Friday, August 28, 2009

Travel Subsidy on the Health Train Express

The real 'deal'

The American Medical Association came out in favor of the House Democratic health care bill when the House Democratic leadership promised the doctors $230 billion in new spending to cancel out any future Medicare physician cuts (which are scheduled under an existing law called the Medicare Sustainable Growth Rate Formula). As a result, the doctors don’t have to give up anything under the health bills, and would actually pick up $230 billion under the House bill over 10 years.

Hundreds of 'sound bytes' and snippetes of highly charged statements are read daily by patients, providers and decision makers. Unfortunately for the uninformed (and even the informed) ferreting out the 'truth' is very difficult.

Both Republicans and Democrats seek the position to regain p ower, or retain power.  One has to take with a grain of salt, analysis from either side of the aisle.

It's up to we the people to analyze and make your own decision regarding health issues, and be certain your opinion reaches your representatives.  Avoid being a leftist or a right winger.

Perhaps we should not make any decision this year in the midst of economic upheaval from which we have not yet recovered.

Bailing out banks, financial institutions, automobile industry have left us all a bit depleted and in no position to make such a critical decision.

Professionals cast a jaundiced eye upon statistics and projections of healthcare financing.  In reality it is difficult to imagine health care costs in 2016, while dealing at the present moment with a diffiicult system that is challenging to navigate for providers and patients alike.

I like to compare health reform to  the end goal of  orbiting  a satellite. The most effective means of accomplishing this task is by 'staging' a rocket with three booster segments.


It would be almost impossible to accomplish this task with a 'one stage rocket'. This is also true of health reform. 

One Small Step


Gravity acts to keep objects on earth and our present health system also retards change with inertia.

Here is some of the last weeks analysis.

WSJ's blog on health and the business of health.

Claims that health reform will be disastrous for businesses and government are wrong, writes Gary Locke, the U.S. secretary of commerce in an op-ed in the WSJ. Making his case for reform, Locke says that climbing health care costs already cost American businesses jobs and revenue, as well as entrepreneurship, and that isn’t sustainable. “In the short term, health-care costs pose a major problem for companies and their employees,” writes Locke. “In the medium and long-term, these costs pose serious challenges to our economy.”

Fixing Health Care will be good for the Economy

How Hospitals Could Profit from Health Reform

Rick Peters writes in The Health Care Blog

Wednesday, August 26, 2009

A Missing Passenger of the Health Train


Edward (Ted) Kennedy, D, Mass, departed from the Health Train yesterday. A significant voice in health affairs has left the stage. Not much more can be said by me when others have so elequantly described his life, and times.  Health Train Express offers condolences to his family and constituents.

A moment of silence.....

image image image

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Ramblings on the Health Train


My day here at the government run undisclosed location started off with my morning read of health related blogs, pundits, and rumor mongers.

Buckeye Surgeon from Ohio presents a personal interview with two of his medical school chums, one in private practice and the other who is employed by the Cleveland Clinic. Rather than trusting media sources and medical management statistics, Buckeye decided to do his highly statistically significant study with a cohort of two…..My take on the interview is that some doctors like to work in a group practice, while others are individualists, and like to work alone or in a smaller controllable environment, where you have a choice of wallpaper color, who you hire and fire, and are accountable for just about all you need to practice medicine, and all that you perform. That is what is so unique and vibrant about our health care system….choices for physicians and patients.

Over at MedPolitics , and RealClear Politics The discussion turns to the uninsured.


Here is the “scoop” from t he CATO Institute regarding the uninsured, and who they really are.



Monday, August 24, 2009

Lieberman--A Voice in the Wildness

Joseph Lieberman, (IDem) Senator from the nutmeg state, CT boldly goes where no man goes before...a voice of reason, perspective and quiet reasoning. (typical of Lieberman).


One of the Senate's most powerful Democrats, Joseph Lieberman  said  Sunday that President Obama should take an "incremental" approach to fixing health care and argued that the country should postpone adding nearly 50 million new patients to the government system until after the recession is over.

