Repairing the Healthcare System

War On Obesity: Part 17

Stanley Feld M.D.,FACP,MACE

In a War on Obesity the media is the message. The media has to produce an effective message.

There is no need reciting the harmful effects of obesity. There is no need outlining the cost to the healthcare system. The rising incidence of Type 2 Diabetes Mellitus is a direct result of obesity.

The message about obesity must be crafted so it can become viral. Attempts have been made to craft such a message. The message has not been constant or continuous.

At the same time, the fast food and junk food industry’s message has be constant and continuous. Its message shows up on every sports event and every comedy show on television multiple times a day. The fast food advertising budget has not been reported. I would guess a thirty second ad during the Super Bowl cost more than the entire public service costs of promoting healthy food intake during a full year.

In 2009, Michelle Obama planted a symbolic 1,100-square-foot plot in a spot visible to passers-by on E Street. The garden was planted to encourage healthy eating.

Double click to enlarge

Please note there is a lot of spinach planted in four large areas of the garden. There are also a lot of peas planted. Kale, chard, and collard also occupy a significant number of square feet in the garden. None of these can compete with junk food and fast food.

At about the same time the garden was planted, there was a media frenzy created around contaminated spinach. Where are the tomato plants? Where are the fruit trees? There is just a small area devoted to blueberries, raspberries, and blackberries. Where are the strawberries?

“Virtually the entire Obama family, including the president, will pull weeds, “whether they like it or not,” Mrs. Obama said with a laugh.”

The first lady said that she had never had a vegetable garden. The idea of a garden came from her experiences as a working mother trying to feed her daughters, Malia and Sasha, a good diet.

Yet, when President Obama goes on the campaign trail, the photo-ops are usually taken in unhealthy greasy spoons. He does not set a great example to encourage a change in eating habits.

We are not told how these vegetables are included in the daily meals of the First Family. We are not taught anything about calorie intake of the first family.

There was a report of lead in the White House vegetable garden’s soil. This was not a good message. We immediately heard White House denials.

“The results prompted a number of headlines suggesting that the level of lead in the garden, 93 parts per million, was dangerous.

It was not. The level is well below the 400 p.p.m. considered hazardous by the Environmental Protection Agency, though not below the more stringent goals recommended by some countries like the Netherlands, at 40 p.p.m.

The head groundskeeper during the Clinton administration says that sewage sludge which contained lead was used once, in 1995.

These reports did not result in encouraging the population to change its eating habits.

The Centers for Disease Control and Prevention recently issued a comprehensive nationwide behavioral study of fruit and vegetable consumption. Only 26 percent of the nation’s adults eat vegetables three or more times a day.

These results fell far short of health objectives set by the federal government a decade ago. The amount of vegetables Americans eat is less than half of what public health officials had hoped.

“Dr. Jennifer Foltz, a pediatrician dedicated to improving the American diet, concedes that perhaps simply telling people to eat more vegetables isn’t working.”

“There is nothing you can say that will get people to eat more veggies,”

The consumption of salads during home prepared dinners decreased from 22% percent in 1994 to 17 percent in 2010. Only 23% of the home prepared meals contained one vegetable.

People know that vegetables can improve health and help with weight loss. The public service campaigns have been ineffective.

Why?

1. Vegetables are a lot of work to prepare.

2. Vegetables are wasted all over the country because they are expensive and often spoil in refrigerators.

3. The moment you have some fresh vegetables you have to schedule your life around eating them.

4. Vegetables have to be prepared properly to taste good.

5. Vegetables are expensive compared to fast food.

6. Americans want taste before health,

7. Americans want convenience before health

8. Americans want low cost before health

Why? Americans have the notion that government will pay for their healthcare when they get sick.

Melissa MacBride, a busy Manhattan resident who works for a pharmaceuticals company, would eat more vegetables if they weren’t, in her words, “a pain.”

“An apple you can just grab,” she said. “But what am I going to do, put a piece of kale in my purse?”

It is clear vegetables and healthy eating has been sold to the public the wrong way. Now, a food growers association is trying to get people to eat vegetables by packaging baby carrots as a junk food.

Heather Ainsworth for The New York Times

I believe President Clinton has figured out the right formula.

