Repairing the Healthcare System

Obama Administration Continuously Declines To Renew Indiana’s Medicaid Waiver

 Stanley Feld M.D.,FACP,MACE

In light of the recent alleged IRS scandel targeting certain groups, I am reminded of the Medicaid incident in Indiana. I believe the incident is resolved now with the Obama administration granting a waiver to Indiana after two years of bureaucratic haggling.

In 2007 Governor Mitch Daniels (R.) was successful in getting the Indiana state legislature to pass a Medicaid reform plan called the Healthy Indiana Plan. It is an expansion of Medicaid. It uses a consumer-driven health plan to encourage low-income beneficiaries to take control of their health and healthcare dollars.

This healthcare plan is a variant of my ideal medical saving account.

 The Healthy Indiana Plan has been very successful.

Healthy Indiana Plan has been the most innovative and successful reform of Medicaid in the history of the Medicaid program.

The federal government’s waiver for the plan was given in 2007 and set to expire on December 31, 2012. Indiana applied for an extension of the Medicaid wavier in early 2011. In November 2011 the Obama Administration rejected the state’s request to extend its federal waiver.

Over 45,000 poor Hoosiers on Medicaid were scheduled to lose this innovative Medicaid coverage in 2013.

Medicaid is theoretically run by the states in cooperation with the federal government.  In reality, any time a state wants to make the tiniest changes in its Medicaid program, it has to go hat-in-hand to the U.S. Department of Health and Human Services with a formal request for a waiver and these waivers are usually denied.

 This federal control has been part of the disagreement states have with the federal government over health insurance exchanges. The central government wants to shift the financial burden on the states while controlling the states’ decisions.

Indiana succeeded in gaining a waiver in 2007 because it was seeking to expand Medicaid to a group of people who weren’t then eligible for the program and because the state’s effort required no additional outlays from the federal government.  Governor Mitch Daniels paid for the Medicaid expansion by increasing the state’s cigarette tax by 44 cents. It made sense to everyone except the people that smoked. 

Patients had skin in the game because they had to pay 2 -5% of their income for their insurance coverage. The plan provided financial as well as wellness incentives.

“We did a lot of reading on criticism of health savings accounts,” says Seema Verma, who was the architect of the Indiana program. “One of the criticisms was that people didn’t have enough money to pay for preventive care. So we took preventive care out, made that first-dollar coverage.

“ Also, people said that people didn’t have enough for the deductible, so we fully funded it. Then, you have to make your contribution every month, with a 60-day grace period. If you don’t make the contribution, you’re out of the program for 12 months. It’s a strong personal responsibility mechanism.”

 I described the Healthy Indiana plan in detail in January 2008 pre President Obama.

Medicaid patients get a specified amount of preventive care for free.  Included are free annual physical exams, pap smears and mammograms for women, cholesterol tests, flu shots, blood glucose screenings, and tetanus-diphtheria screenings.

Medicaid beneficiaries have no cost-sharing requirements (co-pays, deductibles, etc.) except for non-urgent use of emergency rooms.

The money remaining in the Medicaid patients’ POWER accounts at the end of the year can be applied to the following year’s contribution only if they obtain the required free preventive disease services.

“The program has been, by many measures, a smashing success. “What we’re finding out is that, first of all, low-income people are just as capable as anybody else of making wise decisions when it’s their own money that they’re spending,” Mitch Daniels explains in a Heritage Foundation video.”

“And they’re also acting more like good consumers. They’re visiting emergency rooms less, they’re using more generic drugs, they’re asking for second opinions. And some real money is starting to accumulate in their [health savings] accounts.”

The program has been very popular. Ninety (90) percent of enrollees are making their required monthly contributions. Employers didn’t dump their workers onto the program, crowding others out, because you needed to be uninsured for six months in order to be eligible for it.

 “The program’s level of satisfaction is at an unheard-of 98 percent approval rating,” Verma told Kenneth Artz.

Lower income families are not too stupid to be wise healthcare consumers despite popular belief.

A 2010 study by Mathematica Policy Research found that in the program

71 percent met the preventive care requirement and were able to roll the balances over to the following year.  Only 39% obtained preventive care in the first six months. It proves financial incentives work.

The lack of physician access is the biggest reason why health outcomes for Medicaid patients lag far behind those of individuals with private insurance.

Healthy Indiana pays better than traditional Medicaid. The physician access trend has been reversed. Preventive care participation rates are higher than the privately-insured population.

Why would the Obama administration, which controls the states’ Medicaid programs, refuse to grant a waiver for Indiana’s successful program?

The first excuse HHS used was “ HSS  hadn’t written the regulations for Obamacare yet.”

According to Seema Verma  “the state will now have to file a much more complex “State Plan Amendment” that may not get approved before the Healthy Indiana program is set to expire.”

Before his term expired Gov. Daniels had written to HHS Secretary Kathleen Sebelius asking her for permission to use the Healthy Indiana Plan to handle Obamacare’s mandatory expansion of Medicaid. He had not heard back.

The Obama Administration claims to be on the side of the poor.  Why would it not approve a waiver of a popular program for the poor that provides the poor with superior health care?

Whatever the reason, tens of thousands of people will be needlessly harmed.

Regulatory burdens and “poison pills” have been thrown at the Indiana health plan. One such poison pill is not allowing the state to include the $1100 Power account given to Medicaid patients to make wise medical care choices.

Yet the government pays the healthcare insurance industry for help desks and rent for buildings where there are help desks as direct patient care instead of expenses.

It is not only bewildering, it is obscene.

The controversy continued throughout 2012 past the expiration date of the 2007 waiver into 2013.

Mike Pence, the new governor, kept fighting off bureaucratic rules but got nowhere through March of 2013.

The subtext of all of this is the Obama administration wants a top down centrally controlled Medicaid system with the financial burden on the states and Indiana wants to control its own destiny with its successful plan.

Stuff like the following has been going on. Diane Gerrits, CMS' director of state demonstrations and waivers, wrote in a Feb. 25 letter that the state will have to resubmit its application because it had not yet held two public hearings required by law.

CMS said as a result of the failure to comply with the transparency portion of the proposal, the state must begin a 30-day state public comment and notice period. The state must follow with an additional 30-day federal public comment.

This has been going on since 2011

Governor Mike Pence fired back,

 "The Feb. 25, 2013, letter from HHS does not indicate in any way that the waiver application process has been jeopardized," he wrote Thursday. "It does, however, speak to the flawed bureaucratic process that has impeded progress on our successful Healthy Indiana Plan."

The Obama administration is trying to destroy all health savings accounts both public and private. This is probably the reason for these artificial delays.

Suddenly, in mid April, under public pressure and possibly the impending IRS scandal Indiana’s waiver request was approved.

This is a happy ending to the Indiana saga and perhaps a model to get all the Medicaid programs out of the deep ditch they are in.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Don’t Confuse Me With Facts

Stanley Feld M.D.,FACP,MACE

The Obama administration refuses to believe that physicians are not interested in seeing Medicaid patients. The Obama administration must think that by increasing Medicaid enrollment the number of physicians willing to see these patients will increase. I believe the Obama administration is wrong.

A survey called the Health Tracking Study Physician Survey, sponsored by the Center for Studying Health System Change, polled more than 4,700 physicians around the country in 2008.

The survey covered many private practice issues. One question surveyed was about new patients these physicians would likely accept.

The survey showed that Internists are 8.5 times more likely to reject all Medicaid patients as opposed to patients with private insurance.

There is an additional cohort of doctors who only accept “some” (i.e. reject most) new Medicaid patients.

These numbers might surprise some but they reflect reality.

 The physicians who accept “all” or “most” Medicaid patients are a concentrated minority.

This means that if you have Medicaid insurance coverage it will be very hard to find a physician who will see you.

 

The administration refuses to believe that the 32 million new Medicaid patients will have a difficult time finding a physician.

Most other observers accept the fact that Medicaid beneficiaries have a tough time finding physicians. The main reason is due to the fact that Medicaid deeply underpays physicians and hospitals for their services.

There is also resistance by progressive thinkers to believe that Medicaid coverage has poor performance outcomes.

In reality Medicaid coverage is bad insurance coverage.

Scott Gottlieb M.D.’s article in the WSJ in 2011 stated; 

Medicaid Is Worse Than No Coverage at All!

“New research shows that patients on this government plan fare poorly. The question is why does the President Obama want to shove one in four Americans into it?"

Dr. Gottlieb’s question is a very good question.

The Oregon Experiment just published in the New England Journal of Medicine reached the same conclusion.

“We found no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. Medicaid coverage significantly increased the probability of a diagnosis of diabetes and the use of diabetes medication, but we observed no significant effect on average glycated hemoglobin levels or on the percentage of participants with levels of 6.5% or higher.”

The was no difference in “clinical outcomes.”  However, as I explained on many occasions, in the past there are large defects in measuring clinical outcomes.

In additional, the findings in clinical outcome studies are often misinterpreted.

“Medicaid coverage decreased the probability of a positive screening for depression (−9.15 percentage points; 95% confidence interval, −16.70 to −1.60; P=0.02), increased the use of many preventive services, and nearly eliminated catastrophic out-of-pocket medical expenditures.”

The results of screening for depression in the Oregon Experiment are not statistically significant. In order to be statistically significant a p value has to be less that .05.

Ezra Klein of the Washington Post found the words to publish the results as very positive for Medicaid coverage using the Oregon Experiment as proof. The article was entitled “Here’s what the Oregon Medicaid study really said”

Since the media is the message Ezra Klein used the media to get his biased message out even if the message is wrong.

He might be right that Medicaid coverage is important but the Oregon Experiment did not prove it.

The real problem with the Oregon Experiment is that the design of the study is defective. If a study’s design is wrong the conclusions are wrong on both sides of the argument.

There are real structural problems with Medicaid coverage in its present form. Its reimbursement method is also wrong. The only way to provide quality affordable care to lower income families is to fix Medicaid’s structural defects.

To force 32 million people into a defective system is going to lead to disastrous fiscal and medical care consequences.

I have to think the Obama administration does not care about the results or the administration is blinded by its own ideology.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Listen To This !

Stanley Feld M.D.,FACP,MACE

The Obama administration seems to exhibit a definite pattern for releasing unfavorable information. It always seems to occur on a Friday afternoon when everyone is thinking about the weekend.

Last Friday it was reported that, “Health and Human Services Secretary Kathleen Sebelius has gone, hat in hand, to health industry officials, asking them to make large financial donations to help with the effort to implement President Obama’s landmark health-care law,” two people familiar with the outreach said.

Congress has repeatedly rejected requests by the Obama administration for more money for Obamacare.

Sen. Orrin G. Hatch (R-Utah) said “To solicit funds from health-care executives to help pay for the implementation of the President’s $2.6 trillion health spending law is absurd.” 

The Affordable Care Act (Obamacare) included 1 billion dollars to be used in overall implementation of the law. The 1 billion dollars is almost gone. The CBO projects that Obamacare now needs 5-10 billion dollars to get the law “up and running over the next 10 years.”

How come?  There is no explanation available. My guess is that it is the result of waste, inefficiency and excessive bureaucracy.

All of a sudden the government needs money to train and outsource to community organizers the job of getting the underprivileged to sign up for healthcare insurance through the health insurance exchanges. 

In addition many states have not signed up to run their health insurance exchanges.

HSS needs the money to fund and manage the health insurance exchanges in those 33 states.

The Obama administration also promised those states that did sign up that it would pay all the expenses for three years.

I assume the administration did not need congressional approval for this decision.

One could also assume that the Obama administration’s plan was to stick the startup expenses to the states rather than the federal government. 

Congress has refused to provide the requested additional funding for Obamacare.

Obamacare was supposed to be budget neutral. It clearly will not be budget neutral according to present CBO estimates. It will more likely be in the negative by over 1 trillion dollars despite the tax increases.

Taxpayers need only be reminded of the 10 hidden taxes they are already paying to fund Obamacare in order to understand congress’s attitude.

“After Congress rejected a request in March for nearly $1 billion in additional spending for fiscal 2013, the White House asked for $1.5 billion for fiscal 2015 to set up and run dozens of exchanges that will provide Americans options for health insurance. The new marketplace is scheduled to launch in October 2013 for open enrollment.”

It is already anticipated that the promised “affordable healthcare insurance” will be unaffordable to indigent or low-income earners.

Budget documents show that the Obama administration has already pulled hundreds of millions of dollars from projects not specifically earmarked for Obamacare to implement Obamacare.

Additionally, HHS announced that it would use $150 million in Affordable Care Act funds meant to build additional community health centers to train thousands of health-care outreach workers at facilities that already exist.

“Investing in health centers for outreach and enrollment assistance provides one more way the Obama administration is helping consumers understand their options and enroll in affordable coverage,” Secretary Sebelius said in a statement.

 It is strange and unexpected by the Obama administration that few are signing up for Obamacare.

Secretary Sebelius seems to be trying to make congress feel guilty for Obamacare’s costs overruns. I have a feeling there are going to be a lot of cost overruns in the next future along with an attempt to raise taxes.

“We requested additional money from congress but we didn’t receive any additional funding for the exchanges,” Ellen Murray, HHS’s assistant secretary for financial resources, said last month at a budget briefing.

“So we’ve had to come up with a Plan B. We’ve been working very hard to develop that.”

“Part of our mission is to help uninsured Americans take advantage of new, quality affordable insurance options that are coming thanks to the health law.”

 Kathleen Sebelius might have stepped over the federal regulations line once more.   She got into a bit of a jam before last years the election when she violated federal law by ‘accidentally’ endorsing President Obama’s reelection at an appearance in her official HHS capacity. The press and congress gave her a pass and so the miscue failed to gain public notice.

This time it might not be so easy.   Federal regulations prohibited department officials from asking for funds from industry officials, business or subordinates in an official capacity, which has in the past sought to do business with that Department.

Kathleen Sebelius has done just that making multiple phone calls to health industry executives, community organizations and church groups.

She has asked them to contribute whatever they can to nonprofit community organizers that are working to enroll uninsured Americans and to increase awareness of the law.

This was revealed to the press last Friday by an HHS official and an industry person familiar with the secretary’s activities.

Kathleen Sebelius’ only way out of this jam is that the law permits her to solicit as a private citizen. The administration began to spin it as an act of a private citizen soliciting aid from parties interested in helping the healthcare law’s implementation.

It might be dirty pool to some but those stakeholders affected are intimidated from speak out because of their potential loss of business from the government.

After a while Americans get use to and are bored by these tactics.

The press blows them off as insignificant and the public forgets about them.

I do not believe these maneuvers can stop Obamacare from failing under its own weight. It is a law with too many defects.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Surprises For Physicians Coming With In Health Insurance Exchanges

Stanley Feld M.D.,FACP, MACE

 Two important components of Obamacare are Accountable Care Organizations (ACOs) and Health Insurance Exchanges (HIEs).

The adoption of both by medical communities and the states has been slow for good reason.

I have discussed the difficulties of setting up and the executing effective Accountable Care Organizations.

Some hospital systems are trying to set up ACO’s. These hospital systems are buying up physicians’ practices and trying to develop integrated care organizations.

The hospital systems are buying the physicians’ intellectual property and surgical skills sets. It will not work once physicians realize what happened.

The relationship between community hospital systems and practicing physicians had always been tense. Physicians do not trust hospitals and hospitals do not trust physicians.