"We morally, every one of us, would like to cover every American with health insurance," Sen. Joseph Lieberman of Connecticut, told CNN's John King on the "State of the Union" program.

One of the Senate's most powerful Democrats said Sunday that President Obama should take an "incremental" approach to fixing health care and argued that the country should postpone adding nearly 50 million new patients to the government system until after the recession is over.

"We morally, every one of us, would like to cover every American with health insurance," Sen. Joseph Lieberman of Connecticut, told CNN's John King on the "State of the Union" program.

"I'm afraid we've got to think about putting a lot of that off until the economy's out of recession," he added.

"There's no reason we have to do it all now, but we do have to get started. And I think the place to start is health delivery reform and insurance market reforms."



Although we physicians recognize perhaps more than most that out health system is flawed, most know that this must be accomplished in small steps, focusing first on defects in our insurance system, which lead to the increasing numbers of insured, and increasing overhead to physicians and our society in general.

In the back of each our minds are the millions of uninsured who present in our offices, on an hourly basis,  in the emergency department and public health clinics. 

The term "The Public Option" thus far remains clouded in hyperbole, sounds good or bad, depending  if your leaning is to the left, or to the right.

For many "The Public Option" remains a poorly disguised euphemism for Socialized Medicine.

Wednesday, August 19, 2009

Value, Security, Beauty and Elegance

Mark Smith, CEO California Health Care Foundation, (video link)  spoke at the Microsoft Connected Health Conference meeting in June.


Comparisons between Richard Nixon’s Health Reform Proposals and Obama’s described by Mark Smith, illuminate the similarities and differences. Read what a staunch conservative Republican proposed for a national health universal payor program.

Mark Smith and the things to get ‘right’

  1. Standards
  2. How will we wire doctors …nagging fear
  3. Attributes for providers:
    1. Simplicity, Adaptability, Functionality
  4. Attributes for “patients”
    1. Value (for the patient) solve the patients perceived needs.
    2. Security and privacy issues
    3. Beauty, elegance (something ‘they want’)

Dr Smith presented what doctors and patients would like from health IT developers.


Health care financing in itself is a morass of complicated systems. Those who wish to make it as simple as possible, are mistakenly driven toward a universal payor model. What lurks behind the scene with that model is unknown and unintended levels of bureaucracy and the considerable expense of reorganization of the entire system.

It seems public opinion is focusing on these elements:

1. Eliminate cherry picking by private payers, elimination of exclusionary policies and waivers as well as predatory premiums.

2. A public option (which could be temporary) for lapses in employment, and/or insurability, or disability

3. Developing an actuarial insurance base that includes all citizens of the United States.

4. Elimination of free care for undocumented aliens.

5. Elimination of reimbursements based upon procedural coding.

6. Transparency and private oversight of government insurance plans and development of health IT.

7. Improve physician availablity for both primary care and specialty physicians by ''federalizing' medical licensure. Present state regulations amount to restraint of free trade. State licensing largely depends upon national testing standards.

K.I.S.S.  Keep it Simple, Stupid !

Tuesday, August 18, 2009

The SERMO-AMA Disconnect

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Kevin MD today makes some keen observations about the recent dissolution of the AMA – SERMO connection. The sad fact is the outcome weakens the credibility of both organizations. No one knows what the ‘pre-nuptial agreement’, nor what investment in hard cash we as physicians made in SERMO. It would be nice if there were some transparency, other t han the posturing of either side.

My view is that we as physicians were hurt by these events. Neither side seems to want to own accountability for the rupture in the partnership. My guess is that The American Medical Association reacted like a ‘hurt parent’ when confronted by SERMO with the ‘truth’. The AMA and it’s board obviously did not see the relationship as mutually beneficial. The American Medical Association seems to have treated SERMO as a mere ‘marketing opportunity” for the AMA. They never really saw this relationship as a true “partnership.” Partnerships require trust, and trust requires time and actions to prove it’s worth. The AMA lost the opportunity to hear from the disenchanted physicians who no longer belong to the AMA. Perhaps the AMA thinks that by withdrawing its support for SERMO, it will wither and die. SERMO will find a number of other suitors. Mere numbers do not make any organization strong. Many ordinary decision makers and the general public no longer see the AMA as representative of doctors, and the AMA now shares the stereotyping as just one more special interest lobbying group.