President Clinton was once so famous for his fast food diet that Saturday Night Live performed a sketch called "Clinton at McDonald's." In the five minute parody, Clinton eats a fish fillet, a sausage egg and cheese sandwich, a chicken nugget, bites of a hamburger, a milkshake, and several french fries.

Since then he has suffered from coronary artery disease. He had a coronary artery stent. It failed. He then had triple bypass surgery. Recently, he became a vegan and lost 24 pounds. His interview with CNN is riveting. This type of public service campaign could change our nations eating habit and decrease obesity.

America must dedicate itself to fighting obesity to decrease healthcare costs. How many congressional delegates have a high BMI? The life style of the nation can be changed by examples such as President Clinton’s.

Otherwise, healthy lifestyles will remain a joke that cannot compete with the advertising campaigns of the junk food and fast food chains.

A victory over obesity is in the people’s power.

 

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

My Smart Phone Adventure

Stanley Feld M.D.,FACP,MACE

I am an early adaptor. It might seem strange that a retired clinical endocrinologist would be an early adaptor. Physicians are early adaptor when there is something compelling to adapt too.

As proof, I have had a cell phone since 1985.

My son, Brad, wired my medical office building in 1986. Feld Technologies, his first company, also developed a medical financial package and a lab billing program for me at that time. I developed a web site for the American Association of Clinical Endocrinologists in early 1994.

My first cell phone was a large $2,000 brick. I bought it at a benefit auction for $500 in 1985. It had to be installed in the floor board of my Porsche 911. A call cost $2.00 a minute. The phone was compelling to me.

My proudest early adaption was my purchase of the PogoPlug. Without knowing it, I bought the first one ever sold. My buying it led to Brad and Foundry group investing in the company.

Today, I received a beautiful note from Daniel Putterman, President and CEO of Cloud Engines, Inc. along with DVT #1 (first copy) of the third generation of Pogoplug.

He wrote, “I hope you will accept this as a gesture of gratitude and appreciation from the entire Pogoplug team and myself.”

Dan, I do and it will sit in a special place in our house. You are a great kid with a great product.

I had the first Palm Pilot at Brad’s suggestion. I have had a series of cell phones since my first one. My favorite was a SONY CM-RX100.

I cherished my SONY CM-RX 100 cell phone. I then bought an early Treo combining my cell phone with my Palm Pilot.

The SONY is now in my cell phone museum. It is part of Brad and Daniel’s inheritance.

I wanted to buy an IPHONE shortly after it was released. Apple’s method of releasing products has always annoyed me. My first IPOD was 4 GB. It was obsolete in 1 year. My present IPOD is 160 GB.

Steve Jobs builds stuff to be obsolete. He then introduces an upgrade that is “essential” while maintaining his price point. He is doing the same thing with the IPAD.

Two years ago, I made another run at an IPHONE. Brad told me it was “the greatest and I must have one.” I knew ATT’s service was terrible in Dallas. I am not into pain.

Again, I went to three ATT stores. All three had me take a number and wait. The greeter told me the wait would be 15 minutes. After 15 minutes, I asked how much longer I would have to wait. The greeter in each store said another 15 minutes.

I left each store. I finally walked down the street to T-Mobile and got a Blackberry. The sales person at T-Mobile was terrific. The Blackberry did not live up to my expectations.

I was very excited when Google released the Android operating system. I feel Google has great vision for the future. The Android OS fits into this vision. I am confident the Android OS will enhance our living experience.

Google’s marketing of its first Android phone, the Nexus, stunk. T-Mobile shrugged off its role in the service as an inconvenience. As new phones were released, I became more and more excited about the Android OS.

I was in no hurry to spring for the first Android phone. I knew Google would develop the system rapidly.

I followed the specs on new phones. I then asked Brad’s IT person, Ross Carlson, for his opinion. Ross is on top of every phone. His evaluation is astute. He also has the same opinion of Apple’s marketing that I have.

Cecelia, my wife of 47 years, has been happy with her simple clam phone. It took a lot of convincing to get her to agree to an Android phone. I wanted her to get the same smartphone I got so we would experience the learning curve together.