Some physician groups are trying to develop their own ACOs. They are trying to convert hospital systems from being providers of patient care to vendors for their physician ACO.

If there are two hospitals in a community or town the hospital systems might become competitive.

The huge problem for physicians is the assuming of risk. If healthcare insurance companies cannot manage risk, why would physicians think they can manage risk?

 A variable that cannot be controlled in managing risk are patients. With all the obesity and the increase in diabetes mellitus it seems patients do not have the incentives to manage their own risks.

 Patients and physicians must be provided with appropriate financial incentives if there is the slightest chance of managing risk and decreasing the cost of healthcare.

 The adoption of ACOs has been slower than the Obama administration has anticipated.   

 Adoption of the Health Insurance Exchanges has been slow by states. Some states recognize the financial risk the Obama administration is trying to force on them.

This risk is ever present even if the federal government is going to pay the entire bill for the first three years.

As soon as physicians realize the risk the Health Insurance Exchanges are going to impose on them, they will not be willing participate.

These risks become more apparent will each succeeding release of regulation.

Kathleen Sebelius said it two weeks ago when she said there would be plenty of surprises ahead for physicians.

“Health and Human Services Secretary Kathleen Sebelius, who told a gathering a few weeks ago at the Harvard School of Public Health that she has been "surprised" by the political wrangling caused so far by Obamacare, there are likely to be plenty of surprises ahead.”

Physicians could face dramatic financial challenges for treating patients who receive health coverage through the Affordable Care Act's (ACA) Health Insurance Exchanges starting next year.

“ Insurance companies will not process claims on patients who haven't paid their premiums in 3 months, leaving doctors on the hook to recoup payment directly from the patients.”

Obamacare provides a 3-month grace period to individuals who haven't paid their premiums for insurance purchased through the Health Insurance Exchanges.

This provision will prove to be a problem for physicians.

In Obamacare patients who fail to pay their premium are free to sign up for another plan provided by the Health Insurance Exchange.  

They can also start seeing another physician without the insurance company or new physicians being aware of the patient’s delinquent premium record.

"Why would a doctor sign up to treat these patients] if they're going to be completely at risk and have to collect from the patient directly for their care?"  "This is a really bad provision in the bill, and we've got to get it fixed."

Under traditional insurance provided by employers, the plan is still liable for paying doctors even if the patient or employer hasn't paid their premiums,

Under the health insurance exchange the individual is responsible for their monthly premium. If the patients discontinue payment of their premium the healthcare insurer is not obligated to pay the physician for the care provided.

Most of the time patients have stopped paying premiums because they cannot afford them. Patients buying healthcare insurance from the Health Insurance Exchanges are lower income producing patients. 

 The expected annual, out-of-pocket cost for an individual is estimated to be around $6,400 and $12,800 for a family. This is not an insignificant expense for low wage earners.

Recent premium estimates indicate that the premium will be higher. This could be one of the surprises Kathleen Sibelius is referring to.

Another potential shortcoming of the Health Insurance Exchange is the reimbursement rates provided to physicians. The Obama administration believes Medicaid rates are sufficient.

I wonder if any of President Obama’s healthcare policy wonks ever questioned why so many physicians do not accept Medicaid.

The answer is simple. The reimbursement rate is less than the physicians fixed overhead to see the patient.

Medicaid physicians are driven to see many patients a day to try to make a living.

It would be difficult maintaining a physician patient relationship and a high quality of care seeing over 100 patients a day.

When their overproduction is discovered these physicians are investigated for fraudulent practices.

 The rates the healthcare insurance industry will pay physicians will not be set until late summer.

The big provider groups are negotiating with plans on their payments. Small groups will only get a "take it or leave it" contract from the health plans.

It seems obvious that fewer physicians will sign up to accept patients receiving coverage through the Health Insurance Exchanges once physicians understand what Obamacare is doing.

 This will result in a further physician shortage.

 The simple question is what is Obamacare trying to do to the healthcare system?

 Is Obamacare trying to destroy the healthcare system?

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Consumers Are Becoming Terrified Of Obamacare

Stanley Feld M.D.,FACP,MACE

Congress has finally figured out Obamacare’s financial burden to them personally and their staff. They want out and are trying to sneak in a waiver for themselves.

Millions of Americans are going to pay more for their healthcare insurance and get less coverage and a higher deductible cost.

Can ordinary American get the same waiver as government workers?

Actuary consultants from Oliver Wyman in an article published in the journal of the American Academy of Actuaries, found that "around six million of the 19 million people with individual health policies are going to have to pay more—and this even after accounting for the government subsidies offered under the law."

 "For example, single adults age 21-29 earning 300% to 400% of the federal poverty level will be hit with an increase of 46% even after premium assistance from tax credits."

The number of people seeking individual healthcare insurance will be even higher when it becomes clear that employers presently providing healthcare insurance to employees will drop the coverage and elect to pay the penalty.

The present estimate is that 65% of employers are either definitely going to drop healthcare coverage or are seriously considering dropping coverage.

The healthcare insurance industry claims the reason for the increases in premiums is the Obama administration’s regulatory policies for participating in health insurance exchanges.

 Obamacare's community-rating regulations, which require insurers to accept everyone but limit or ban them from varying premiums based on age or health.

1.  The law also mandates "essential" benefits that are far more generous than those currently offered and thus raise the premiums.
2. The healthcare insurance industry will be required to pay a tax on every healthcare insurance policy sold through the health insurance exchange. The industry is anticipating the tax and passing it on the anticipated cost to the consumer.
3. Employers with over 50 employees are decreasing the number of employees to less than 50 employees so as not to pay a penalty for not providing insurance.
4. Employers are not required to provide insurance for employees working less that 30 hours a week and so employers are decreasing employee work hours.

 The Bureau of Labor Statistics reported on a category of workers who will almost surely be involuntarily under-employed as a result of health reform.

“The present estimate is that 10 million part-timers now working 30-34 hours per week will have their work week decreased to under 30 hours a week.”

According to Congressional Budget Office projections in July and September 2012, three million people will lose their insurance altogether in 2014 due to Obamacare.

Six million will have to pay the individual-mandate tax penalty in 2016 because they don't want or won't be able to afford coverage, even with the government subsidies.

It is anybody’s guess how many people will be uninsured. The more uninsured people that are eliminated from the insurance pool the higher the insurance premium for those insured.

Rather than providing universal affordable care the Obama administration has created a system that will result in more uninsured consumers and faced with unaffordable costs.

Are all these people going to qualify for Medicaid? I do not believe so. They will earn too much to qualify for Medicaid and too little money to afford the upcoming premiums.

It is estimated that 30 to 40 million American families’ will experience an adverse affect in healthcare coverage as a result of Obamacare.

Americans are becoming concerned as the reality of the negative effects of Obamacare become clear.

Even the traditional mainstream media is starting to report those concerns as Obamacare’s negative effects are being felt.

Theoretically Obamacare sounds good. Practically it will collapse the healthcare system.

“Health and Human Services Secretary Kathleen Sebelius, who told a gathering a few weeks ago at the Harvard School of Public Health that she has been "surprised" by the political wrangling caused so far by Obamacare, there are likely to be plenty of surprises ahead.”

What are the other surprises? What is going to happen to all the uninsured and underinsured?

It looks like the outcomes are going to be the opposite of the goal of Obamacare.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Why Does Congress Want to Exempt Itself from Obamacare?

 Stanley Feld M.D.,FACP.MACE

In mid-April Max Baucus one of the authors of Obamacare and a major proponent of the law made the following statement to Health and Human Services Secretary Kathleen Sibelius at a Senate hearing.

 

  .  
 

http://youtu.be/Y9airckwqA8

Unfortunately only 11,723 people watched this 29 second You Tube.  The traditional media gave his statement sound bite coverage without explaining the reasons for him saying Obamacare is going to be a "train wreck."

West Virginia Senator Jay Rockerfeller said Obamacare is beyond comprehension.

  

http://youtu.be/Fy6vc9yWE_U

Only 157 people looked at this You Tube whick has been up for 3 weeks.

It would have been a good idea for congress to have read and understood the bill.

Meanwhile, congressional leaders in both parties have been engaged for months  now in high-level, secretive confidential talks about exempting lawmakers and Capitol Hill aides from Obamacare’s  health insurance exchanges that they are mandated to join as part of President Barack Obama’s health care overhaul, sources in both parties said.

These talks involve the Obama administration, Senate Majority Leader Harry Reid (D-Nev.), House Speaker John Boehner (R-Ohio), along with other top lawmakers.

“These talks are extraordinarily sensitive, with both sides acutely aware of the potential for political fallout in the 2014 mid term elections from giving carve-outs from the hugely controversial law to 535 lawmakers and thousands of their aides. “

Politico along with other Internet news agencies has been the only news agency to have in depth coverage of this attempt to exempt congress and its aids from Obamacare and its health insurance exchanges.

Henry Chao, the Administration’s chief technical official in charge of  the implementation of the Obamacare’s health insurance exchanges, “just hopes that Americans can avoid a “third-world experience.”

Why would both Democrats in congress want to avoid participating in Obamacare and its health insurance exchanges?

We need to be reminded that the Democrats had overwhelming majorities in both houses of congress at the time of passage of the law in 2009 without a single Republican vote.

I am reminded of Nancy Pelosi’s argument for Obamacare's passage.

  

http://youtu.be/KoE1R-xH5To

 Now that congress knows what is in Obamacare they want to be exempt.

Congress is content to let the rest of us suffer.

What is congress afraid of?

 

1. Higher healthcare costs for themselves, their families and their aides.
2. Being mandated into Obamacare’s health insurance exchanges will result in  them not qualifying for government subsidy.
3. Congresspersons and their aids could also lose their employer-based coverage.
4. This is also true for millions of ordinary Americans.
5. They would also face higher costs of insurance through health insurance exchange.
6. Every policy the healthcare insurance industry sells will be taxed. It will result in passing the tax on to the policy holders.
7. Contrary to the President’s promises, independent analysts expect health insurance premiums to rise sharply, particularly for younger workers and their families.       

Congressional members have other fears if they fail to create an exemption for themselves and their aides. These fears are:

1. They fear the impact on Capitol Hill employment.

2. The increase in healthcare insurance costs “could lead to a ‘brain drain’ on Capitol Hill, as several sources close to the talks put it.”  

3. Ordinary Americans who run businesses are also faced with the same problem. President Obama and Democratic congressmen have refused to be responsive to the dilemma faced by ordinary businessmen.

4. American business owner fear they will not be able to hire or retain valued employees.

5. These businessmen are presently reducing full-time workers to part-time employees in order to avoid Obamacare’s mandatory insurance coverage or penalty.

6. This will have the consequence of increasing the unemployment rate and decreasing consumer spending.

7. In turn it will create an unending spiral which will seriously impact economic growth.

8. The question Americans must ask is “what about me.”

 

The Obama administration and congress have done similar things before in their effort to passing Obamacare.

Obamacare was passed using backroom dealings such as the “Cornhusker Kickback,” the “Louisiana Purchase,” and the threats to political careers.

This congressional exemption also brings back memories of (more than 1,200 waivers) to favored businesses and unions who received special exemptions from Obamacare’s insurance rules.

“If Congress quietly wants to exempt itself from Obamacare, that’s great—so long as it includes the rest of us in that midnight amendment.”

If you are "mad as hell and do not want to take this anymore"  sign this petition.

  

 

http://youtu.be/QMBZDwf9dok

 

Please click on this link to sign up and send the link on to your friends.

https://www.change.org/petitions/force-congress-to-obey-obamacare

This is the petition

To: 
Senator Harry Reid, Senate Majority Leader 
Rep. Nancy Pelosi, House Minority Leader 

You told me we had to pass Obamacare to find out what was in it. Now your gold-standard health insurance is on the chopping block as Obamacare is implemented. 

If the tin-plated plan is good enough for me, my family, and my friends, it is good enough for you and your staff. 

You passed the law -- now live with it like the rest of us. Or overturn the whole rotten thing!

Stop the effort by liberal Democrats to seek an exemption from Obamacare for Members of Congress and their staff.

Sincerely, 
[Your name]

Some of us will remember Walter Cronkite’s signature was ending each newscast with the phrase, "And that's the way it is".

 I am adding this “it is now up to you ladies and gentlemen.”

 

Please sign the petition. Thank you.

 

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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EMRs Real Politics.

Stanley Feld M.D.,FACP,MACE

 

Dr. Jerome Groopman and Dr.Pamela Hartzmen uncovered the real politics of EMRs.  They are both on the staff of Beth Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical School.

 Dr. Groopman wrote a best seller “How Doctors Think.”

In a Wall Street Journal article they wrote,

 “The electronic medical record (EMR) is touted as the key to containing costs, reducing errors, improving quality, and simplifying administration: an “elegant exercise in wishful thinking

Dr. Groopman and Pamela Hartzman debunk the 2005 RAND study. The RAND EMR study of 2005 led to President Obama’s belief that EMRs will save $81 billion dollars a year for the healthcare system.

Groopman and Hartzman show that there is little evidence to support the president’s belief.

The RAND analysts claim that more than $350 billion would be saved on inpatient care and nearly $150 billion on outpatient care over a 15-year period of time.

Unfortunately, data from three other studies, a cardiology group, a Harvard group and Canadian group showed there is no savings difference between paper records and electronic records.

Dr. Groopman claims the RAND study is self-serving to EMR software companies that sponsored the study.

 

 Allscripts Healthcare Solutions, the Cerner Corporation and Epic Systems of Verona, Wis. are the major EMR software companies.

 “In February 2009, after years of behind-the-scenes lobbying by Allscripts and others, legislation to promote the use of electronic records was signed into law as part of President Obama’s economic stimulus bill.

“But today, as doctors and hospitals struggle to make new records systems work, the clear winners are big companies like Allscripts that lobbied for that legislation and pushed aside smaller competitors.”

At Allscripts Healthcare solutions, annual sales have more than doubled from $548 million in 2009 to an estimated $1.44 billion last year.

At the Cerner Corporation of Kansas City, Mo., sales rose 60 percent during that period.  

“Current and former industry executives say that big digital records companies like Cerner, Allscripts and Epic Systems of Verona, Wis., have reaped enormous rewards because of the legislation they pushed for.”

Unfortunately, many of the EMR systems bought by large hospital systems and physician practices are not fully functional. They do not fit the administration’s criteria of meaningful-use EMRs. These EMRs are requiring additional hospital systems and physicians; practices outlays of cash to make them fully functional.

Panama City-based Pain Clinic of Northwest FL filed a purported class action lawsuit on Dec. 20, 2012 against Chicago-based Allscripts (NASDAQ: MDRX).

“The purported class action lawsuit says that about 5,000 small group physicians were sold an EMR called MyWay from 2009 until late last year, when the company stopped supporting the product.”

“The company was also hit with a federal shareholder class action securities fraud lawsuit in the Northern Illinois District last year over allegations that it misled investors about the performance of its EHR programs.”

 The MyWay EMR cost about $40,000 per physician. ThePain Clinic of Northwest Florida claims it was misled by Allscripts Healthcare Solution.  The Clinic stated that MyWay has “shortcoming and inherent defects,”  

The complaint says Allscripts was unable to obtain “meaningful use” bonus status for MyWay because of the problems with the program. The lawsuit claims that

 “Allscripts has been unjustly enriched by retaining the money paid by MyWay purchasers and users without delivering an EHR software product that performs as it was intended to work,”

 These costs are always passed on to the consumer. Drs. Groopman and Hartzman  go on to say,

“The president and his health-care team have yet to address these difficult and pressing issues.