Even as an early supporter of SERMO, and Dr. Palestrant’s meteoric rise in medical social networking, as well as major media, I feel somewhat chagrined, and can feel the angst of Dr. Palestrant….

I do not know the inner workings or the need for capital that SERMO required when the partnership was formed. The AMA is a much more mature and well structured organization, not dependent on the actions of one man. Dr. Palestrant seems to act alone, however I do know that I once served on an advisory council. I haven’t heard anything about that council for several years.

The fact that so few replied to the survey about the AMA is not surprising, given that most surveys have a very low yield . Also, given the fact that most doctors only occasionally sign into SERMO occasionally most missed the actual survey itself.

The fact is that doctors need the AMA, and also need organizations such as SERMO.

Other organizations have made the same observations

Saturday, August 15, 2009

Daniel Palestrant, MD

Dan Palestrant, CEO and founder of has made the rounds of three media giants CNNMSNBC,  & CNBC.

image image image

In a friendly face-off with the AMA and other organized medical groups, Dr. Palestrant ably demonstrates that the AMA does not accurately represent many physicians. Of the 800,000 physicians less than 250,00 are AMA members.

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What is fascinating to me is that SERMO began only three years ago as a meeting place for grand rounds, and physician to physician interaction regarding interesting clinical cases and treatments.  Members must be authenticated as duly licensed and credentialled MDs or DOs.  Sermo's 110,000 members represent all specialties of medicine from family practice to all specialties.

Members communicate almost in real time posting in different categories of interest, ranging from business, politics, practice management to each specialty. SERMO also surveys it's membership regarding clinical issues and treatment. The high interest in health reform and AMA positions on health reform stimulated active discussions on the SERMO boards, and it became apparent that 90% of participants did not support AMA positions.  Dr. Palestrant decided to provide a more formal poll of issues. In the limited time available for sound bytes he was unable to elaborate on all the other issues of concern to physicians.

Sermo has unexpectedly developed into a sounding board for previously  alienated physicians, not it's original intent.

SERMO has only been in existence less than three years.

Not only will SERMO continue to play an important part in health reform discussions, but it will also have a moderating effect on the AMA from a formerly silent minority (majority) of physicians.

Hat's off to Daniel Palestrant MD  another courageous physician and true visionary.

Thursday, August 13, 2009

Mr. President: 'Shut up!'

The above title is my own..GML
The $50,000 Gangrenous Foot

By Buckeye Surgeon

"This one just takes the cake. We're definitely going to need another Beer Summit after President Obama's latest gaffe:

"If a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they're taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that's 30,000, 40, $50,000 immediately the surgeon is reimbursed. But why not make sure that we're also reimbursing the care that prevents the amputation? Right? That will save us money."

The ignorant arrogance, it just oozes. Vascular surgeons are getting 50 grand to lop off legs? Interesting. I surely would have done a vascular fellowship if that were the case. Sounds like a gravy train. Sit around, wait for poorly remunerated, overworked primary care docs to neglect the diabetic care of their patients, and boom, one day six of them show up in the office with gangrenous feet. Jackpot!
Listen, amputation is the procedure of last resort. And generally patients don't get referred to vascular surgeons needing amputations. They get referred with rest pain or with ischemic/diabetic ulcers. And then it's a progression of intervention. Conservative care. Stenting. Fem-pop bypass. Revision bypass. Fem-distal bypass. And then, finally, when all else has failed, the patient may need an amputation. And this process is generally managed entirely by the vascular surgeon!
There are those who would say (my least favorite Obama phrase) that our President "simply misspoke". But in the context of his recent remarks on ENT docs whacking out tonsils for financial gain, I tend to think that we're starting to see a pattern. The American College of Surgeons does as well. Once again, we see the President attacking the fragmented physician faction, demonizing us as the primary source of our health care woes. And the way he opted to use leg amputation as an example; chosen randomly out of thin air or a deliberate ploy? There is no more gruesome procedure in surgery than an elective amputation. The imagery and connotation it evokes is powerfully negative--- rich proceduralists hacking off your leg for a cash bonanza. Again, this man does not speak flippantly or off the cuff. Everything is purposeful.
I eagerly await the Great One's clarification of any "misrepresentations".