In early September, I read the pre-release specs on the Verizon Fascinate. I decided that the Fascinate was the Android phone for Cecelia and me. It had a 4-inch "Super AMOLED" display that looked stunning on the video. Picture quality looked fantastic, and colors were rich. 

Perhaps more importantly, one is able to see the screen in direct sunlight. The Fascinate has a larger form factor than an IPHONE or Incredible. It is thinner than the Droid X and has rounded edges. The Fascinate has a 5 mgp camera with flash and 720 p HD video capture.

The Android 2.1 OS is reported as excellent. There are a few glitches. I expect the upgrade Android 2.2 will eliminate the glitches.

Cecelia complained about not being able to return a voice mail call without going to the call log. There is a work around to Bing being the browser and Navigator being the GPS maps program. There should be a work around to downloading and synchronizing tasks and notes in Outlook from MS exchange to the phone as there is for synchronizing the calendar. Market applications are too numerous to count. It is difficult for me to find applications I might want.

I called Ross. He said this looks like it is the best new Android phone released so far. Verizon is the best provider in my area. He did not have time to play with the phone yet but he knows Samsung makes a sturdy phone.

Cecelia and I stopped into the Verizon store on the day of release. We finished dinner and were on the way to a chamber music concert. I did not realize Verizon had a promotional special of two for the price of one. The promotion made the phone sound even better.

Ralph Garcia was an unbelievable Verizon sales representative. He knew he did not have to sell me. He immediately focused on Cecelia. He made her very comfortable with the Fascinate. She picked the Fascinate over the Incredible and the Droid X

The difference in this experience between Ralph Garcia/ Verizon and IPHONE/ATT was between night and day. ATT was doing me a favor selling the phone and service. Ralph Garcia understood our needs and provided us with information to make a choice. He was consumer focused.

We felt we were engaged in the decision making. We had the freedom of choice. We had a feeling that the person selling the phone was concerned about our satisfaction. Customer satisfaction and freedom of choice should be the goal of every sale no matter the product being sold by whatever profession.

Hooray for Verizon and Ralph Garcia. Hooray for Google and the Android OS.

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

Smoke And Mirrors With Patients And Physicians Being Vhe Victims

 

Stanley Feld M.D.,FACP,MACE

An interesting debate occurred in the Washington Post between Michael Leavitt was the former secretary of Health and Human Services, and a member of the Medicare Board of Trustees from 2005 to 2009, and Dr. Don Berwick, the director of CMS.

Michael Leavitt wrote a scathing article criticizing President Obama’s Medicare Reform Act calling it an illusion. Don Berwick wrote a rebuttal to Michael Leavitt’s article.

Michael Leavitt starts off his article by stating, “Despite the report from Medicare's trustees this month that the hospital insurance trust fund will not be depleted until 2029, 12 years later than was predicted just last year, Medicare is no better off than it was a year ago. “

The Medicare Trustees Report was strange. Nothing was done to change anything and all of a sudden, the hospital insurance fund was extended 12 years. I thought it was funny arithmetic.

Medicare Trustees is supposed to be an organization independent of the administration. Shortly afterward Richard Foster, Chief Actuary for Medicare, who is independent of both the Medicare Trustees and the administration, wrote an “Alternative Report.” He report received little coverage in the traditional media.

I wrote an article about Mr. Fosters report.

“The Medicare Chief Actuary Alternative Report: Richard Foster

After the Medicare Trustees Report was published, Richard Foster the Chief Actuary for Medicare warned “the projections in a Medicare Trustees Report “unreasonable” and “implausible.”

He encouraged everyone to ignore the report and view instead an “Illustrative Alternative” report. He said, “The projections shown in the report do not represent the “best estimate” of actual future Medicare expenditures.”

“Noting that the formal Trustees report assumes Medicare physician fees will be reduced by 30% over the next three years, Chief Actuary Richard Foster says that’s “implausible.” In addition, the Trustees report assumes Medicare fees will fall below Medicaid rates by 2019 and fall further and further behind private payment rates in future years, as the following chart shows:”

In his April 22 report, Richard Foster laid out the implausible aspects of the math. President Obama has used funny arithmetic to get his healthcare reform bill passed with a promise of budget neutrality. Foster said;

• Cuts in Medicare spending of $575 billion over the next decade.