 Our culture adores technology, so it is not surprising that the electronic medical record has been touted as the first important step in curing the ills of our health-care system.

But this notion is an overly simplistic and unsubstantiated part of the solution.

It is important to note Drs. Groopman and Hartzman’s total and refreshing frankness.

“We both voted for President Obama, in part because of his pragmatic approach to problems, belief in empirical data, and openness to changing his mind when those data contradict his initial approach to a problem”.

“ We need the president to apply scientific rigor to fix our health-care system rather than rely on elegant exercises in wishful thinking.”

Please note that Drs. Groopman and Hartzman said it not me.

In a new study The RAND Corp has backed off on its 2005 study earlier this year and withdrew its estimate of saving to the healthcare system of $81 billion dollars annually.

In the RAND Corp’s view, the disappointing performance of health IT to date can be largely attributed to several factors:

 

1.  “Sluggish adoption of health IT systems
2.   Coupled with the choice of systems that are neither interoperable nor easy to use;
3.   The failure of health care providers and institutions to reengineer care processes to reap the full benefits of health IT.
4.  We believe that the original promise of health IT can be met if the systems are redesigned to address these flaws by creating more-standardized systems that are easier to use,
5.  EMR are truly interoperable,
6.  Afford patients more access to and control over their health data.
7.  Providers must do their part by reengineering care processes to take full advantage of efficiencies offered by health IT, in the context of redesigned payment models that favor value over volume.”

 

It should not be a blame game.

General Electric sponsored this new RAND study.  It is important to note that GE is a major Allscripts competitor.

There is true value in the EMRs to patient care. However the focus of the marketing and development is on the wrong customer.

The RAND still does not get it. Perhaps it does not want to get it.

EMRs should be for the benefit of physicians and their patients. It must be at a price physicians can afford to pay. It should not be for the benefit of the government, the healthcare insurance industry and hospital systems.

It should be a tool to continually educate physicians and patients. It should not be a tool used by secondary stakeholders to penalize physicians and patients.

Patients and physicians control My Ideal Electronic Medical Record. It should be seriously considered to achieve the maximum benefit of EMRs’ potential.

I believe it would be of value to interested readers to go to this link.

 http://www.lijit.com/search?uri=http%3A%2F%2Fwww.lijit.com%2Fusers%2Fstanleyfeld&start_time=&p=g&blog_uri=http%3A%2F%2Fstanleyfeldmdmace.typepad.com%2F&blog_platform=&view_id=&link_id=7386&flavor=&q=Idel+Electronic+Medical+Record+%28EMR%29&x=33&y=6.

 Those articles will not only describe the problems with EMRs, problems which I have predicted and are now recognized. These articles will also outline real  solutions to having universal adoption of EMRs.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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The False Promise of Electronic Medical Records (EMR)

 Stanley Feld M.D. FACP,MACE

The promise of the Electronic Medical Record (EMR) is fading for physicians and patients. The EMR was supposed to reduce the cost of medical care, improve quality of care, improve physician communications, reduce duplicate testing and improve efficiency of care.

 I believe EMRs can accomplish all of the above goals but not with their present rollout format.

In 2009 President Obama declared that EMRs,

  “would save some $80 billion a year, safeguard against medical errors, reduce malpractice lawsuits, and greatly facilitate both preventive care and ongoing therapy of the chronically ill.”

President Obama's estimate is a little higher than that of the Rand Corp. study on the same issue.

EMR’s have not accomplished its goals. EMRs have been a money-loser for most physicians.

I predicted that fully functioning EMRs were too expensive for most practicing physicians. In addition to the initial expense there are very high maintenance costs.

EMRs bought by physicians and hospital systems in the past are not fully functional.  Less than 20% of hospital systems and physicians practices that have fully functional EMRs

Physicians and hospital systems that already have EMRs will have to purchase new fully functional EMRs.

Physicians historically know that all data collected, whether accurate or not, has been used against them in the past.

They are hesitant to provide more data at their own expense that compromise the privacy of their patients and potentially harm their own reputation.

Physicians would be happy to participate in EMR implementation if the EMR improved their ability to serve their patients without a potential penalty.

It is clear the government and healthcare insurance industry want to control the healthcare system. The stakeholder who controls the data controls the healthcare system.

A recent survey from forty-nine community practices in a large EMR pilot study by the Massachusetts eHealth Collaborative studied the projected five-year financial returns on investment to physicians’ practices. It was published in Health Affairs.

The survey concluded,

"We found that the average physician would lose $43,743 over five years; just 27 percent of practices would have achieved a positive return on investment; and only an additional 14 percent of practices would have come out ahead had they received the $44,000 federal meaningful-use incentive."

Only a few practices would have had EMR’s that qualified for the Obama administrations meaningful –use incentives. The Obama administration’s criteria for meaningful-use are too strict and complex for EMR software that physicians can afford.

More amazing is that the only way for a practice to have a positive cash return on investment for their EMR is to game the healthcare system using their EMR. The resulting cost of medical care would rise.

 “The largest difference between practices with a positive return on investment and those with a negative return was the extent to which they used their EHRs to increase revenue, primarily by seeing more patients per day or by improved billing that resulted in fewer rejected claims and more accurate coding.”

This does not constitute an improvement in medical care. It also contradicts the idealistic advantages of the Electronic Medical Record.

The survey concludes that current meaningful-use incentives alone may not ensure a positive return on investment from EMR adoption.

The survey’s authors suggest,

“Policies that provide additional support, such as expanding the regional extension center program, could help ensure that practices make the changes required to realize a positive return on investment from EHRs.”

 The government and healthcare insurance industry’s goal is to reduce physicians’ reimbursement to those physicians that do not meet Obamacare’s imposed criteria for quality medical care. The controversial Independent Physician Advisory Board (IPAB) will set these criteria.

Many physicians in practice object to converting medical care into a commodity. Medical care is a very personal and complex interaction not taken into account by the rigid criteria.

I have said previously that about 50% of the therapeutic index (therapeutic effect) of a physician’s treatment is determined by the patient physician relationship.

 "We need to move to EHR for a number of reasons, but if I am a small practice I am going to really think about a few things," she says. "One is how to decrease the cost of adoption and the cost of the system itself.

“ To the extent you can reduce the upfront cost that is going to help bring down the amount you have to figure out how to make up elsewhere.

Increasingly there are new models taking this into account for small practices to decrease the big upfront costs."

There are two basic issues, the cost of a fully functional EMR and the real purpose of EMRs. I believe both can be remedied.

The costs of an EMR to a medical practice can be paid for by the click. The data would be fully secured. The data would be available only to patients and their physicians.

Physicians would pay for the EMR by the click. The EMRs would be maintained and updated for free in the cloud.

The EMRs could not be used for penalizing physicians. It would be used for educating patients and physicians thereby improving the quality of care.

If there is a bad physician in the community, a way needs to be found to deal with that physician within his community. All medicine is local.

This is where a consumer driven healthcare system with public critique of physicians would be an effective deterrent to bad physicians.

The current healthcare system is defective. It has to be changed. Obamacare is making the business plan worse.

America cannot afford it becoming worse.

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Getting Around The Rules: Hospital Readmission Rates

 Stanley Feld M.D.,FACP, MACE  

Everybody knows about the Obama administration’s tricks and cover-ups. Few know what to do about them. Some know what to do. More and more people are seeing right through the charades. 

In America, unfortunately, strong vested interest lobbies are effective. I pointed out some of the abuses of hospital systems lobbies a few weeks ago.

Consumer advocacy lobbyists do not seem to understand the real issues causing the healthcare system to be dysfunctional, nor have the money to fight these issues.

Steve Brill’s article in Time Magazine published hospital retail prices and not the actual prices the hospital collects. Retail price get the public’s attention. The real issue is the wholesale prices the government and the healthcare insurance industry pay. These allowed wholesale prices are also grotesque.

There is a lot of non-transparent funny business going on behind closed doors with Medicare. It is going to be accentuated with Obamacare.

Most of us have heard that hospitals will be responsible for the costs of patient care if the patient is readmitted to the hospital within 30 days.

This is a very stupid rule. Sometimes it is the hospital that should be responsible for readmission because the care was poor, the patient was not ready to be discharged or the patient had inadequate education about their disease to avoid hospitalization.

The hospital systems’ pressures are to get patients discharged quickly.

My guess is it is the patient that is responsible for the readmission most of the time.

Many factors could contribute to a patient’s readmission. They include

1. Not following the physician’s post discharge orders.
2. Not given appropriate post discharge orders
3. Not being taught to become the professor the their disease.
4.  Not participating in adequate follow-up care. Follow-up care is important but it has become outrageously expensive.
5. Medicare has permitted home healthcare services to charge high prices for simple services and procedures that have little impact on patient education and avoidance of readmission.
6. Documentation by the home healthcare service drives the expensive reimbursement and not the value of the care.

The real question is should the hospital system be responsible for patient irresponsibility?

The answer is clearly no. The bureaucracy’s answer to the problem is that one size fits all.

Hospital systems are aware of this defect. Hospital administrators and their lobbyists are working hard to get around the rule.

Some have figured it out. They are keeping the patients in the emergency room and charging ER fees that they can collect rather that putting patients in the hospital and generating charges they cannot collect.

Hospital systems can charge patients increasing fees the longer patients stay in the emergency room.

“Medicare does not count most discharged patients who come to the emergency department (ED) but are not readmitted, according to a study in Annals of Emergency Medicine.”

The study looked at nearly 12,000 discharged patients from Boston Medical Center. Twenty five percent of the patients discharged from the hospital appeared in the emergency room in less than 30 days and forty percent of those patients were readmitted to the hospital.

Hospitals keeping patients in the ER amounted to a great saving and indeed profit for the hospital.

Defective rules and regulations lead to many unintended consequences. No one has tried to motivate patients to be responsible for not being readmitted to the hospital.

Some readmissions cannot be avoided. Many readmissions can be avoided.

The main question would be how to motivate all stakeholders to have incentive to avoid readmission to the hospital.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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What Happened to the “Physician/ Patient Relationship?”

Stanley Feld M.D.,FACP,MACE

The only way America’s healthcare system will be repaired is by revitalizing the Physician/ Patient Relationship.

Veterans complaining about the VA Hospital System in my last blog brought on a flurry of negative comments about practicing physicians not connecting with their  Medicare and commercial insurance patients in the private sector.

The chief complaint is that physicians are not connecting to their patients or their patients’ illness. I have heard enough stories to believe it is true.

A 44-year-old male with private healthcare insurance sent one such complaint to me.

His acute illnesses history was compatible with acute prostatitis.

He needed a new physician because his previous primary care physician had taken a sabbatical leave.

He called for help in finding a physician to his friends on Facebook, Twitter and Link In. The consensus was the physician he describes below.

The physician did multiple tests, several of which I did not think were necessary, along with a cursory physical examination. The physician thought the patient had prostatitis and prescribed Cipro for one month. A follow-up examination was not scheduled.

The last paragraph in the patient’s note to me was,.

By the way, my doctor's office called to let me know the lab results are in and they are mailing them to me. The doctor told the front desk person to send me a letter, which I'll get in a day or two. According to the front desk person, in the letter he says that my labs look good, and that I need to work on getting my lipids up. Apparently he included a link to a website that I can learn more about lipids. Pretty great patient care, eh...

This is horrifying to me. The patient will probably do well. However there is no contact or concern about the patient’s outcome in this interaction. There was no physician patient relationship formed for a patient who is looking for a primary care physician.

I would be very upset if this interaction happened to me.  I would be more upset if I then receive a bill for $800 for the visit.

This patient does not know what the bill will be because the office said it will bill his insurance company.

The evidence of the loss of the Patient-Physician Relationship of delivering medical care did not happen overnight.

A reader Dr. Dale Fuller sent me this commentary. He walks us through the evolution of the destruction of the Doctor- Patient relationship.

Dr. Fuller’s view is similar to the view I have discussed in this blog on multiple occasions. I believe it is important to publish his thought in its entirety.

 

 "Whatever Happened to the “Doctor- Patient Relationship?”

 

Dale Fuller M.D.

Lately, I find myself thinking about this question more and more.  I think the first time I heard the term, “doctor-patient relationship” was back during Harry Truman’s administration, when there was an effort led by the Democrats to create a National Health Insurance Program.

“Socialized Medicine” the opposition cried, and “The end of the doctor patient relationship!   I wasn‘t even a student in college back then, and in the absence of more information, I saw the doctor-patient relationship in the context of my experience with the doctor who looked after me on those rare occasions when I needed to see him,

Dr. T.D. Jones, who was a very kind man.  He was a small town doctor, and the only doctor in my hometown as well as a good many other towns around it during World War II.

I kind of understood the term “socialized medicine” in the context of the then-new National Health Service being launched in Great Britain. 

Truman and company lost the battle for NHI back then.

The next big “Socialized Medicine initiative arrived in 1960  “Socialized   during the Republican administration of Dwight Eisenhower.

Senator Robert Kerr, of Oklahoma and Rep. Wilbur Mills of Arkansas, both Democrats introduced the Kerr-Mills act, the “Medical Assistance for Aged Act 1960-1965” (benefiting primarily the elderly on Old Age and Survivors’ Assistance).

Kerr-Mills was passed in 1960, again over cries that it would destroy the doctor-patient relationship.  But this time the cries were neither so loud, nor as successful.  By this time I am a newly minted MD, and my awareness of the total meaning of the term is still mostly intuitive.

During the administration of Lyndon Johnson, came the Social Security Amendments of 1965, which brought us Medicare and Medicaid. 

When I entered practice in 1968, Medicare and Medicaid were just getting under way, so I never experienced what it was like to practice in the absence of the law.

In March of 2010, President Obama signed into law The Patient Protection and Affordable Care Act, and we are now living through the incremental steps preceding that law becoming fully in effect in 2014.

The various legislative initiatives have, to be sure, impacted the doctor-patient relationship in many ways, as the opponents predicted, but it appears to me that we have been hearing less and less about that relationship as the years have passed. 

I think it might just be that the relationship we are discussing may be threatened by a number of other forces other than the laws described above, but before I attempt to list those forces, I want to spend a little time setting the stage to describe just what the doctor-patient might and might not mean.

Goold and Lipkin, in an article published in 1999 (1) called the doctor-patient relationship “a keystone of care: the medium in which data are gathered, diagnoses and plans are made compliance is accomplished, and healing, patient activation, and support are provided.”

They say that the medical interview is the major medium of health care, and that more than 82% of diagnoses are made by history alone.

The three functions of a medical interview are the gathering of information (both through history and physical examination) developing and maintaining a therapeutic relationship, and communicating information.

In the eyes of the law, physicians also have a fiduciary responsibility toward their patients. Physicians are bound to act in their patients’ interests even when those interests may conflict with their own.

In that physicians are often directly involved with events and conditions that are life-altering for their patients and families, at birth, during severe illness, healing or death, it can also be said that in being a physician, and providing health care, doctors are engaging in a moral enterprise.

There was a time when the unwritten social contract laid out above, simply existed as an understanding between patients and doctors.