Mr. Obama's speech writers and advisors on health care are more than misinformed.  They ignore (?purposefully?) the real facts, substitute platitudes and offer politically correct lies to bolster their reform proposals.   GML

Wednesday, August 12, 2009

The Great Medicare Debate Part I JFK-Annis 1962

1962 and 2009, what do they have in common?  Let's watch and listen to this presentation by John F Kennedy at the 'birth of medicare'.

I was there as a pre-medical seems we have not come very far since then.  $12.00/month for medicare premium... Originally presented as a program that required proof of need. JFK used the argument that the government had the duty to promote the 'general welfare"....sounds good to me.

Tuesday, August 11, 2009


War Games?


An interesting article appeared in iHealthbeat during the past month. iHealthbeat is a part of the California Health Foundation and also publishes on the internet at

The article points out what ‘we’ are up against with the coming health care reform, and the massive infusion of capital into health IT.

Several clips from the article:

War Game Forecasts Future of Electronic Records

by Leonard M. Fuld and Kim Slocum

Dateline: April 3, New York, N.Y.: Microsoft makes a play for Allscripts, then failing that attempt, pursues Kaiser Permanente to create an exclusive EHR-PHR agreement with the pre-eminent managed care behemoth. Allscripts independently cuts a deal with a large health care company to expand its sales force to aggressively penetrate the 80%-plus physicians who currently do not use EHRs."

Almost none of this has happened yet -- except within the confines of a war game used to stress test company strategies in the rapidly changing electronic health records industry. This war game, "The Battle for Healthcare Information," took place this spring, employing savvy health care-experienced business school students from Columbia, Kellogg, MIT and Wharton business schools. They formed teams, representing a variety of EHR players: Allscripts, Kaiser Permanente, McKesson and Microsoft.

image War Game Defined

What is a war game? It's a disciplined series of exercises designed to stress test company strategy.  It does so by introducing today's economic reality and constraints rolled together with fact-based background on all the players, mostly competitors

A key point when considering staging a war game or strategy game: Do your homework. You need to do research on each of the companies whose roles you will play or test during the exercise

Another important echo comes in the comments on blogs reporting on the game. Doctors, hospital administrators, software designers and a large mass of patients have reacted strongly. Many patients are nervous about privacy issues. Doctors both fear the administrative burden and the potential distancing from patients that this technology will bring. The technology community admits that existing systems will not stand yet cannot see who can break down these tech walls, preventing true universal adoption of EHRs and PHRs.


The article diverges into areas not germane to this post.

Much of what this article discusses in regard to Health IT also applies to health reform.

image Drive through pediatric office

Do providers and hospitals need to play more ‘War Games”? Without this strategizing no one can tell or even prophecy about unintended consequences of health reform. Because each segment of the health care industry plays to it’s own unique players, health reform may not have it’s intended consequences.

Will the changes increase the number of primary care providers? Will the changes reduce over-utilization.


Will it equalize reimbursements between primary care providers and specialists? Will bureaucracy be reduced? How will insurance companies react to legislated and mandatory rules forbidding cherry picking, waivers and exclusions, and discriminatory premiums?

Health reform is a big ticket item, complicated and will have many repercussions.


It's important to get the political issues, assumptions and ghosts regarding the "fearsome" competitor on the table in advance.

The health care industry is a highly regulated segment of the economy and has demonstrated in the past it’s unique reaction to market pressures.

clip_image002Porter’s five force analysis (see above) can well be applied to the forthcoming changes being proposed for health care. Porter referred to these forces as the micro environment. They consist of those forces close to a company that affect its ability to serve its customers and make a profit. A change in any of the forces normally requires a company to re-assess the marketplace. The overall industry attractiveness does not imply that every firm in the industry will return the same profitability. Firms are able to apply their core competencies, business model or network to achieve a profit above the industry average. A clear example of this is the airline industry. As an industry, profitability is low and yet individual companies, by applying unique business models have been able to make a return in excess of the industry average. In other words one cannot generalize about issues. Those who plan strategically with the forthcoming changes will profit immeasurably.