• 7½ million members of Medicare Advantage plans to lose their coverage and cause another 7½ million to face higher premiums and benefit cuts.

• About one in seven facilities — hospitals, skilled nursing facilities, home health agencies, and hospices — to become unprofitable and possibly drop out of Medicare altogether.

• Many doctors to quit seeing Medicare patients entirely.

The public no longer believes President Obama and his projections. They understand his motives.”

 

President Obama constantly claims his healthcare reform law will “Bend the Cost curve” According the Chief Medicare actuary report it will bend the curve in the wrong directions.

In his rebuttal, Dr. Don Berwick uses the Medicare Trustees Report as a given truth to defend President Obama’s healthcare reform law.

“The Medicare Board of Trustees estimated last month that the Affordable Care Act produces savings that extend the life of the Medicare Hospital Insurance Trust Fund for 12 years, to 2029. The actuary of the Centers for Medicare and Medicaid Services (CMS), an independent office, reached the same conclusion.”

Dr. Berwick has misquoted Richard Forster, the chief actuary of the Centers for Medicare and Medicaid Services.

Dr. Berwick goes on to say, the Congressional Budget Office has estimated that the law will reduce the federal deficit by more than $100 billion over the next 10 years and more than $1 trillion in the following decade.

Those real savings help today's and tomorrow's Medicare beneficiaries.

The problem with that statement is that is what the CBO said before the bill was passed. The CBO was given assumptions by Nancy Pelosi, Harry Reid, and President Obama.

After the bill was passed in May 2010, the CBO revised the estimate. Rather than decreasing the deficit, it will increase the deficit by $115 billion dollars over ten years.

The problem begins with double counting. The Congressional Budget Office estimates that the health law will reduce Medicare spending by about $450 billion over 10 years. But all of those savings, plus massive tax increases, are used in the new law to pay for an expansion of Medicaid and a new entitlement program to subsidize insurance premiums for low-income households.

Dr. Berwick explained the double counting away by pointing out that Medicare cuts can be used to improve the government's capacity to finance benefits in the future or to pay for another entitlement.

If there are cuts to Medicare payments of $450 billion dollars over 10 years how are Medicare benefits going to improve. The CBO and Medicare's actuary said the $450 billion dollars could not be used for both Medicaid and Medicare. More importantly, congress has already committed those funds to other projects.

Dr. Berwick says this is not double counting. It sounds like double counting to me.

“Some, including Leavitt, claim these savings are "double counted." This argument is inaccurate and oversimplifies what is really going on.”

The government accounting rules opaquely cook the books and increase the deficit. Medicare’s estimated saving is credited to the Medicare Trust Fund. The Medicare Trust Fund buys treasury bonds. The government uses the bond proceeds to fund other projects. When Medicare needs the money, they sell the treasury bonds. The government prints more money without congressional approval. The increased funds will then pay for Medicaid expansion.

It is double counting.

Many Americans have a hard time following these manipulations.

I must warn President Obama and Dr. Berwick that Americans’ are interested now. There is a developing mistrust for the administration and the increasing budget deficits. The mistrust is growing especially since nothing is being accomplished except bigger government control over the healthcare system.

This is all smoke and mirrors with patients and physicians being the victims

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

Lest We Forget

 

Stanley Feld M.D.,FACP MACE

I have pointed out the many trick plays President Obama used to pass his healthcare reform plan. These trick plays are now obvious to the majority of Americans. The tactics have led to profound mistrust for President Obama.

Democrats running in this falls midterm election are avoiding talking about their vote for the healthcare reform law. Twenty-one states believe the bill is unconstitutional.

Two weeks ago, Politico broke the news that a major coalition of liberal supporters of the health care overhaul was telling activists not to mention deficit or cost reductions when attempting to sell people on the bill. Now, Politico reports, another major liberal health care activist group, Health Care for America Now, has an even better strategy for helping out the politicians who voted for the bill: Maybe just avoid talking about the law entirely! 

 

Over the next couple of weeks President Obama is going to campaign to persuade voters of the benefits and constitutionality of the Patient Protection and Affordable Care Act (Obamacare).