In the early 1940’s the arrival on the scene of what became the Blue Cross and Blue Shield program, initially serving the employees of the Dallas, Texas Independent School District began to interpose a third party, the insurance company, working through the employers, in the social contract that was the Doctor-Patient relationship.

Initially that interposition was pretty innocuous, with the insurance plan simply paying the bills of the doctor as they were presented. The phrase, “usual and customary” arose to define the fees involved that the insurance company paid. Unusual fees or fees exceeding customary levels became subject to challenge, requiring justification if they were to be paid.

Over time, a database of fees that really were usual and customary began to become a better and better tool to define where the usual kind of fee stopped and the unusual kind of fee was recognized.

Kerr-Mills, when it came along, introduced the federal government as a payer, and relatively soon thereafter, the health care bureaucracy began to grow and insert itself between doctors and patients to an increasing degree.

Since this was in the “Pre-Medicare era” the number of patients involved was relatively small, and so the impact on the doctor patient relationship was still somewhat limited.

The arrival of Medicare and Medicaid served to illustrate that the old “camel entering the tent” analogy was beginning to come true.

Initially, while the organizations were formed to administer the programs, “usual and customary” was still the order of the day where payments were concerned, and the social contract still functioned much as it had always done.

At the request of the Department of Defense, organized medicine (AMA) created a set of relative value scales in an attempt to standardize professional fees. The set of codes was called “Current Procedural Terminology (CPT codes)” (first introduced in 1966).

The charges were to be based upon a blend of time required, professional skill involved, and liability risk.

The compendium of procedures have grown over the years, the principles remain essentially the same.

In a fit of zeal, the Federal Trade Commission inserted itself and accused professional societies of “price fixing” via the CPT codes.

Settlements eventually ensued, and money passed from the societies that were sued to the FTC, and life, after the “nolo contendere pleas’ went on as usual.

The reason for this was that the societies were not well enough funded to defend their position vs. the FTC, even though they might have won their cases.

Increasingly though, as might be expected, the government began to insert itself more and more into the transaction between doctors and patients, generally, drawing upon the reality that it was paying, directly or indirectly, for more than 50% of the care given in the US.

Regulations and rules have proliferated, respecting what can and cannot be done for patients who are beneficiaries of federal programs. 

Another force was also becoming more vocal in making statements and policy regarding what could and could not be done for patients.

This force began with the passage of the Health Maintenance Act of 1973.  This act enabled a vast acceleration of the whole concept of managed care. 

Healthcare Insurance Companies citing the growing demand for, and cost of medical care to employers, found a ready market among employers for their “products” to serve as “benefits” for their employees. 

Physicians and hospitals, fearing that they might be left out of the managed care programs, made haste to “join” this program or that program, seeking access to the populations of patients enrolled in the programs by the insurance companies selling coverage to employers. 

The fear was that exclusive arrangement with insurance companies would eliminate whole populations of patients from providers who had not “signed up”.

This meant that the traditional bilateral social contract between doctors and patients essentially had come to an end of sorts.

Patients’ expectations were that service and behavior of the doctor they were allowed to see remained pretty much the same except for a small by important fact.

Those employees covered by managed care were required to see the doctors who participated in the program, and to use the hospitals the programs had agreements with.

Financial penalties awaited those patients who sought their care “out of plan”, for whatever reason. 

Now patients and doctors both have someone else “calling the tune” when it comes to the delivery of healthcare.

Each time the “plan” purchased by the employer changed, for whatever reason, there could be a change in the physicians and hospitals available to the patient. 

This brings us to a key element of the doctor-patient relationship. A key element is continuity of care.

Continuity of care brings with it an opportunity develop relationships in which doctors and patients really know and trust one another. This relationship allows physicians to recognize changes in patients and recognize the early onset of disease.

Neither the physicians’ understanding nor the patients’ trust cannot be rebuilt immediately between two individuals each year who are basically strangers to one another.

 Doctor of days past, the trusted counselor, often friend and confidant, is no longer exists.  Now, patients are simply seeing another person in an office. Both parties are at sea when it comes to knowing what they need to know about one another to allow the encounter to produce the necessary result within the time allowed.

Time, like continuity, is also a vanishing element in the doctor-patient relationship.  Fewer and fewer practitioners have the time, amidst the pressures of “patient throughput” to really engage in patients’ needs.

Physicians must gather and record data, establish a diagnosis, and create a treatment plan of quality.

The documentation has to be complete in order to get paid by the government or the healthcare insurance carrier.

Doctors must also explain his treatment plan in such a way that they are assured of patients’ compliance with the treatment proposed in the time available to doctors.

As a result of decreasing reimbursement and increasing overhead the time necessary for patient education is insufficient. Patients do not understand the significance of the therapy. The result is a lack of compliance.

Another problem is that the “third party payers” rather than the patients approves of any tests and procedures that doctors believe are needed to strengthen the diagnosis.

The result is a further erosion of patients trust in the doctor.

The time for a consultation is short. Tests and procedures are now increasingly used to substitute for the gathering of data to make the diagnosis.

Tests and procedure escalate the costs of medical care.

Data gathering by history and physical examination is time consuming. If a history and physical examination is properly done it can yield the diagnosis of patients’ problems about 80% of the time.

The doctor-patient relationship is indeed fading into the past. The third party carriers and the federal government have, in their zeal to contain cost, pretty much seen to that.

The reality is that the destruction of the doctor-patient relationship costs more in the long run.

The federal government, in its enthusiasm to make a positive impact on the quality of care patients receive, has mandated the use of electronic medical records.

The EMR in its own way have also served to diminish the doctor-patient relationship.

In many doctors’ offices, the focal point in the room is a computer with data entry. The keyboard and the screen have almost the full attention of the doctor, who, without looking at the patient, asks the questions and types the responses.

The patient is lucky if the doctor makes eye contact with him/her for a brief interval a couple of times during the visit, thus further diminishing the possibility that trust can be built in the encounter. 

The quality of the encounter can, in the opinion of various policy makers and consultants, be measured and changed in the same way that manufacturing processes can be impacted by applying the principles taught by Deming and others.

Maybe it can, but it has yet to be demonstrated.  Processes peripheral to the interaction of patient and doctor, may be made better, but there is little evidence that the same approach can bring back anything like the doctor patient relationship we used to know."

The three basic goals of Obamacare are to create an affordable healthcare system with access to care of high quality.

A complicated and complex bureaucracy that is over regulation will be very difficult to enforce.

It will penalize physicians’ judgment as it tries to decrease reimbursement. It will restrict patients’ access to medical care. It will reduce freedom choice.

Obamacare will not enhance the Patient Physician Relationships that are so vital to a successful therapeutic effect. 

A healthcare system that places consumers in control of their healthcare dollars and provides incentives to consumers to be responsible for their health and healthcare will encourage physicians to save money and rejuvenate the Physician Patient Relationship for improved therapeutic outcome at an affordable cost.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Perception Is Reality

Stanley Feld M.D.,FACP,MACE

I mentioned Joe Klein’s criticism of the VA healthcare system in my last blog. I promised to cover some of the problems veterans are having in the VA healthcare system.

I cannot believe the VA healthcare system is as bad as illustrated by the following examples.

However, perception is reality.

I believe if the government completely takes over the healthcare systems and creates a single party payer system, Americans will have the same perceptions that these veterans have had about the VA healthcare system.

I have read some of the government’s official reviews of complaints by veterans. The VA Office of Inspector General Office of Healthcare Inspections writes the government’s official reviews.

The typical conclusion of the Inspection General for the VA was that the overwhelming majority of the complaints in various VA hospitals are unwarranted or insignificant.

“The VA Office of Inspector General Office of Healthcare Inspections conducted an inspection in response to allegations of misdiagnosis and other care issues at the Atlanta VA Medical Center (the facility) in Atlanta, GA, and two community based outpatient clinics (CBOCs) in Veterans Integrated Service Network 7.”

 

"The purpose of this inspection was to determine the validity of the allegations. We did not substantiate that a facility emergency department physician misdiagnosed a stroke as vertigo (a feeling of motion while one is stationary) in September 2010. We determined that the facility emergency department physician’s evaluation and management of the patient’s complaints and hyperglycemia were appropriate."

"We did not substantiate that the patient received deficient care or that facility and CBOC providers failed to appropriately meet the patient’s vision, hearing, and stroke rehabilitation needs."

This is the typical verbage of many reports written by the VA’s Inspector General. Unfortunately, these conclusions do not foot with veterans’ complaints.

The general characteristics of most of the complaints fall into specific categories.

One universal characteristic of each complaint is the lack of development of a positive doctor patient relationship. 

An Army Major with a combat brain injury felt he had never been treated so poorly in his life. A VA physician reviewing his condition did not even look at his record. The physicians showed no compassion when the patient needed compassion the most.

“I have such a low regard for the VA. I have never been treated in my life as poorly as I had with the VA.”

His perception was that “everyone in the system blames others or passes the buck to someone else.”

 The physician simply wrote a prescription for some medication.”

The physician showed no interest in the patient or his disease. He showed no empathy for the patient.

Another former Marine, Mike Ligurri, who has written the book, The Sandbox. He was diagnosed with Post Traumatic Stress Disorder.

Mike Ligurri also expressed the lack of personal contact with him by the VA physician. He was given medication to take without explanation of the medication.

 “My attitude was I don’t want to take pills just because you tell me I will feel better.’  

He felt the physician he dealt with was cold hearted and not involved.  

There is no incentive for VA physicians to become involved with patients in the VA system. The patients are not their patients. At each clinic patients usually see a different physician.

The perception of patients is that the VA physicians and the VA system do not connect with them.

Patients are treated as commodities.  

I can relate to that feeling. When I was in training at a charity hospital I was never able to form a relationship with patients. I did not even see the patients I admitted to and discharged from the hospital.

There was little continuation of care or follow-up by me.

When I went into practice the patient was my patient and I was his doctor. The positive patient physician relationship made the visit more satisfying to me and more therapeutic for the patient.

If I didn’t relate to my patient while in private practice, my patient had the option of leaving my practice and finding another physician.

I, as other physicians in private practice, made it my business to relate to my patients. My incentive was to build my practice and reputation. I was a consultant to other physicians as a clinical endocrinologist.

In order words, I had incentive to treat my patients well and my patients and referring physicians had freedom of choice of any other physician.

The experience patients have at the VA is reflected in the following comment,

“They made me feel like they had no time for me. All they did was to take notes, never engaging with me, and after ten minutes decided to write me a pill prescription. I was never told about alternate forms of therapy.”

Patients want to know about their disease. They want to learn the reasoning for their treatment. They are not stupid. They want to know what to expect from their disease and their treatment.

They want to have a caring and comforting physician because they are frightened about their disease.

Patient education and a positive patient physician relationship are essential for good therapeutic outcomes.

A few weeks ago at medical grand rounds I sat next to a fellow physician and good friend who was cured of testicular cancer 30 years ago at age 32.

At that time he was frightened out of his mind because he had no experience with testicular cancer. He was sent to a radiation oncologist who explained his disease, his prognosis and what to expect throughout the course of therapy. This relationship was a total comfort to him.

He mentioned this to me during our conversation. He said that he felt very bad because he had not appropriately thanked the radiation oncologist for the fantastic physician patient relationship. The relationship permitted him to tolerate his therapy well. He said he been given hope of surviving and a positive feeling about his outcome.

I told this physician I was going to have lunch with that radiation oncologist the next week. He asked me to be sure to tell the oncologist that he thinks of him all the time.

He has been so thankful for his help. He added that post testicular cancer therapy he enjoyed a fantastic marriage and has been blessed with two wonderful sons.

Now that defines a wonderful physician patient relationship! 

Another complaint of VA system patients is the long wait time for appointments and the mountain of paper work that has to be completed in order to make each appointment.

If a patient misses an appointment because of bad weather or unforeseen circumstances you have to start the process all over again.

It must be maddening for VA patients. A Veterans’ study committee has reported an average wait time has been quoted as 50 day to 273 days.

Recently an older veteran told me that he had a cataract that was progressing yearly. He was at the point that he needed cataract surgery to be able to see.

He was told that the wait and backup was one year.

He made enough of a stink about the delay in his surgery that the VA healthcare system sent him to a private practicing ophthalmologist. The private ophthalmologist did the cataract surgery in one week.

He was thrilled because he could see clearly again.

I am compelled to tell some of these stories not to point out the solutions to the problems with the VA system.

The VA system is run by long term employees entrenched in their jobs without a threat of either losing their patients or their jobs.

These employees have little accountability; they create reports and publish meaningless evaluations. These reports are of little value in fixing a healthcare system that works poorly for patients but looks good on paper.

 “Even Jon Stewart is blasting the handling of Veterans’ benefits, “That is f---- criminal. The VA has a backlog of 900,000 people. McDonalds handles ten times that many customers in an hour, and may I remind you they are run by a clown.”

The point is that Obamacare with its ever increasing bureaucracy, agencies, and regulations is going to lead the entire population into this trap by decreasing incentives and limiting choice.   

It Is “Coming Our Way with Obamacare.”

 

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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The Traditional Mainstream Media Is Waking Up To Obamacare's Defects

 Stanley Feld M.D.,FACP,MACE

 

Joe Klein is TIME's political columnist and author of six books, most recently “Politics Lost.” His weekly TIME column, "In the Arena," covers national and international affairs. In 2004 he won the National Headliner Award for best magazine column.

He is a Democrat and a big supporter of President Obama.

Joe Klein is a major liberal leaning reporter within the traditional mainstream media. His last two articles in TIME magazine are finally starting to show understanding of the problem with Obamacare. Here are some of these articles more important statements.

He starts one article with,

 “Let me try to understand this: the key incentive for small businesses to support Obamacare was that they would be able to shop for the best deals in health care superstores — called exchanges.

 "The Administration has had three years to set up these exchanges. It has failed to do so."

 "This is a really bad sign.”

The administration continuously claims it is not its fault programs are failing. It is always the other guy’s fault.

The other “guys fault” was the main strategy of President Obama’s reelection campaign. He needs more time to make things work.

“There will be those who argue that it’s not the Administration’s fault. It’s the fault of the 33 states that have refused to set up their own exchanges. Nonsense. Where was the contingency planning?” 

The Obama administration just announced it couldn’t have the health insurance exchanges program ready by January 2014.

It is refreshing to read a liberal mainstream media writer saying what I have said all along.

The Obama administration’s trick here was to stick the states with the costs of the exchanges.

The states that have thought out the consequences have refused to accept responsibility for the health insurance exchange.

The Obama administration has also demanded that states follow the administration’s conditions and rules. The states have viewed this as a threat to states rights.

The Supreme Court sided with the states’ rights argument.

 

"The Obama Administration has announced that it won’t have the exchanges ready in time, that small businesses will be offered one choice for the time being — for a year, at least."

A hidden story is the administration does not have the funding to pay the states for the health insurance exchanges for three years.

This is one of the reasons President Obama is again demanding the ability to raise taxes in a budget agreement. Republicans are saying he has received his tax increases January 1, 2013.

“No doubt, small-business owners will be skeptical of the Obama Administration’s belief in the efficacy of the market system to produce lower prices through competition. That was supposed to be the point of this plan.”

Joe Klein goes on to say,

“We are now seeing weekly examples of this Administration’s inability to govern. Just a few weeks ago, I reported on the failure of the Department of Defense and Veterans Affairs to come up with a unified electronic health care records system.”

