolios, the Public Health Service, the National Institutes of Health and major welfare and social program responsibilities.

Thompson brings to the big job a solid track record of achievement. He was the first governor in the nation to apply on a broad scale what Bush has identified as "compassionate conservatism." His pioneering welfare reform program, based on a waiver from HHS, resulted in a stunning 91% reduction in welfare caseloads, and against all of the dire predictions of the Left, low-income residents in Wisconsin were not left starving in the streets, but many found themselves with jobs and a new sense of self-respect. It is not too much to say that without Thompson's performance, the revolutionary 1996 welfare reform act would never have been enacted. Not only does Thompson match Bush's profile of a "compassionate conservative"-a social contractarian who offers government assistance laced with a strong dose of personal responsibility-he is strongly pro-life, a backer of parental consent for abortion for minors, and a vocal opponent of partial birth abortion, the horrendous practice which was routinely protected from a Congressional ban by Clinton's veto. And of course, he achieved some of the biggest tax cuts in Wisconsin history.

If the past is prologue, Thompson, like Colin Powell, promises to be a high-profile cabinet member, as well as a team player, and very possibly a household name in America. He has a passion for action, and has stated his intention to fight vigorously for "meaningful changes," not just tinker around the edges of the status quo. In his acceptance remarks, please note that Thompson stated his admiration for Bush's willingness to take on Social Security, the "third rail" of American politics, and ignoring "safe," stale, and conventional political wisdom. So it looks as if Thompson is going to be a tough and relentless battler for the Administration's agenda. Thus, Thompson will either be taking point or riding shotgun for the White House in a major efforts to tackle the troubled financing of Medicare and Social Security. Hopefully, he will be putting into place an improved system for both, working out the inevitable wrinkles, well before the retirement of the 77 million baby boomers.

Please note: The transition team, now at work at HHS, is headed up by Sally Canfield, a top legislative staffer with the brainy Congressman Jim McCrery (R-LA), who has emerged, with House Majority leader Dick Armey, as one of the top Congressional champions of tax credits and consumer choice as the pillars of health care reform. It's very early, but the initial signals are impressive.

Robert Moffit is a prominent Washington health policy analyst and Director of Domestic Policy at the Heritage Foundation.