Undoubtedly this will also apply to healthcare, pharma, hospitals and payors. Universal payor at first glance would seem to eliminate the vagaries of the ‘marketplace”, however it is also problematic adjusting to short and long term changes.

Sunday, August 9, 2009

Which Health Plan is Better??

Those of you who have read my two previous posts realize how fortunate we are to have Dr.Tom Coburn as a U.S. Senator. He uniquely represents  physicians (as advocates of the patient). and is highly articulate, and well informed.  His comments on the previous posts were from the Health, Education, Labor, and Pensions Committe during their discussions on SR 325.

United States Senator Tom Coburn


The Patients Choice Act   S 1099  or:

The Democratic House Bill  HR 3200

Health Train Express--Personal Observations


I was just responding to a thread between several of my former classmates from GWU Med School.  After composing it and reading it I realized my thoughts probably reflect those of you who read my blog. 


Dear Gary,
    I thank you for your letter to Al.  Your continued leadership is a blessing.  Jim  Rowsey  On Aug 8, 2009, at 7:52 AM, Gary Levin wrote:

> Dear Al,
> Sorry my response was so abbreviated.  I was thinking a great deal
> about what you said about opposition vs. leadership.
> As you and I know this is a very complex  "industry'. Each segment
> responds to market pressures in it's own way.
> I agree that physicians must be leaders, as we have always attempted
> to do so as patient advocates...
> Frankly my feeling (and many others) is that our advocacy for patients
> and our desire to 'comply' and not rock the boat has led many segments
> to take advantage and use their own advantages to obtain what they
> desired.
> Now we are being asked to agree with an overall sweeping change to
> further accommodate and endorse what we already know does not work.
> Some of these changes started as far back as 1971 when the HMO act
> began a series of events that had many unintended consequences such as
> the failures of many practices, unethical marketing practices, the
> construction of many evanescent organizations which controlled
> physician referrals, closed out markets to new entrants (ie, new
> physicians). And some of these have led to the shortage of primary
> care physicians.
> Our present system gives more credentialing clout to insurance
> companies than state medical boards, The only group of people that
> have consistently been asked to do more for less while our overhead
> has soared is physicians and hospitals.  It is close to a miracle we
> have survived.  Many of us went bankrupt in the late 1980s here in
> California.  Medicaid is an unfunded mandate, and actually Medicare is
> as well.
> The devil is in the details.  I doubt if any legislator is capable of
> analyzing the impact of this gargantuan bill.  Our leadership should
> consist of careful advice in regard to the known impact and the
> unintended consequences of each portion of this 'global HR 3200.
> I am not opposed to change, however slick slogans and the 'crisis
> mentality'
> of our present administration is disingenuous.  Doctors have been
> talking crisis for the past 20 or more years.
> Change can be made.  The first is that the insurance industry must
> stop cherry picking and have a level playing risk pool. Health
> insurance should not be an employer responsibility.  That is obvious
> by the many who lose their coverage for no good reason other than they
> lost their job and COBRA rates are punitive.  If someone in their mid
> 40-50s becomes ill and loses their coverage, it is neigh well
> impossible for them to regain coverage due to exclusions wavers and
> predatory premiums. These changes are do- able.
> Reimbursing primary care doctors equitably would swell the ranks of
> primary care. Even though I have been an ophthalmologist the majority
> of my career, I miss many aspects of general medicine.  Primary care
> physician spend a lot of time triaging to specialists. They are not
> reimbursed for this cognitive skill.
> I know that most physicians have tried to be calm, reasonable, and
> also have compromised a great deal (under the economic threat of
> worse)....
> Perhaps the younger physicians will not know better.
> Americans will lose their freedoms if medicine goes the way Obama
> wants it to. We are a deeply divided nation.  I don't think we need to
> look at other countries for a 'better solution'...we have it in our
> power to develop a beter system right here, and now.
> The argument that if we don't do it now, it will not be done, and our
> economy, the country and the world  will go away. Balderdash!!! The
> taxpayers were forced to bail out the financial world, why should they
> be asked to continue throwing money down the toilet. (there is no end
> to medical expenses, Who wants to let their parents, brothers, etc
> die?
> Especially if mandated by a huge unfeeling government or insurance
> entity.
> For many years children, brothers and sisters made those decisions
> based upon their family's needs and desires.
> We now have to get authorizations, certifications, approvals to have a
> bowel movement. How much money does all of that cost?  A doctor can no
> longer express his anger or discontent at the hospital without being
> sent to 'anger management'  I doubt if there is a group of
> professionals who have been taught more about imperturbability and
> equanimitiy than physicians.