We have been told that the VA had an excellent electronic health record. The VA advertises that every physician can download it and use it free. I downloaded it.

The VA EHR is very difficult to use.

 Joe Klein had sharp criticism for the “Head Start Program”,

 "There have been the oblique and belated efforts to reform Head Start, a $7 billion program that a study conducted by its own bureaucracy — the Department of Health and Human Services — has found nearly worthless." 

 The list of Obama administration failures is indeed endless. It is the work of a community organizer trying to run a big business.

 “Barack Obama is not a “how” President. Oh, he pays lip service to government reform. His people can tell you the number of unnecessary regulations they’ve eliminated.”

 “ It barely scratches the surface of what needs to be done—there is no creative destruction in government, regulations pile up on top of each other like silt, generation after generation.”

 The next statements confirm Joe Klein’s liberal leanings.

 “One thing is clear: Obamacare will fail if he doesn’t start paying more attention to the details of implementation.”

 “But, as a Democrat — as someone who believes in activist government — he has a vested interest in seeing that federal programs actually work efficiently. I don’t see much evidence that this is anywhere near the top of his priorities.”

 “And, in a larger sense, the notion of activist government will be in peril — “  

“The problem is not, as the Republicans claim, big government. It’s bad government.”

At last the traditional mainstream media is starting to get it. There is starting to be recognition of the problem with government controlled and operated systems.

I have explained many times that the mess in the healthcare system is not a liberal or conservative problem.

It is a problem in creating a healthcare system that aligns all the stakeholder incentives and works for every consumer of healthcare.

A consumer driven healthcare system with appropriate tort reform will have to be developed by the government.

A healthcare system must be constructed that allows consumers to own their healthcare dollars and be responsible for their health and healthcare.

The government could provide the subsidy to the needy. The result would be a healthcare system that would be more efficient and less costly.

Individual responsibility and freedom to choose is essential for a successful healthcare system.

 

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Reality Vs. Fantasy

Stanley Feld M.D., FACP, MACE.

“I’m Busted” ,my last blog, generated several interesting comments.  

The comment below was a standout. It represents a total disregard for historical understanding of what made the healthcare system totally dysfunctional.

It is obvious from the comment that this individual has not gone to any of my links in the blog nor has he been a long time reader. I suggest he read the letters I sent to President Obama at the time after his first election.

“We’ve been through this before Dr. Feld.  While your generation was/is in charge of the U.S. Healthcare System our Quality has Sunk and the Costs have Risen Dramatically.  (www.ifhp.com/documents/2012iFHPPriceReportFINSALMarch25.pdf )” 

Physicians are not in charge of the healthcare system.The government and the healthcare insurance industry is in charge.

I could not open the link this reader sent. He goes on to say,

 “ Take Some Responsibility for this Healthcare Mess.  Stop Crying and Placing Blame on those searching for Workable Options to Fix What You Proudly Created.  Please share this with your readers.  Stop being so one-sided. 

Thank you. 

XY

I have stated innumerable times that all stakeholders including physicians are responsible for the dysfunction in the healthcare system.

Key to the understanding of the healthcare system's dysfunction is the need to understand the evolution of the dysfunction. I cover the history in my summary blogs. 

The dysfunction in the healthcare system started in 1965 with the passage of Medicare.

Every subsequent government regulation was followed by a more expensive reaction to the regulation by the stakeholders.

Life was simple pre 1965. The healthcare social contract was between the patient and the physician.

 

•  Personal Care – The Physician Knew Me And My Family
•  The Healthcare System Was Efficient – Consumer Driven
•   It Was Adequate for 90% of Medical Problems
•   It Was Democratic – Rich & Poor

Disadvantages

•  Lifespan / Expectancy – Short
• Lived Unhealthy Lives
• Misdiagnosed Many Illnesses- Lack of Technology
• Limited Body of Knowledge- Limited Treatments And Drugs

 

Patients made their own healthcare decisions. Patients and physicians had positive relationships.

This positive patient/physicians relationship is 50% of the therapeutic outcome.

As the medical knowledge base increased more money was pumped into the healthcare system thanks to Medicare. Secondary stakeholders were needed to deal with the increase in money and complexity. Soon these secondary stakeholders began to dominate the healthcare system.

 Secondary stakeholders have disrupted Patient/physician relationships. These stakeholders have created large barriers between physicians and patients.

 

 

Both patients and physicians have become commodities. In its present form, the healthcare system, as it has grown in complexity and expense has precipitously diminished physicians’ control over his medical care and his ability to apply his medical judgment.

Obamacare is adding more layers of complexity to the healthcare system to an already dysfunctional healthcare system.

Obamacare will be difficult to execute and impossible to enforce.

When the reader says, “Stop Crying and Placing Blame on those searching for Workable Options to Fix What You Proudly Created.”

 I am not crying. I am sad for patients and their future medical care within the Obamacare healthcare system.

I am trying to get consumers to see the inevitable.

Past evidence has proven that when government controls and operates any systems the actions proposed are unworkable and unenforceable. The result is great costs and more inefficiency.

 The healthcare system’s incentives will only be aligned when the system is consumer driven. The government must support but not control the healthcare system.

The government should set the rules to align incentives and then get out of the way.

I have made a strong case for consumer driven healthcare.

The healthcare system model the government brags about is the VA Hospital System model.

Recently the VA has received bad press in the traditional mainstream media.  VA public relations department has tried to marginalize the criticism.

It has also tried to compensate for the criticism by outsourcing medical and surgical care to the private sector with success.

 Elise Cooper’s article in the American Thinker: “The VA: a Culture of Disconnect” says it all. I will add to her title “Coming Our Way” with Obamacare.

 

• "Many veterans feel disconnected with the VA. They regard it as a huge bureaucracy that is very impersonal and unhelpful. The vets get frustrated because they do not know where to turn for help.”

“American Thinker interviewed veterans and others involved with the VA to reveal some personal examples and to see if the complaints are justified.”

I will discuss in detail these interviews shortly. I will say the complaints are justified.  

America is running out of time to repeal Obamacare. Consumers have to wake up now and see what it is doing to their healthcare system, their taxes and their economy.

  The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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`

I’m Busted

Stanley Feld M.D., FACP, MACE.
As we get closer to 2014 and the scheduled full implementation of Obamacare conditions in the practice of medicine are getting worse.

I have described how most of the major programs initiated by Obamacare,

(such as the Accountable Care Organizations, the Electronic Health Record initiatives and the Health Insurance Exchanges development), are failing or off to a slow start.

 A detailed critique of the Obama administrations’ Obamacare can be found using the search engine in my blog.

If you receive my blog by email (RSS) double click on the blog title or go to the web site http//:stan.feld.com.

Search for the topic in the search engine in the top right corner of the blog post.

The shortcomings of Obamacare are becoming obvious to many citizens. Most physicians and hospital systems are finding Obamacare’s new programs difficult to execute.

A reader wrote

"Dear Dr. Feld,

Once it becomes so painful for the average voter, Obama will simply say, “a single payer system is the only way to fix this insurance company mess.”  He’s doing exactly what he planned to do, he’s just not telling the truth about it.

X"

It is becoming more apparent that President Obama’s goal has been to destroy the public and private sector healthcare systems. In reality the money in both the public and private healthcare system has been controlled by the healthcare insurance industry and not by the government.

The Obama administration is building the infrastructure to easily convert the healthcare system to a single party payer system. The majority of Americans are opposed to a single party payer system. It eliminates choice.

The expense of Obamacare has been and will be enormous to all stakeholders with 300 new agencies and 20,000 new regulations.

The new healthcare taxes are scheduled to take effect almost monthly.

At present at least 40% of the healthcare system is a single party payer system when considering the government healthcare plans in place.

The Obama administration will have two major problems converting America totally to a single party payer.

The public will be outraged when it becomes aware of that the direct costs to them, the lack of availability of medical care and restriction to access to care caused by Obamacare.

There are two possible solutions. Either repeal Obamacare and start from square one or let the government control the entire system.  

The government will not be able to afford a single party payer system. It will have no choice but to increase taxes further to support the healthcare system.

The other major problem Obamacare will have with a universal single party payer system is the healthcare insurance industry will continue to control the money in the system.

The government does not have the infrastructure to provide the administrative services and to adjudication claims. There are many hidden cost in the movement of money that most are unaware of.

 

The entire situation reminds me of Ray Charles’ song “I’m busted.”

  

 

http://youtu.be/D_Ew-768xmk

In 2008, after President Obama was elected I wrote him six letters explaining how he could reduce the costs of medical care in America by introducing cost savings initiatives.

Dear President Obama Part 1

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/11/dear-president-elect-obama.html

Dear President Obama Part 2

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/11/dear-president-elect-obama-part-2.html

Dear President Obama Part 3

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/11/dear-president-elect-obama-part-3.html

Dear President Obama Part 4

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/12/dear-president-elect-obama-part-4.html

Dear President Obama Part 5

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/12/dear-president--elect-barack-obama-part-5.html

Dear President Obama Part 6

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/12/dear-president-elect-obama-part-6-why-dont-you-listen-to-practicing-physicians.html

I took a Willie Sutton approach. “ Go where the money is.” 

If the government provided incentives to decrease wasteful spending, the healthcare system would self correct without the myriad rules and regulations    that will not work and cannot be enforce.

Simple things such as:

1. Incentivize individual responsibility with Medical Savings Accounts,
2. Encourage the use of a Universal Electron Health Record with a fully functional EHR in the cloud. Physicians and hospitals would pay for its use inexpensively by the click. It would be sort of like a toll way fee without capital expense. The EHR could be upgraded and serviced at no expense.
3. Create a healthcare system that is consumer driven with consumer owning their healthcare dollars and being responsible for their healthcare choices.
4. A Tort Reform System that eliminates the need for defensive medicine that over tests patients to avoid law suits.
5. Chronic Disease Management Systems to teach patients to be the professor of their disease in order to avoid costly complications of their disease.
6. Develop patient educational systems available on the Internet 24/7 as an extension of their physicians’ care.
7. Help develop disease specific Social Networks. The development of a disease specific community can serve to solve some problems patients have.
8. Eliminate secondary stakeholder waste, fraud and abuse.
9. Eliminate the purchase of first dollar healthcare coverage from the healthcare insurance industry  

I believe if all of the above was done correctly it would save $750 billion to $1 trillion dollars a year for the healthcare system.

President Obama has ignored every point I have tried to make. Obamacare has not included any of the real cost drivers in a non-punitive way.

He has simply added a huge bureaucracy with rules and regulations that are expensive, difficult to execute and more difficult to enforce.

If my recommendations were initiated and executed properly America would have a sustainable healthcare system.

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone

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Obamacare's Deception

 Stanley Feld M.D.,FACP,MACE

We all remember Nancy Pelosi’s famous declaration when she said “we will not know what is in the bill until we pass it.”

I could remember asking to myself how stupid can Americans be to listen to this lady?”

Americans are going to be shocked to learn the extent to which they have been deceived by Obamacare. The legislation neither protects patients nor makes  the Health Insurance Exchange plans affordable.

The details of Obamacare have been anything but transparent. New details are appearing every day in the form of new regulations by new agencies.

I believe it would be impossible for someone without an intense interest in Obamacare to understand it.

There have been over 20,000 new regulations from 300 new agencies so far. Mass confusion has been generated as regulations from one agency contradict  regulations from other agencies.

The Obama administrated has said recently that the public should not expect cost saving from Obamacare.

 The Obama administration has also asked for an additional $1 trillion dollars over the next ten years in order to fulfill Obamacare’s promise to the American people.

It looks as if none of the administration’s advisors or the administration had considered the unintended consequences.

“Obamacare works for the insurance companies but not for Americans.”

The slogans such as “shared responsibility,” “no free riders” and “ownership society.” dress the insurance industry’s raid on public resources in the cloak of a “free market” health care system.

Obamacare neither protects patients nor are the healthcare insurance plans to be offered by the health insurance exchanges affordable.

Americans with incomes between 133% and 400% of the Federal Poverty Level (Income above 133% of the federal poverty level = $31,322/yr. or $2,610/mo. Income above 400% of the federal poverty level= $94,200/yr. or $7850/mo.) will pay for the least expensive   subsidized policies from 2% to 9.5% of Modified Adjusted Gross Income (MAGI) from their IRS reported income.

Americans with the least income are faced with a substantial yearly and monthly after tax salary reductions even though their healthcare insurance policy is subsidized by the government.

On January 1,2014 they are mandated to have healthcare coverage.

A person with a Modified Adjusted Gross Income receiving $27,925 from all sources of revenue will pay $187.33 per family member per month.

The total price for a family of four is ($2,247.96 per year times 4)  $8991.84 in after tax dollars. This pays for a Silver level plan that is next to the least expensive plan to be offered by the health insurance exchanges.

If a person who has this plan goes to a physician or a hospital  the patient’s deductible will be sizable despite the government subsidy.

Even if the family has subsidized healthcare insurance these families might not be able to afford to use the insurance.

The quality of life of a low earner will be compromised. He must buy the subsided healthcare insurance. The result will be he will have to make cuts in buying food and adequate housing in order to pay for the healthcare coverage.

We have not heard much about this problem from the Obama administration.

As the insurance industry raises premiums on private insurance they are also going to raise the prices in the Health Insurance Exchanges.

If the family opts out of buying the insurance they will have to pay a penalty.

It is actually better to pay the penalty and then sign up for insurance if you or a member of your family gets sick.

 The fee paid for insurance in 2014 will varying according to 2012 income. If a family income rose in 2012 and the breadwinners lost their jobs in 2013 and 2014 the family could not afford the MAGI healthcare insurance premium they would be required to pay.

If income increased in 2013 they would be liable for the increase the next year.

“The stress alone from such a regressive scheme is, without a doubt, not conducive to good health and well-being.”

On January 1, 2014 everyone is required to buy healthcare insurance or else pay a penalty. Even with the government’s subsidy a low income earner could be forced out of the market.

In the meantime, states such as California are decreasing reimbursement for physicians. Physicians are choosing not to participate in both Medicare and Medicaid. This will increase the physician shortage.

The only choice states have left is to tie medical license renewal to physicians accepting Medicare and Medicaid.

At the same time states and the federal government are decreasing funding to already financially stressed charity safety net hospital systems. Many of these institutions have closed. Most of them are failing.

The decrease in safety net hospital systems will further decrease the options for low-income earners to receive medical care.

Obamacare is turning out to be a not well thought out plan. It is a series of Catch 22s.

The only winner is the healthcare insurance industry which will provide the administrative services to the government to adjudicate claims. It will receive both the government subsidy and the payment made by the low-income earner. 

Obamacare has deceived the public.  As I have stated in the past Obamacare has some good ideas but the structure, regulations and execution are terrible.

Obamacare sounds good when President Obama talks about it but it is an impending disaster medically and financially for Americans.

Only a consumer driven healthcare system with the bullet-proof ideal medical savings account will align all the stakeholders’ incentives.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.



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St. Patrick’s Day 2013

Stanley Feld M.D.,FACP,MACE

St. Patrick’s Day is my birthday. This St. Patricks’s day was my 75^th birthday.

A little background has to be presented before I talk about the phenomenal birthday party my wife Cecelia threw for me in the Eilan Hotel Resort and Spa in San Antonio.

When I was three years old my mother took me to the New York City Fifth Avenue St. Patrick’s Day Parade. She sewed a kelly green jump suit for me to wear.