I think President Obama will be shooting Democrats running for re-election in the foot.

The majority of Americans is not buying anything President Obama has promised.

Remember Nancy Pelosi telling us not to worry because we will understand the bill after it is passed?

Americans are now finding out what is in the bill. It is not pretty.

If you like your plan, you can keep your plan.

Americans are realizing that President Obama couches his words with double meanings.

“What I’m saying is, the government is not going to make you change plans under health reform,”

Everyone knows employers change plans each year. These new plans do not qualify under President Obama’s statement. In a draft document laying out grandfathering rules it states that most plans will relinquish their grandfathered status if the plan is unchanged after a period of time.

Healthcare Reform will cost around $900 billion.

President Obama told a joint session of Congress that his health care plan would cost “around $900 billion over ten years.” He even said it would save tax payers money.

It will be paid for “mostly” by shifting around money that we are already spending.

Actually, the majority of the money from the bill’s official scored cost comes from new taxes. According to the CBO, “the two pieces of legislation [that make up the health care law] were estimated to increase mandatory outlays by $401 billion and raise revenues by $525 billion.”

The original CBO’s report said the final cost estimate for the law came in at about $950 billion. After the bill was law the CBO report stated the law will actually require about $115 billion in additional discretionary spending, putting the official price tag well over $1 trillion. http://cboblog.cbo.gov/?p=835

My guess is this estimate is still low.

President Obama said healthcare reform law will not cut Medicare benefits.

He said, “Nobody’s talking about reducing Medicare benefits.” But according to the head of the Congressional Budget Office, “thanks to $130 billion in planned cuts to companies that offer Medicare Advantage plans, the health care law will “reduce the extra benefits that would be made available to beneficiaries through Medicare Advantage plans.”

President Obama’s statement again represents another misdirection of reality.

President Obama declares that his healthcare reform law will put Medicare on better fiscal footing.

In August 2010, the Obama administration’s Department of Health and Human Services released a report claiming that the PPACA would “extend the life of the Medicare TrustFund by 12 years.”

Affordable Care Act Update: Implementing Medicare Costs Savings

“This new law recognizes that Medicare isn’t just something that you’re entitled to when you reach 65; it’s something that you’ve earned. It’s something that you’ve worked a lifetime for, having the security of knowing that Medicare will be there when you need it. It’s a sacred and inviolable trust between you and your country. And those of us in elected office have a commitment to uphold that trust – and as long as I’m President, I will.And that’s why this new law gives seniors and their families greater savings, better benefits and higher-quality health care. That’s why it ensures accountability throughout the system so that eniors have greater control over the care that they receive. And that’s why it keeps Medicare strong and solvent – today and tomorrow.”

- President Barack Obama, June 8, 2010

The Director of CBO Douglas Elmendorf said that “to describe the full amount of HI trust fund savings as both improving the government’s ability to pay future Medicare benefits and financing new spending outside of Medicare would essentially double-count a large share of those savings.”

Medicare’s top actuary agreed. He said “in practice the improved (Medicare hospital insurance) financing cannot be simultaneously used to finance other Federal outlays (such as the coverage expansions) and to extend the trust fund.”

President Obama’s Healthcare Reform act will give consumers more access and greater choice.

I do not think so. It will generate many unintended consequences.
Organizing for America, the successor to Obama’s campaign organization, claims that the new health care law will result in “more choices...for millions of Americans.”

Most experts expect that the health care overhaul will result in a serious doctor shortage, particularly amongst primary care physicians, meaning many individuals will have to wait longer for care, and may not get to see the doctor they want to see. Meanwhile, insurers in some states are already cutting back on insurance options. Healthcare insurance premiums will increase dramatically.

It will bring down the price of insurance.

President Obama, Nancy Pelosi and Harry Reid promise their healthcare reform bill would provide affordable healthcare insurance. The even called the bill the Patient Protection and Affordable Care Act.

The healthcare insurance industry is raising the cost of insurance between 10% and 29% next year. Insurance deductibles are increasing. Consumers’ out of pocket expenses are increasing.

“The CBO predicted that the law will cause average health insurance premium prices to rise by 10-13 percent in the individual market. And a recent survey indicates that most businesses expect insurance prices to rise as a result of the PPACA.”