A word from Senator Coburn D Oklahoma, physician.



My next post will contain Part II>
> It's great that our class is still so active in these matters.
> My best to you , old friend...I hope your health maintains..
> Gary Levin

The failure of cost comparitive Medical Care


Part I is on my previous blog post.

Saturday, August 8, 2009

How many rules does it take to make a Ruler?

Matt Holt, last week proposed these two basic rules to guide us in health care reform:

Rule 1 A health care reform bill needs to guarantee that no one should find themselves unable to get care simply because they cannot afford it. Neither should anyone find themselves financially compromised (or worse) because they have received care.

Rule 2 A health care reform bill needs to limit the amount of GDP that is going to health care to its current level, with an overall aim of reducing the share of health care going to GDP.

This week Uwe Reinhardt expands a bit:

Writing in his blog in the NY Times, Uwe Reinhardt sets out three overarching goals of health reform

1. Financial barriers should not stand between Americans and preventive or acute health care that they sincerely believe will address concerns over a troubling medical condition, in a timely manner, before that condition grows into a critically serious illness.

2. Having received needed health care, no American family should be so financially devastated by medical bills that it cannot meet routine daily living expenses — for example, make utility or mortgage payments on time or finance the education of the family’s children.

3. The future growth in national health spending should be constrained to fall significantly below currently projected spending growth, which has the United States devoting about 40 percent of its G.D.P. to health care by mid-century.

All other goals are subordinate to these three overarching goals, as are the means to reach them.

How do we get from here to there?

Friday, August 7, 2009


Another word for SERMO. Dan Palestrant (founder of Sermo) was on for another ‘debate’ with “established’ organized medicine. This time it was with the head (/Dr. William Struck ) of the Bassett Hospital in Cooperstown, New York. The argument again was about ‘salarizing’ physicians as a means of cost containment.

Viewers of this ‘sound byte’ need to know about Bassett Hospital.. Bassett Hospital operates in a rural area of Northern New York. It is a pristine small community with a fairly large drawing area of a lightly populated region. Solo private practice in that communitiy would be untenable economically. Bassett Hospital also is affiliated with Columbia University School of Medicine, and has multiple training programs for residents from Albany Medical Center (over 100 miles distant) and also from Columbia University in New York City, over 200 miles distant.

This is a unique population of physicians and their practice setting. The presence of residents in training (who are salaried at a much lower level than attendings) shifts a great deal of work load, night call and physician administration, such as record keeping to junior physicians who are not yet qualified to practice independently..

Attending physician work load in this setting is diminished when compared to other settings. The lowered physician income does not decrease overall costs, and any benefit is shifted to the administrative staff, capital expenditures, and operating budgets. Physician income is a very small component of their budget. (so is income for physicians not in integrated health care systems.)

When asked, the CEO of Bassett hospital dodged the question from about how much savings there were by salarizing their physicians. I suspect this was because he either did not know, or would not admit there are “NO SAVINGS” overall.

Dr Struck contends that salarizing physicians removes the added administrative tasks from physicians and allow them to focus on their patient care. This begs the question and denies the culpability of the insurance industry and regulatory affairs that has imposed these tasks upon the physician. It puts the horse before the cart and attempts to make physicians responsible to reduce the cost of this burden imposed by insurance and government payors.