When we got to the Parade she told me all those people were marching to celebrate my birthday. This happened every year until I was six. I finally caught on.

She celebrated St. Patrick’s Day with me  the rest of her life. After I moved out of the house she would call at 6.30 am every St. Patrick’s Day and sing Happy Birthday to me.

My sister-in-law took over after my mother’s death. I get a chill up my spine every time Cindy does it. She never misses a beat.

Cecelia sent me this as a little extra birthday present.

"Stan,

I helped fund Doug and Telisha's new CD with a donation through Kickstarter.

Here it is, FOR YOU, their personal video. HAPPY BIRTHDAY! "

"Hi Cecelia,

Here is a link to Stanley's special video telegram:

 

 
http://youtu.be/oVpj4_mODnY

Sincerely,

Telisha"

I started my practice of Clinical Endocrinology in the summer of 1970. At the beginning of March 1971 I bought a kelly green wool blazer to wear while seeing patients on my birthday. If March 17^th landed on a Sunday I carried out the ritual on Monday. If it landed on Saturday I wore my jacket on Friday.

It was lots of fun. After a few years the same patients made an appointment to see me on my birthday.

After a while more people than I could see in one day wanted an appointment on that day. Some of the people made appointment a year in advance so they would have the slot.

I think they had more fun than I had. Patients started bringing me St. Patrick’s Day clothing. They brought in green ties, sweaters, vests, leprechaun shoes and hats of all shapes and sizes.

I had so much stuff and so many patients that wanted to have an appointment on my birthday that I extended the celebration to two days and started wearing a different costume each day.

My birthday has been a glorious day. This year Cecelia wrote to her entire email list and asked them to say something about me. She has not given the album to me yet because she has not finished it and the notes keep coming in.

She said many of the notes made her cry and she is sure they will make me cry.

Brad put his note to me in his blog. It made me cry. I remember all of it.

Cecelia and I drove down to San Antonio on Wednesday March 13^th. We thought it would be fun to drive. It was a mistake. I-35 is still a mess between Waco and San Antonio after all these years.

I would be remiss if I did not put some of my outfits into this blog.

Arriving at Eilan Hotel Resort and Spa

 I wore this soccer shirt to dinner at La Fonda with Brad and Amy.

 Thursday Daniel, Laura and Sabrina arrived. We explored the new end of the Riverwalk before dinner. 

 

Doesn't Daniel look great? 

 

Dinner was wonderful at Il Sogno Tratoria at the Pearl Brewery 

 

Friday's Outfit

 

 Charlie and Cindy arrive.

 

 

Dinner at Boudros on the Riverwalk

 

All dessed up for Saturday  

 

They dyed the San Antonio River green for my birthday.

They did it in Chicago,too. My birthday is a great day.

My fabulous and beautiful wife and I before dinner at Sustenio at the Eilan Hotel

Brad, Amy and I before the birthday dinner.

My cake. Do not let the green fool you. It is solid chocolate

Brad, Stan and Dan with the most wonderful person in my world, Cecelia.

 

I wish to thank Cecelia publicly for creating this fabulous weekend. 

I love you

 

Stan

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.



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I Can Hear The Train A Comin’

Stanley Feld M.D.,FACP MACE

  

http://youtu.be/v7gV5C5mB7A

It is almost past the time for physicians to listen to that train whistle coming down the line.

A reader wrote

 

"Great blog Dr. Feld.

 Ask your Physician friends this question:

 “What and how will you feel when your license to practice medicine is no longer sanctioned at the state level, rather it is issued by the Federal Government and tied directly to your willingness to see a certain percentage of Medicare/Medicaid patients?”

 That’s where this train is headed, most physicians are simply too blind it to see it or too deaf the hear it.

M "

 

M., I have tried to warn my physician friends that the train is coming. Physicians’ freedoms and the patient-physician relationship are circling the drain.

The only option they will have will be to practice medicine without a license. This is a ridiculous thought.

Where is the silent physician majority? I have only heard from Dr. Ben Carson. I have a feeling the press is going to start calling him a lunatic very shortly. The goal will be to marginalize and silence him.

 

 

http://youtu.be/hNvIfCZWCtQ

 

Where are the organizations that are supposed to represent physicians and their patients?

If you ignore the pain you do not know the cancer is growing. If you do not feel the pain you do not know if it is growing either.

The cancer cannot be cured if it is ignored.

Physicians cannot ignore this problem any longer. Neither can consumers. Entitlement spending run wild will drive America into bankruptcy.

Cancer is comparable to the national debt. It will not be cured if it is recklessly ignored. The end result will be bankruptcy.

President Obama has demonstrated an apparent disregard for the literal interpretation of the constitution’s First, Second, Fourth and Twelfth Amendments during his term in office.

States rights seem meaningless. The Democratic congress has empowered President Obama to do anything he wants to do to the healthcare system.

Congress has transferred all decision making to the executive branch of government.

Congress is supposed to represent the people. Most consumers do not know what is going on. The information is not readily available.  If they do not know what is going on will not mount a protest.

Consumers who enjoy the benefits of the entitlements are not likely to be willing to give them up. It is not as much a matter of entitlements as it is a matter of waste and inefficiency resulting from complex government bureaucracies.

President Obama has told us that Medicare and Medicaid are very efficient. Yet he has not provided proof. The administrations claim is the waste is the result of fraud and abuse. My question is by whom?

Public opinion cannot be expressed if the public does not understand the issues.

The traditional media has ignored most of the important issues; it has not published the possible consequences of the administrations rules, regulations and actions.

If congressmen express an opinion contrary to the party line of the establishment they are called a Wacko Birds.

The press will jump all over this because it might sell newspapers or magazines. The public accepts the catchy phrase as the truth.

I have outlined and described in detail the logical solutions to Repairing The Healthcare System.

With the 20,000 new regulations and 300 new agencies the Obama administration has tightened the box. They have disabled the physicians’ ability to practice medicine unless they comply with government dictates.

This is called government control and takeover of the healthcare system.

Many physicians think they can finesse this imprisonment. These physicians are wrong. Many think they will be able to stop accepting Medicare and Medicaid and continue to practice medicine. They are wrong.

Physicians’ ability to use their medical judgment is being taken away.

The Obama administration’s response would obviously be that is silly. They are not trying to control medical judgment.

However the government continues to proceed in commoditizing medical care. 

Physicians are going to scream when they wake up and realize what is happening to medicine and medical care.

Some physicians say they are powerless to do anything. These physicians are wrong.

All they have to do is learn the details of the real issues. Then they have to explain it to every patient. Patients are not going to like what is happening.

Physicians can provide their patients with talking points or an already written letter to send to congress and President Obama.

Remember this is a government by the people for the people. We hire these guys. Our vote provides these politicians with their job. Congress and the President are scared stiff to have our disapproval.

The government runs like Franz Kafka’s bureaucracy in his book “the Castle.” No one has authority to make a decision and no one takes responsibility for the consequences.

Who took responsibility for the Benghazi disaster? The press ignored it. The facts were not forthcoming and no one took responsibility.

Americans’ health is too precious to ignore the impending disaster.

Who is going to take responsibility for the disaster?

 

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.



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Obamacare’s Actions To Destroy The Healthcare System

Stanley Feld M.D., FACP, MACE

The Obama administration is doing everything it can to destroy the healthcare system. President Obama continues to campaign that he is going to save Medicare and Medicaid and provide universal care while saving $4.25 trillion dollars.

It does not add up.  The Obama administration keeps raising taxes, decreasing benefits and increasing deductibles on Medicare and Medicaid premiums. The administration is decreasing the work force by regulation and executive order.

Everything that is being done increases the burden on seniors and insured workers.

To my amazement no one in organized medicine except the American Association of Physicians and Surgeons (AAPS) has protested.

I applaud Jane Orient M.D. executive director of AAPS and her Board of Directors for stepping forward and trying to defend the rights of patients and their physicians.

At stake are patients’ ability to choose their physicians and physicians’ ability to practice medicine as they choose.

Where are the AMA and all the specialty organizations in the federation medical organizations?  It is little wonder these organizations are losing members.

All medical organizations should join with Jane Orient M.D. and her Board of Directors lawsuit against the government.

AAPS filed suit against PPACA three days after it was signed into law, but the National Federation of Independent Business (NFIB) and 26 states stayed the case pending a Supreme Court decision in the case brought.

All of us know that the Supreme Court upheld the Obamacare law. It was deemed by Chief Justice Robert that the executive branch has the power to levy a tax. It is not within the power of the executive branch to create a mandate. President Obama insisted throughout the legal process that this was a mandate and not a tax.

 

http://youtu.be/hV-05TLiiLU

In my opinion this decision by Justice Roberts was a big mistake. Obamacare is a terrible law that will not create universal healthcare. It will be ineffective and inefficient. It will destroy the healthcare system. Obamacare cannot possible work.

I think this is President Obama’s goal.

The Supreme Court in its decision acknowledged, "any tax must still comply with other requirements in the Constitution."

No one except the AAPS has challenge this point.

“The motion filed by AAPS is the first to ask an appellate court to rule on whether PPACA violated the Origination Clause of the U.S. Constitution, which requires that all "bills for raising revenue" originate in the House of Representatives.”

More and more physicians are not participating in Medicare. Physicians still have the ability to choose to participate in Medicare and Medicaid.

At the beginning of 2013 a new regulation went into effect. Previously, if a physician did not participate in Medicare the patient had to pay the physician his fee. The patient could then bill Medicare and collect 70% of Medicare’s allowable fee.  Medicare does not pay the patient after January 1^st,2013.

Non-participating physicians may use laboratory, x-ray departments or consultants that participate in Medicare. The participating consultants, labs and x-ray departments can bill Medicare directly and receive their usual and customary fee from Medicare. 

Effective May 1, 2013 (a new regulation issued March 1, 2013 by HHS) the Department of Health and Human Services will deprive patients of benefits for blood tests, x-rays, and specialist consultations—benefits for which they were forced to pay all their working lives, and which would be covered if ordered or referred by a non participating Medicare physician.

I believe the Obama administration’s goal is to force physicians to participate in Medicare.

"Because of Medicare's increasingly costly and restrictive rules placed on doctors, many Medicare-eligible patients are receiving medical care from physicians not enrolled in the program," states Jane M. Orient, M.D., executive director of the Association of American Physicians and Surgeons (AAPS).

AAPS filed an emergency motion for injunctive relief  in the U.S. Court of Appeals for the District of Columbia Circuit.

The Founding Fathers fought for independence largely because of excessive taxation without representation. When the Constitution was drafted, the founders insisted that taxes originate in the House, the legislative body closest to the people, both in representation and in election cycles.

“ObamaCare originated in Senator Reid's 2000-page amendment to a 6-page House bill about tax credits for members of the armed forces who are called into overseas assignments. AAPS has raised several arguments why ObamaCare constitutes an illegal tax, including violation of the constitutions Origination Clause.”

This new executive order disregards the constitution’s “Origination Clause” to try to stop physicians from not participating in Medicare

Only the AAPS had the guts to speech out against this executive branch breech of its power and defend patients and physicians rights as granted by the constitution.

Hooray for the AAPS.

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.



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The False Promise of Electronic Medical Records (EMR)

Stanley Feld M.D. FACP,MACE

The promise of the Electronic Medical Record (EMR) is fading for physicians and patients. The EMR was supposed to reduce the cost of medical care, improve quality of care, improve physician communications, reduce duplicate testing and improve efficiency of care.

In 2009 President Obama declared that EMRs,

  “would save some $80 billion a year, safeguard against medical errors, reduce malpractice lawsuits, and greatly facilitate both preventive care and ongoing therapy of the chronically ill.” 

EMR’s have done none of the above. EMRs have been a money-loser for most physicians.

I had predicted that fully functioning EMRs were too expensive for most practicing physicians. EMRs bought in the past were not fully functional. Therefore physicians would have to purchase new fully functional EMRs.

Physicians understand that all data collected, whether accurate or not, has been used against them in the past. They are hesitant to provide more data at their own expense that compromise the privacy of their patients and potentially harm their own reputation.

They would be happy to participate in the project if the EMR improved their ability to serve their patients without a potential penalty.

Physicians suspect there is another agenda underlying President Obama’s insistence on the adoption of EMRs.

It is clear the government and healthcare insurance industry want to control the healthcare system. As the payers they do not want the physician/patient relationship to control the healthcare system.  

A recent survey from forty-nine community practices in a large EHR pilot study by the Massachusetts eHealth Collaborative studied the projected five-year financial returns on investment to physicians’ practices. It was published in Health Affairs.

The survey concluded,

We found that the average physician would lose $43,743 over five years; just 27 percent of practices would have achieved a positive return on investment; and only an additional 14 percent of practices would have come out ahead had they received the $44,000 federal meaningful-use incentive.

Only a few practices would have had EMR’s that qualified for the Obama administrations meaningful –use incentives. The Obama administration’s criteria for meaningful-use are too strict and complex for EMR software that physicians can afford.

More amazing is that the only way for a practice to have a positive cash return on investment for their EMR is to game the healthcare system using their EMR. The resulting cost of medical care would rise.

 “The largest difference between practices with a positive return on investment and those with a negative return was the extent to which they used their EHRs to increase revenue, primarily by seeing more patients per day or by improved billing that resulted in fewer rejected claims and more accurate coding.”

This does not constitute an improvement in medical care. It also contradicts the idealistic advantages of the electronic medical record.

The survey concludes that current meaningful-use incentives alone may not ensure a positive return on investment from EMR adoption.

The authors suggest,

“Policies that provide additional support, such as expanding the regional extension center program, could help ensure that practices make the changes required to realize a positive return on investment from EHRs.”

 The government and healthcare insurance industry’s goal is to reduce physicians’ reimbursement for those physicians that do not meet Obamacare’s imposed criteria for quality medical care. These criteria will be set by IPAB.

Many physicians in practice object to converting medical care into a commodity. Medical care is a very personal and complex interaction.

I have said previously that about 50% of the therapeutic index (therapeutic effect) is determined by the patient physician relationship.

 "We need to move to EHR forward for a number of reasons, but if I am a small practice I am going to really think about a few things," she says. "One is how to decrease the cost of adoption and the cost of the system itself.

“ To the extent you can reduce the upfront cost that is going to help bring down the amount you have to figure out how to make up elsewhere. Increasingly there are new models taking this into account for small practices to decrease the big upfront costs."

There are two basic problems, cost and the real purpose of EMRs. Both can be remedied.

The costs of an EMR to a medical practice can be remedied easily.  My ideal electronic medical record could reside in the cloud. It would be available at no cost to physicians. The patient data would be fully secured and only used by patients and their physicians.

Physicians would pay for its use by the click. The EMRs would be maintained and updated for free.

The EMRs could only be used for physician education purposes and not for penalizing physicians.

If there is a terrible physician in the community a way needs to be found to deal with that physician within his community. This is where consumer driven evaluation would work.

Lost in this discussion is the real politics of EMRs.

 Jerome Groopman and Pamela Hartzmen wrote,

 “The electronic medical record (EMR) is touted as the key to containing costs, reducing errors, improving quality, and simplifying administration: an “elegant exercise in wishful thinking

Dr. Groopman and Pamela Hartzman debunk the 2005 RAND study that led to this belief by President Obama. They show that there is little evidence to support the president’s belief.