I wonder what President Obama meant when he said the law would “bend the cost curve”? The implication is it would reduce the cost of healthcare coverage. I think it is bending the curve in the opposite direction.

CBO Director Douglas Elmendorf said in presentation at the Institute of Medicine; “the health legislation enacted earlier this year does not substantially diminish [the] pressure” of rising health costs.”

The big question should be where is all the money going? It is not physicians. Reimbursement is continuously being reduced.

The money is going to the additional government bureaucracy, and the healthcare insurance industry.

I think the American people get it. I wanted to repeat it

Lest We Forget.

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

Government Control vs. Innovative Free Market Forces

 

Stanley Feld M.D.,FACP,MACE

 

President Obama cannot understand why the American people are frightened about his healthcare reform act. The reasons are obvious.

The new healthcare reform law is increasing government bureaucracy and increasing regulations. Americans believe this is shorthand for increasing cost of care, decreasing access to care, rationing care, and increasing deficits.

President Obama has not demonstrated respect for Americans’ fear or wisdom.

President Obama’s healthcare reform act is on a collision course toward complete government control of the healthcare system. America’s destiny is a single party payer system. Why would President Obama want America to have single party payer system? The single party payer systems are failing in Canada and England. Those two countries are in the process of switching to a decentralized healthcare system.

Disintermediation of the healthcare system could solve many of the problems in our healthcare system. Presently, the healthcare insurance industry controls private insurance as well as public insurance by its administrative service fees. The federal government outsources its administrative services to the healthcare insurance industry.

Harry Reid and Nancy Pelosi are going to finance this debacle by increasing taxes.

Two of the most successful innovative entrepreneurs of our time, Jeff Bezos of Amazon.com and Michael Dell of Dell Computing have invested in Qliance Medical Management.

Qliance Medical Management is a company that disintermediates healthcare insurance. Its plan is to deliver real market-based solutions for healthcare by eliminating the middleman.

“According to Qliance, 40 cents of every dollar spent on health care goes toward dealing with insurance companies and paying for overhead.”

I have calculated the administrative services cost to be closer to sixty cents of every dollar spent.

“Qliance plans bet is that by getting rid of insurance companies and associated administrative fat, such as elaborate customer billing and reporting, they can deliver cheap, quality health care.”

Qliance is like a health club membership for healthcare. Membership includes unrestricted access to a Qliance clinician and clinic services for one monthly fee.

“Instead of dealing with costly overhead, we reinvest that 40¢ in our clinics, electronic medical records and in patient services. You experience shorter wait times, longer appointments and lower costs.”

Jeff Bezos and Michael Dell are on the right track but the plan has several defects.

“ Qliance customers pay a flat monthly fee of $44 to $84 dollars – depending on age and level of care you choose - to become a member.  For this, they get health care in clinics that are open seven days a week, covering 90% of the problems that we see doctors for, such as “check-ups…minor fractures…as well as ongoing care for chronic illnesses.”

Qliance customers must purchase catastrophic coverage for all other illnesses not covered. Qliance Medical Management is an attempt to deliver real market-based solutions for health care. This model is one of the first attempts to disintermediate the healthcare insurance industry.

Qliance is not the answer. It has too many defects. The most significant defect in the model is it depends on the population that joins, and the use or overuse of the system. Most importantly, the model is lacking patients’ incentives to remain healthy and live a healthy life style. If patients have a chronic disease, the model does not include motivation for patients to self-manage their disease.

Today, medical payments of insured patients are paid by the government or the healthcare insurance companies. The healthcare insurance companies also provide the administrative services for the government. There is a 40 to 60 cent burden on every healthcare dollar. This is the largest source of waste.

As government controls and regulations displace consumer power and choice, our health care costs and expenditures increase, not decreased. The Massachusetts healthcare reform experiment has proved this point.

“When you buy a car, a computer, purchase a cell phone plan, you shop.  Vendors compete for customers by finding innovative ways to make and distribute their products so they can deliver higher quality and lower costs than the competition.”

Our highly regulated health care reform act has none of these characteristics. 

President Obama believes more government regulations rather than innovation and freedom of choice is the answer. He is wrong.