Dr. Palestrant and Sermo join other real physician advocates in their proactive and aggressive education program for the general public.

Wednesday, August 5, 2009

Summer Recess


As some of us prepare for the long awaited "August" vacation, remember that your elected congressman, senators are also spending time in their congressional districts.  Keep them busy at this critical time and voice your opinions on health reform. 

Things are reaching a critical mass, and this now has national attention, with everyone weighing in...Make our voices heard, fellow physicians and health care workers.

It is apparent that some beginning of health reform will take place. Most opinions revolve around increasing availability of primary care, levelling  reimbursements between primary care (family practice for you other dinosaurs) and specialty care.


Rather than over all revolution it seems that the insurance companies should be the focus of initial changes in regard to cherry picking,image


increasing risk pools and universal coverage via market economics, not government intervention. Government should act to enable this to occur via present structures rather than inventing new government bureaucracy and restrictive regulations.


It seems the critical mass has boiled down to "




Tuesday, August 4, 2009

Health Train Express and Calculus

Health reform created a weird calculus of outcomes, decision makers and political intrigue

by Catherine Rampell

Update | 2:11 p.m. List of states has been corrected.

My colleagues David Herszenhorn and Robert Pear had an article on Tuesday on the Baucus Six — the group of six senators tasked by their parties to hammer out a new health care package to be considered by the Senate Finance Committee (and then, presumably, the full Senate).

The senators are from Maine, Iowa, Montana, North Dakota, New Mexico and Wyoming. A colleague noted that it’s a somewhat odd group to be asked to design a new health care system, given their constituents.

Whom, exactly, do these senators represent?

They come from some of the country’s least populous states, with no true urban centers to speak of. None of their home states contains even one of the 20 biggest cities in the country. Forget that: Of the country’s 100 biggest cities, just one is in these states (#34, Albuquerque, N.M.).

These states represent less than 3 percent of the country’s population, and hold only 2 percent of the nation’s uninsured, according to Census Bureau estimates.

It makes sense to give the residents of Montana and Wyoming a strong say in the future of health care reform, which will likely affect residents of every state. But shouldn’t someone representing a state with a few big complicated cities also have an official seat at that table, which is trying to determine a compromise that works for (almost) everyone? The way health care functions varies greatly from region to region, in terms of things like patient needs, delivery systems and resources. A more metropolitan state with a few rich, research-oriented medical facilities will operate differently, with regard to everything from expenses to treatment options to patients, from a rural state with fewer resources.

There would be a similarly problematic imbalance if the senators asked to design a template for the future of American health care were all from California, New York, New Jersey and Florida, and excluded all the Iowans and North Dakotans from the table. The plan that resulted from some Bizarro-World, urban-state-only cabal would have altogether different blind spots, of course.

This problem transcends the issue of health care reform; there are surely many occasions when the actual representativeness of our “representative democracy” seems in doubt.

But in this case — where the richer, more populous states will likely disproportionately contribute the federal taxes used for any additional government involvement in health care — it seems especially curious, not to mention impolitic, to exclude a California or a New York from the current discussions.

The Baucus Conference Room:

Last week, there were chippers — chocolate-covered potato chips — described on a sign as “North Dakota Diet Food.” More often, there are Doritos, pretzels, Oreo cookies and beef jerky: fuel to get through hours of talks on topics like the actuarial values of private insurance plans or the cost-sharing provisions of Medicare.

The fate of the health care overhaul largely rests on the shoulders of six senators who since June 17 have gathered — often twice a day, and for many hours at a stretch — in a conference room with burnt sienna walls, in the office of the Senate Finance Committee chairman, Max Baucus, Democrat of Montana.

President Obama and Congressional leaders agree that if a bipartisan deal can be forged on health care, it will emerge from this conference room, with a huge map of Montana on one wall and photos of Mike Mansfield, the Montanan who was the longest-serving Senate majority leader, on the other.

The battle over health care is all but paralyzed as everyone awaits the outcome of their talks.