Dr. Groopman claims the RAND study is self serving to software companies that sponsored the study.

 Allscripts Healthcare Solutions ,  the Cerner Corporation  and Epic Systems of Verona, Wis. are the major EMR software companies.

“In February 2009, after years of behind-the-scenes lobbying by Allscripts and others, legislation to promote the use of electronic records was signed into law as part of President Obama’s economic stimulus bill.

“But today, as doctors and hospitals struggle to make new records systems work, the clear winners are big companies like Allscripts that lobbied for that legislation and pushed aside smaller competitors.”

At Allscripts healthcare solutions, annual sales have more than doubled from $548 million in 2009 to an estimated $1.44 billion last year, partly reflecting daring acquisitions made on the bet that the legislation would be a boon for the industry.

At the Cerner Corporation of Kansas City, Mo., sales rose 60 percent during that period. With money pouring in, top executives are enjoying Wall Street-style paydays.

Current and former industry executives say that big digital records companies like Cerner, Allscripts and Epic Systems of Verona, Wis., have reaped enormous rewards because of the legislation they pushed for

The weird thing is many of these EMR systems bought by large hospital systems are not fully functional (meaningful-use). The EMRs are requiring additional hospital system outlays of cash to make them fully functional.

These costs are passed on to the consumer.

The president and his health-care team have yet to address these difficult and pressing issues. Our culture adores technology, so it is not surprising that the electronic medical record has been touted as the first important step in curing the ills of our health-care system. But it is an overly simplistic and unsubstantiated part of the solution.

It is important to note Drs. Groopman and Hartzman total and refreshing frankness.

We both voted for President Obama, in part because of his pragmatic approach to problems, belief in empirical data, and openness to changing his mind when those data contradict his initial approach to a problem. We need the president to apply scientific rigor to fix our health-care system rather than rely on elegant exercises in wishful thinking.

Please note that Drs. Groopman and Hartzman said it not me.

I have said this many times in the past. The same statement applies to the Obamacare in its entirety.

”We need the president to apply scientific rigor to fix our health-care system rather than rely on elegant exercises in wishful thinking.”

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.



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Facts and Misuse Of Facts

 

Stanley Feld M.D.,FACP,MACE

All of us try to understand the facts and make logical decisions by synthesizing the facts.

There is a lot of misinformation and disinformation being printed. This misinformation and disinformation leads to the wrong conclusions because the facts are inaccurate.

 A master purveyor of this misinformation and disinformation is Paul Krugman.

I believe his misuse of facts is icreasing as he is subconsciously realizing his ideology is incorrect.

Here are a few examples of disinformation or misinformation in Paul Krugman’s most recent article “Mooching off of Medicaid” 

“For there is a lot of price-gouging in health care — a fact long known to health care economists but documented especially graphically in a recent article in Time magazine. “

This is true. The margins on hospital systems retail prices are outrageous. The margins on some discounted hospital system prices are equally outrageous.

 There is a continuous price war between hospital systems and payers (government and healthcare insurance companies).

 The uninsured and under insured primary stakeholders (consumers) are stuck with these outrageous prices.

"As Steven Brill, the article’s author, points out, individuals seeking health care can face incredible costs, and even large private insurance companies have limited ability to control profiteering by providers."

 This statement is not quite true. Most people have healthcare insurance. The healthcare insurance industry and government have negotiated discounted prices that are as low as 10% of the retail prices published in Steven Brill’s article.

In the struggle to retain providers, private insurance companies offer slightly higher prices than the government.

The healthcare insurance industry knows the government’s exact reimbursement prices. The private insurance companies provide the administrative services for the government’s healthcare plans.

Individuals not under the umbrella of these discounted prices are liable for these high prices. As insurance premiums increase, employers are reducing insurance coverage for employees.

The deductibles and co-pays are increasing to unaffordable levels for everyone as an increasing numbers of employees are becoming under insured.  

 “For there is a lot of price-gouging in health care —"

 Price gouging is the result of a lack of transparency and special deals the government and the healthcare insurance industry makes with certain hospital systems   

“Medicare does much better at preventing price gouging , and although Mr. Brill doesn’t point this out, Medicaid — which has greater ability to say no — seems to do better still”.

 This is false. There are fewer physicians seeing Medicaid patients because reimbursement is very low. In fact, in most cases physician reimbursement is lower than physician overhead. The result is access to care for a Medicaid patient is restricted. The access to care for private insured patients is not.

Hospitals receive a bonus for seeing Medicaid patients. This fact is not transparent and known by few.

 “And despite some feeble claims to the contrary, privatizing Medicaid will end up requiring more, not less, government spending”,

Paul Krugman makes declarative statements as if they are unequivocal evidence. 

 “because there’s overwhelming evidence that Medicaid is much cheaper than private insurance.”

The evidence in Paul Krugman’s quoted study is not that overwhelming.

I reviewed this 2008 study. The demographic difference of the Medicaid group compared to the privately insured group is different. The difference can reveal alternate conclusions.

 

 

Note the demographic differences of the Medicaid vs. Private insurance patients.

 

Heath status good      53.5% vs 41.2%

Mental health             17.4 % vs  6.4%

Hispanic                     23.4% vs 16.9%

African American        27.5% vs 16.4%

White                          49% vs 66%

Employed                   48% vs 74.6%

No hi school degree   36.7% vs 17.2%

Married                        33.6% vs 51.7%

Income less than poverty 62.3% vs 22.2%

 

An alternate conclusion could be that it is too difficult for Medicaid patients to find a physician. Medicaid patients are more poorly educated. The do not seek physicians’ help compared to the privately insured group. Medicaid patients cannot afford the minimal out of pocket expenses.

 

To my amazement the unadjusted annual per person Medicaid spending was higher in this article for the Medicaid insured group than the privately insured group by $1000.  

Paul Krugman states Medicare and Medicaid have lower administrative costs.

“Partly this reflects lower administrative costs, because Medicaid neither advertises nor spends money trying to avoid covering people”.

 He goes on to say.

 “But a lot of it reflects the government’s bargaining power, its ability to prevent price gouging by hospitals, drug companies and other parts of the medical-industrial complex.”

The government does have bargaining power. However reimbursement to physicians is so low that it is difficult for Medicaid patients to find a physician.

This could be a reason Medicaid costs are lower than privately insured patients with a high school education and a job.

Acute care hospitals have a 10% Medicaid threshold. They can also be eligible for incentive pay.

 “In addition, to be eligible to receive a Medicaid EHR incentive payment, acute care hospitals must also meet a 10 percent Medicaid patient volume threshold.”

Paul Krugman and others conclude,

“Our nation cannot control runaway medical spending without fundamentally changing how physicians are paid.”

Physicians receive only 9% of healthcare dollars spent. The real facts are physicians write orders for the inflated services of the hospital systems without receiving financial benefit. In fact, the government restricts physician participation. Physicians’ reimbursement decreases yearly.

It is very easy to draw the wrong conclusions when relying on inaccurate facts from so called experts.

The real challenge is to dig down and get the correct facts.

This is not done because ideology, non-transparency and bias stand in the way. This contributes to the healthcare system becoming more dysfunctional and costly each year.

 Healthcare policy errors are made because policy is made using incorrect facts.

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.



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A Point Of View

Stanley Feld M.D.,FACP,MACE

Steven Brill’s 24,000 word article “Bitter Pill” is an excellent review of some hospital charges. He presents examples of outrageous hospital charges.

 Many consumers have experienced these charges but have ignored them. Few have understood them. Their healthcare insurance coverage negotiated the reduced payment.

His examples of charges from real patient bills such as $199.50 for a troponin test. Medicare pays hospitals $13.94 for the test. The hospital accepts the charge. The actual cost of the test is less than $4.00.

A hospital charge for a simple complete blood test was $157.61. Medicare would pay $11.02.  The actual cost to the hospital might be fifty cents.

A simple finger stick blood sugar hospital charge was $18.00.  Accu-chek gives the machine away to sell the sticks. A box of 50 test strips costs $27.00 or $.55 a strip. It cost less that one penny to produce a strip.

Now that more people are unemployed and fewer people are insured or have adequate insurance, consumers are starting to pay attention to these fees.

 It is about time that a major news media outlet published something about these outrageous hospital system charges to consumers.

After all, the media is the message!

Maybe the message will generate the necessary community outrage for effective reform.

I have often heard “when you are sick enough to need a hospital you do not have the time to shop around,” for the best price.

It is true. However, no one has questioned hospitals for charging those rates.

The poor, uninsured and underinsured are the consumers this price system hurts the most. Society needs to protect these Americans from this outrage.  

Consumers with adequate healthcare coverage do not even look at the explanation of benefits for their healthcare bills.. Their healthcare insurance company pays the bill after negotiating the price with the hospital system.

As premiums and deductibles rise these fee are getting more attention.

There is so much data in Steven Brill’s multi-page document that I am sure comprehension is low. It does not mater. 

Steven Brill’s message is crystal clear. The situation is intolerable. The American public is being ripped off. Healthcare pricing is destroying our nation’s economic growth.

Brill does not explain the reasons how these high prices evolved. He does not explain whom if anyone should be doing something about them.

He does not come out and say the solution is government takeover of the healthcare system. However, he implies it throughout his article.

Any fair minded individual would be sympathetic to this implied notion. However. Steven Brill disregards the fact that the government got us into this mess.

I have explained this over and over again.

The Berkeley economist James C. Robinson pointed out that improving the healthcare system is different than making technological improvements in an outmoded corporation.

The success of all other transformations has been consumer driven.

The healthcare system has evolved to the point that consumers must shut up, do as they're told, and be prepared to write a blank check.

 Healthcare policy wonks have concluded that healthcare must be commoditized and depersonalized.

This thinking has resulting in the present healthcare system’s pricing. No one understands it or is attempting to modify it.  

• “The corporate system of health care has produced stronger organizations and more intense performance competition than the traditional system dominated by professionals.
• This transformation of the health care system has swept away the framework of professional dominance in medicine.”

The excuse has been that consumers do not know how to drive the healthcare system. It is too complicated.

This excuse has been used to "justify every inefficiency, idiosyncrasy, in the healthcare system driven by professionalism, by interest-serving institutions and corporations in the health care industry to control and raise the price of healthcare."

Hospital systems have realized that in order to control the system medical care must be commoditized. There is also government agreement.

 “Hospitals, insurers and other institutions involved in health care battle over available dollars.

These institutions also know that hiding the true cost of healthcare from the consumer is the way to inflate value and increase cost.”

Hospital systems also know in order to control the healthcare system completely they need to own physicians’ skills and intellectual property.

Patients and physicians drive the healthcare systems not corporations and hospital systems.

Physicians like the public are blind to hospital charges and costs. There is no price transparency. The hospital systems are positioning themselves as parasites to take advantage of patients and physicians.

The government is trying to encourage hospital employment of physicians so it has fewer entities to deal with. This is a mistake.

Steven Brill indirectly implies government driving healthcare for all is the cheapest and best way. He is wrong.  

A government single party payer system will only increase the price of healthcare and create unhappier patients with restricted access to medical care.

Physicians are not interested in having their skills and intellectual property treated as a commodity.

Physicians will become more cynical. They will unionize and restrict their hours worked in a week.

These developments will cause the ultimate demise of the healthcare system.

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.



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Hospital Systems’ Abuses Of The Healthcare System

Stanley Feld M.D.,FACP, MACE

In my very first blogs in 2006 I made the point that all the stakeholders are to blame for the dysfunctional healthcare system.

Most of the incentives that created a technology driven healthcare system have been perverse. All the major stakeholders’ incentives are misaligned.

The major stakeholders are consumers, physicians, government, healthcare insurance companies, pharmaceutical companies and employers.

The primary stakeholders are consumers and physicians. The government, healthcare insurance companies, pharmaceutical companies and employers are secondary stakeholders. Some secondary stakeholders provide administrative services and some reimbursement. None provide medical care.

None of the actions of any of the stakeholders are transparent. All the stakeholders are trying to take advantage of the payers (consumers, employers and the government).

The government should be the neutralizing force. It should level the paying field for all the stakeholders. Government should not permit one stakeholder take advantage another stakeholder.

Everyone except the primary stakeholders “patients and physicians” figured out the money game in the healthcare system early on.

Government and employers were next to last in figuring out the game of money gouging.  This happened in the early 1980’s when both said they cannot pay any higher price for healthcare services.

At that point the hospital systems and the healthcare insurance industry figured out another way to continue the money gouging. The result was HMOs and managed care. They did not work.

The opacity of pricing continued, cost shifting flourished, and the price of medical care continued to rise.

Physicians are not blameless. However, they are the easiest to blame. Physicians are the least organized and least aggressive stakeholders in the healthcare system.

In the past, I have pointed out the real problems that have resulted in the dysfunctions of the healthcare system. Health policy wonks seem to ignore the real problems.

Consumers and physicians are mere pawns in this money game.

Without consumers or physicians there would be no healthcare system. They generate the engine that provides the need for medical care and administrative services.

I have covered much of the abuse of the healthcare system by most of the stakeholders.

I have been relatively easy on hospital systems and pharmaceutical companies until now.

However, the basic problems in the healthcare system must be to be recognized and then fixed. All of the problems have to be recognized at the same time and fixed simultaneously.

A patch on one problem simply intensifies the overall problems.

Obamacare does not solve any of the real problems. It is an attempt at patching a problem. It will only make the problems worse and will not reduce the cost of care.

On February 20,2013 TIME Magazine published an article by Steven Brill. The article is an excellent article pointing out the abuses of the hospital systems.

“Bitter Pill Why Medical Bills are Killing Us” presents examples of the abuses of large and small hospital systems.

The basic philosophy that hospital systems should operate by should be “Patients First.”  It is not. It is how much money can I make from each patient.

Steven Brill asked the major question. “ Why are hospital bills so high?”

He presented the answer:

 

http://www.time.com/time/video/player/0,32068,2178453595001_2136781,00.html

The answer is obvious to all physicians.

One fellow physician wrote.

Stan

Although we know much of this, this is an excellent overview of healthcare costs.

 Steve

All Americans ought to understand the distortions hospital system pricing creates. The government ought to make hospital pricing transparent to everyone..

The government should include the hospital system’s retail price, wholesale price and actual cost for an item or service.

Then, consumers can choose the hospital system to go to.

Policy makers continually criticize this ideal saying that illnesses are sudden and patients are not in a position to choose a hospital system or negotiate price.

If the hospital system is compelled to compete on price the price will be the same as the competitive price when the patient gets sick. If one hospital is much higher than the next hospital the patient will know this before hand.

Hospital system charges are actually higher than they appear. Most hospital systems are non-profit organizations. The hospital systems do not pay taxes.

Hospital charges are opaque to everyone, including physicians. Physicians generate the services hospitals charge for.

As seen in Steven Brill’s article oncology charges are extremely high.

One oncologist wrote to me and said he could administer the same therapy in his office for one-tenth the hospital cost.

However, neither the government nor the healthcare insurance industry would reimburse him for the office procedure. It is the same procedure he performs in the hospital.

Doesn’t that seem strange? What is going on?

Steven Brill discovered that it is almost impossible to find out what hospital systems are charging.

The same opacity is true for pharmaceutical charges.  The pharmaceutical charges are further inflated by multiple middlemen involved in drug distribution.

This has been less true for drugs since Internet Drug stores publish drug prices.