Mike Tanner of the Cato Institute in his paper entitled “Bad Medicine.” points out that President Obama’s healthcare reform law will fail in all three goals. He estimates that the bill will cost three times the estimate and fail to provide healthcare insurance for all Americans, reduce insurance costs for, businesses, and government, and increase the quality of health care and the value for each dollar of health care spending.”

“The Reid Pelosi Obama plan that we’re now stuck with builds on what has already failed.  More government, more spending, and less freedom.  Unleashing entrepreneurs like Bezos and Dell is what we need to address health care.”

Qliance is a first step in the march to consumer driven healthcare. It must be combined with an ideal medical savings account to disintermediate the healthcare insurance industry.

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

Where Have President Obama and Dr. Berwick Gone Wrong?

Stanley Feld M.D.,FACP,MACE

Director of CMS, Dr. Don Berwick, has the same central government control philosophy as President Obama. They have different reasons for central control.

Dr. Berwick is going to feel disappointed and deceived when he fails to effect meaningful change or reduce medical costs. President Obama’s healthcare reform law is going to increase the cost of Medicare and Medicaid, restrict access to care and result in rationing of care.

President Obama wants to increase quality and decrease cost of healthcare with more efficiency. Everyone has the same goal. President Obama is going about it the wrong way

Dr. Berwick has stated that he loves the British National Healthcare System. He was hired as a consultant to that system by Tony Blair. The goal was to modernize Britian’s centralized system. He failed to reduce their costs. Britain is now decentralizing its healthcare system.

Dr. Berwick thinks in systems terms using the concepts of Fredrick Taylor. In a 2009 speech Dr. Berwick said,

“The idea of a system is neither a frill nor a fine point if we are to get reform right,” “System of healthcare lies at the very center of the scientific and political challenges that stand between us and the care we seek. With a proper understanding of systems, authentic health care redesign is feasible and socially productive. Without that understanding, ‘reform’ will likely do more harm than good.”

Our healthcare system does not coordinate care using teams. If they did the patient must be at the center of the team not the government.

All the stakeholders must be members of the team. They all must be accountable to each other. Members include patients, physicians, hospitals, healthcare insurers, and the government. Dr. Berwick is only considering physicians and other healthcare providers. He is giving the healthcare insurance industry a pass. The healthcare insurance industry is the biggest villain in our dysfunctional healthcare system..

Patients and physicians are the most important members of the team. Physicians are the managers, patient are the workers.

In order for a system to work, team members first have to know the elements of the system. The team members should then be provided with incentives so they are motivated to make the system work.

Dr. Berwick is not considering incentives for patients and physicians. He does not believe in the value of the free market. I believe his attitude will be a huge problem in his attempt to convert medical care to Taylor’s principles of scientific management..

I do not doubt his ability to create systems of care. I disagree with his punitive system of fulfilling systems of care. It will not work.

“Health care reform without attention to the nature and nurture of health care as a system is doomed,” Berwick said. “It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is care as our patients, their families and their communities .”

Dr. Berwick has criticized physicians care. He does not criticize patients lack of adherence to recommended care or their lack of compliance to healthy lifestyles. There has been little discussion on where money is wasted in the healthcare system. The healthcare insurance industry, hospitals’ or government’s role in the dysfunction of the healthcare system is not being discussed.

His has focused on waste created by the deficiencies in safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. There is no doubt the healthcare system’s needs the scientific management approach in each area. However, this is not where the bulk of the waste is.

“The improvement of health and health care depends on systems thinking and systems redesign,” Berwick said. “ ‘Reform’ without systems thinking isn’t reform at all.”

I agree we need systems of care. This philosophy is expressed in AACE’s System of Intensive Self-Management for Type 2 Diabetes Mellitus. I was the chairman of the task force for these guidelines. I ask develop of system of care for the diagnosis and treatment of osteoporosis.

President Obama favors a single-payer system with central control. Central control does not increase efficiency.

Dr. Don Berwick believes that the only efficient way to develop a process of scientific management in healthcare is central control with a single-payer system.

There are multiple defects in his notion.

1. Medical care should not be a set of algorithms that are centrally dictated. Algorithms should be a guide to care. Physicians must use clinical judgment.