However, since the patients’ physicians prescribed the drug patients are hesitate to use substitute drugs. The patients’ attitude is that the healthcare insurance company will pay for the drug less the copay.

Therefore the patients are not interested in looking up the difference in price or the options for substitution.

This is the reason consumers need skin in the game.

The result of consumer apathy is an increase in healthcare insurance premiums.

Steven Brill covers the grotesqueness of retail hospital system charges. He also points out the amount Medicare reimburses for the grossly inflated charge.

The consumers without insurance are the consumers that get stuck with the retail charges. Insurer consumers recieve a large discount.  The uninsured consumers are least likely to be able to afford these charges.

In some cases Medicare reimbursement is less than 20% of the hospital retail charge. Steven Brill points out that at this time Medicare reimbursement to hospitals is still 10 times its actual costs.

The article “Bitter Pill” is excellent. It covers many categories of hospital system abuse by the use of case studies.

The facts are overwhelming.  I am going to try to categorize these facts in my next blogs. The abuses will be easier to remember.

Consumers must be educated. The hope is consumers can be activated by education. Only a consumer driven healthcare system can drive the abuse out of the healthcare system. 

Then, Americans will have an affordable healthcare system.

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.



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Why Not Avoid The Financial Problems?

 Stanley Feld M.D.,FACP,MACE

It is very clear to me that neither the Obama administration nor the senate wants to solve the root causes of the federal deficit problem.

The sequestration debates are not getting to the root causes of the deficit. Eighty five billion dollars will not make a dent in America’s 16 trillion dollar budget deficit.

President Obama is running around the country scaring everyone with the notion that vital services must be cut or else the country will be paralyzed.

Recently the congress and the President appropriated $60.2 billion dollars for aid to Sandy victims. This is almost as much as the sequestration is going to eliminate.

“The Senate voted Monday to provide $50.5 billion in aid for victims of Superstorm Sandy. The vote means Congress has approved a total of $60.2 billion in aid for Sandy victims”.

America’s big deficit problem is created by out of control entitlement programs. Obamacare is adding to entitlement spending. It will only increase the deficit.  

Our politicians’ should be working hard to figure out a solution to increasing entitlement spending. Yet the Obama administration has refused to consider entitlement reform.

America’s two largest entitlements are Medicare and Social Security. Food stamps, and unemployment insurance, among others has some impact on the deficit.

Simple reforms and a decrease in waste could solve the problem.

The following two articles summarize the illusion of the existence of Social Security and Medicare Trust Funds.

In reality the money goes into these trust funds from payroll withholdings. The government then borrows the money to pay general expenses. It provides an IOU to the trust funds. In essence the trust funds are broke and the IOUs are an unfunded liability of the federal government..

“And since the federal government borrows the surplus from both funds (Social Security and Medicare) to pay other expenses, the only thing in those trust funds own special, non-negotiable, interest-bearing IOUs.”

 http://articles.washingtonpost.com/2012-10-18/opinions/35502037_1_trust-fund-medicare-trustees-health-care

http://www.forbes.com/sites/merrillmatthews/2012/08/21/think-social-securitys-trust-fund-is-a-scam-medicare-has-one-too/

In order to pay Social Security and Medicare obligations the government shifts revenue of current accounts into the trust fund accounts.

Citizens paying into Social Security and Medicare all those years thought they were paying for a retirement annuity. The assumption was the money would grow with wise government investments and those funds would be able to pay their promised liability to seniors.

Those payments were really a disguised tax. As baby boomers become eligible for Medicare and Social Security the obligation is increasing.

America is reaching the point where more people are receiving these entitlement benefits than the younger people who are funding them.

The logical result is the premium price for Medicare coverage is scheduled to double in 2014. The deductibles for services are scheduled to increase. The age requirement for eligibility is about to rise.  Access to care is decreasing as physicians refuse to take Medicare. Rationing of care is increasing as hospitals are being forced to assume risk. No one wants to assume the risk of taking care of sick people. Especially when they are not very good at evaluating the risk.

Everyone knows all of this. Nevertheless they turn away as the government either borrows more or prints more money.

Americans have been told by multiple administrations that citizens could not handle their own Social Security or Medicare annuity very well. Therefore the government must do it for them.

The government has done an awful job managing our retirement annuities.

Social Security and Medicare Trust Funds must become real trust funds that grow in value in the future or the government should hand control over to the people.

The Obama administration refuses to believe the significance of defensive medicine. Defensive medicine’s cost to the healthcare system is somewhere between 300 to 700 billion dollars a year.

The Obama administration’s estimate is it costs 3 billion dollars a year. They are wrong. Ask any physician.

Why should physicians or hospital systems assume the risk of missing a diagnosis by not doing a test?

The emotional and financial consequences of a frivolous lawsuit can be devastating.

Simple and fair tort reform will save the healthcare system around 500 billion dollars a year.  The 500 billion dollars is more than 5 times the cost of the 85 billion dollar sequestration. The administration is wasting 500 million dollars to protect the business of malpractice trial lawyers.

The administration claims its overhead for Medicare is only 2 ½ %. This represents the cost to pick an insurance company to adjudicate insurance claims. The true cost is not clear. However, it is somewhere between 40-60% of every Medicare dollar spent.

The insurance company is permitted by the government to pack many expenses into the direct patient care column and avoid going over the 15% medical loss ratio allowed.

The ten hidden taxes written into Obamacare are now starting to be felt. The Obamacare taxes are going to increase the cost of medical care not decrease the cost as the affordable care act promises. 

Patients are directly responsible for many of their own medical outcomes.  If patients had skin in the game and financial incentives they would pay attention to their self -care and their physicians’ recommendations. 

There are no incentives in Obamacare for patients to manage their care effectively. Financial gain would get their attention.

These are just a few of the solutions to the real problems in healthcare. There is much more waste in federal spending than $85 billion dollars a year.

All you have to do is look at the list of extraordinary waste that Senator Tom Coburn has compiled.

Rand Paul did a clever thing. He sent $600,000 of his senate office budget back to the U.S. Treasury after carefully trying to save money. The 49 other senators and over 400 congressperson ought to do the same. It would set an example for all of the bureaucracy to do the same. In fact President Obama ought to demand it.

“The Kentucky Republican returned $600,000 in funds he saved from his Senate office budget in the last year, the Louisville Courier-Journal reported.

“It’s the only budget I control,” Paul said at a news conference in Louisville. “It’s not enough, but it’s a start.”

If every congressperson saved 600,000 a year as Rand Paul did the deficit would be reduced by $321 million dollars more a year. If all the cabinet positions and their agencies tried to save money and were rewarded for saving money we would start to make some progress in decreasing the deficit.

The Simpson Bowles Report commissioned by President Obama would be helpful in eliminating unnecessary agencies and duplication. Their report has been ignored by the Obama administration.

Why has President Obama refused to listen to people who have exposed the many areas of government waste? It is incomprehensible.  

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.



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My First Date With Cecelia

Stanley Feld M.D.,FACP,MACE

 

Cecelia and I are approaching our 50^th wedding anniversary. We were married on June 16,1963.

Our first date was on March 31,1959. March 31^st has been a magical day for me.

I had my Bar Mitzvah on March 31^st even though my birthday is March 17th.   

Cecelia and I became engaged on March 31^st. 

I all began with my Aunt Anna. My aunt Anna was a friend of Cecelia’s mother. Aunt Anna met Cecelia. She liked her. She told Cecelia’s mother she had the perfect boy for Cecelia.

Cecelia did not need to be introduced to any boys. At 16^1/2 years old she was already a beautiful woman.

Aunt Anna was a persistent woman. She bothered my brother Charlie at least 3 times a week for months to call Cecelia and take her out.

My brother was a senior in high school. He played on the high school’s basketball and baseball team. He was a big man on campus. In addition to all of that he had a steady girlfriend.

He had no time or interest in taking Cecelia out.

My family lived in a small three story attached two bedroom house. My brother and I shared a bedroom. One night he asked me to help him get Aunt Anna off his back.

He asked me to take Cecelia out.

I said sure. I made a date to take her out for pizza on a Wednesday night. I took her to the Pizza Parlor on Boston Post Road and Gun Hill Road in the Bronx. The Pizza Parlor is gone now.

Years later I found out that she was not impressed with the pizza. She was impressed with my father’s baby blue 1959 Pontiac Bonnieville convertible and its gigantic fins.

 

 

http://www.ebay.com/itm/1959-PONTIAC-BONNEVILLE-CONVERTIBLE-BLUE-1-18-DIECAST-CAR-MODEL-BY-SUNSTAR-/140604420397

 

I fell in love with Cecelia at first sight.

She was beautiful in her blue button down shirt and jeans. She was very intelligent. She had many interests. She was a great conversationalist.

I dated many girls in high school and college. I was never as impressed as I was by the brightness of this woman. As my father would say, “I was smitten”.

Cecelia was going to High School of Music and Art. We had many of the same interests.

At Columbia College I was a pre-med with a concentrates in chemistry and fine art.

Columbia College was my first exposure to fine art and its history. At that point Cecelia knew as much or more about the arts than I did.

Her élan blew me away.

When I got home that night I told my brother I thought I would be marrying Cecelia.

He looked at me as though I was nuts. We then turned the light off and went to sleep.

The rest is history. Cecelia and I have had a wonderful trip through life together. We have always had mutual respect for each other. We have grown in life together by cultivating mutual interests. We have supported each other’s dreams.

Cecelia has always been my heroine. I know I have always been her hero.

We raised two sons, Daniel and Brad. When I think about it, they are a combination of both of us in different proportions.

Daniel and Brad are fine men and dedicated husbands. Both are married to wonderful women.  Cecelia and I are very proud of them.

As Cecelia and I approach our 50^th wedding anniversary with a great family, I can only think of the corny phrase my mother used over and over again when she was alive and the family was together,

“My cup runneth over”.

It was a very lucky first date.

 The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.



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Why Obamacare Will Fail

Stanley Feld M.D.,FACP,MACE

Obamacare will fail because none of the stakeholders’ vested interest are aligned.

The storm is brewing in the healthcare system.

Even Democrats are concerned.

Recently, I have been criticized for blaming the impending failure on President Obama. President Obama would rather blame the impending failure on congress.

 A reader wrote;

“President Obama is a nice guy. He is trying very hard. Give him a chance.”

It is true. He seems like a nice guy. My criticism is not personal. The fact is his philosophy and tactics are responsible for the mess. As time goes on it seems more likely that Obamacare will not work out.

There are multiple reasons for the impending failure. A major reason is Obamacare is developing new perverse incentives for stakeholders rather than aligning all the stakeholders’ vested interests.

Obamacare is extraordinarily complex. It is confusing to all the stakeholders,  especially as new rules and regulations are being written.

By forcing the development of programs such as health insurance exchanges, accountable care organizations, pay for performance plans, functional electronic medical records, and the consolidation of healthcare hospital systems and physicians against their will, Obamacare is creating tensions and uncertainties that will be difficult to overcome.

Patients’ medical care and their relationships with their physicians are personal issues. Obamacare is commoditizing medical care. It is destroying the patient physician relationships. These relationships account for at least one half of the therapeutic effect of medical treatment.

The 2300 page law usurps the power of the legislative branch of government and shifts it to the executive branch. This is dangerous. It has created additional tension and uncertainty for the nation.

Many congressmen who voted for the law did not read the law’s 2300 pages. The implications of much of the law were not understood. It did not have bipartisan support.

In 2012, the executive branch of the federal government issued another 70,000 pages of guidance for participants in Obamacare. The executive branch has created at least 22,000 new regulations and 68,000 new ICM codes.

The more complex a law becomes the more likely it is to be unsuccessful.

There is no question the healthcare system nears repairing. Healthcare costs are exploding. Waste and bureaucracy are expanding.  Dysfunctional interactions between stakeholders are mounting.

All of this results in an inability to deliver effective medical care.

At present 55% of Americans of all ages receive healthcare insurance through an employer sponsored healthcare plan. An additional 32% receive healthcare insurance through government programs.

Thirteen percent (13%) of the population are uninsured or under insured. Obamacare’s goal is supposed to provide healthcare insurance for that 13%.

Present predictions are that Obamacare will not provide universal care. It is predicted that it will not save $850 billion dollars. The CBO, on the basis of numbers provided by the administration, predicted the law would save $850 prior to the passage of the law.  The CBO’s current prediction is Obamacare will cost the nation an additional  $1.2 trillion dollars over 10 years.

Healthcare insurance rates are rising by double digits each year. Employers are passing the costs of the increasing insurance rates to their employees through higher deductibles and copays along with lower healthcare coverage plans.

 Obamacare will require employers, who offer skimpy healthcare benefits such as Mini-med insurance, to provide more robust ones.

To date the Obama administration has waived more than 2000 employers from providing more robust healthcare insurance coverage. At the time these waivers expire companies with waivers, such as McDonald’s, will scream bloody murder.

They will opt out of providing any healthcare insurance at all and avoid government penalties. They will accomplish this by decreasing the number of hours an employee will work to less than 30 hours a week. This is not good for minimum wage workers. The uninsured rolls will increase.

The penalty of $3,000 per employee is less than the $15,000 healthcare insurance cost per employee for employees working more than 30 hours a week.

Surveys have been published concluding that more than 50% of employers are planning to drop healthcare insurance coverage.

The federal government is trying to discourage this by invoking the IRS anti-abuse rules;

“The IRS has indicated that anti-abuse rules will be implemented to curtail the use of Obamacare loopholes to dodge the play or pay requirement.

  Yet as some have already questioned, can the IRS legitimately utilize rule-making to modify core components of a federal act? Or will this rule-based clean-up effort simply spawn more lengthy litigation?” 

Obamacare’s health insurance exchange program is in big trouble. Less than half the states have signed up to participate.

 States have opted out because of the potential cost overruns. States are struggling to balance their budgets. The federal government is only going to pay for health insurance exchanges’ development and execution for the first two years.  The cost burden will then fall on the states.

The federal government keeps extending the deadline for states to sign up. The federal government does not have infrastructure or manpower to set them up.

The health insurance exchanges are supposed to be up and ready to sign up consumer up in October 2013 and operating in January 2014.

Physicians do not know what to do about Obamacare. Physicians feel helpless. They know Obamacare cannot work. Physicians do not have a leadership organization that can direct physicians to have an effective voice.

Accountable Care Organizations (ACO’s) will fail because physicians are trained to use medical judgment. They have not been trained to obey the rules of hospital administrators.

They bristle when their value is determined by hospital systems or federal agencies such as IPAB. They prefer to have their value determined by their patients.

Physician leadership needs a new mentality to enable physicians to act and articulate  the steps needed to be taken to repair the healthcare system.

Physicians want the healthcare system to function equitably for all the stakeholders and effectively for their patients.

Medical organizations have been consistently losing membership because it has not represented or articulated the needs of practicing physicians.

If Obamacare works as President Obama hopes, he will have secured his legacy and solved the long-festering problem of the uninsured.

Obamacare will not solve the problems of increasing healthcare costs nor provide universal care in its present form. This has been a pipe dream all along.

Another reason Obamacare will fail is because it does not consider the cost of defensive medicine significant. President Obama is not interested in tort reform.

Obamacare doesn’t align any of the stakeholders’ vested interests.

When Obamacare fails it will provoke a citizen backlash that will be very difficult to overcome.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.



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