2. The patient physician relationship must be nurtured. A large part of the therapeutic effect is that relationship. Medical care is not a commodity.

3. Clinical judgment is vital to successful patient outcomes.

4. Systems of care, with an interdisciplinary team approach, should be taught in medical schools and post graduate courses.. Presently, all disciplines are taught in isolation. When physicians go into practice, they realize the importance of interdisciplinary relationships. Models for interdisciplinary treatment approaches must be promoted and incentivized.

5. Dr. Berwick’s approach assumes that politicians and politics do not play a role in forming healthcare policy. Few believe this notion. Politics plays a big role in dictating agency policies.

6. In 1945, Friedrich Hayek pointed out that the command approach to dictating work flow is doomed to failure. Commanders do not receive accurate information about what is happening on the ground. This results in faulty central decisions.

7. Technocrats, like Dr. Berwick, may believe they can marshal statistics to optimize the health-care system. Statistics on outcomes and treatment plans have been misleading..

8. Statistical analyses rely on too many assumptions and too much unreliable data. These are the reasons government programs often result in colossal amounts of waste, fraud, and abuse.

9. The interaction of all the stakeholders must be considered. If the abuses of all the stakeholders are not considered and eliminated, the decision reached by the technocrats could be incorrect.

President Obama believes technocrats (Dr. Berwick) can solve the problems in the healthcare system. Dr. Berwick sees the problems in the healthcare system from 30,000 feet.

Our healthcare problems will only be solved by consumers at ground level along with disintermediation of the middlemen in favor of consumers.

Repair of the healthcare system can be achieved with consumer driven healthcare and ideal medical saving accounts. Consumers must be empowered by the government to take care of their health and their medical care individually with the appropriate incentive.

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

Taylorism vs. Disintermediation

 

Stanley Feld M.D.,FACP,MACE

President Obama has to understand the differences between Taylorism and Disintermediation. He would then understand the difficulties Americans are having with his healthcare reform law.

President Obama must combine the advantages of Taylorism with the advantages of Disintermediation in order to Repair the Healthcare System. The system must be for the benefit of consumers.

The disadvantages of Taylorism combined with central government bureaucracy will destroy healthcare in America.

President Obama’s only concern is to increase centralized government even if America cannot afford it.

Dr. Berwick is the right technocrat for President Obama. Dr. Berwick’s only concern is to convert the practice of medicine and the delivery of medical care to Frederick Taylor’s Principles of Scientific Management.

Taylorism

Frederick Taylor published his monograph The Principles of Scientific Management in 1911. Henry Ford utilized Taylor’s concepts in mass producing the automobile.

Taylor believed that decisions based upon tradition and rules of thumb should be replaced by precise procedures developed after careful study of an individual work process. Its application is contingent on a high level of managerial control of the worker.

He stated that central authority must provide detailed instruction and rules to each worker. Managers have to supervise and grade workers in the performance of their tasks. The managers plan the work. The workers actually perform the tasks.

Taylor was convinced that productivity efficiency lies in scientific management, rather than in searching for extraordinary creative workers to perform the work. .

Scientific management commoditizes products and lower cost of production. Medical care should not be a set of algorithms and rules that are centrally dictated. Algorithms should be a guide to help physicians’ with clinical decisions.

The problem with President Obama and Dr. Berwick’s plan is it disregards the role the healthcare industry plays in the inefficiency and cost for healthcare. It disregards the cost and inefficiency created by 160 new bureaucratic agencies to create new rules and regulations. It disregards the waste created by defensive medicine.

Disintermediation

Disintermediation is a term used in the “science of economics.” It is the elimination of the intermediaries in a supply chain. Simply put it cuts out the middlemen.

President Obama and Dr. Berwick are not eliminating the biggest middleman with their plan, the healthcare insurance industry.

Michael Dell of Dell Computing and Jeff Bezo of Amazon.com are the masters of disintermediation. They have eliminated the middlemen and revolutionized the computer industry and the publishing industry. Steve Jobs did the same to the music industry with the IPOD and ITUNES.

Consumers are empowered by market transparency. The middlemen were bypassed. Disintermediation has liberated consumers and reduced costs.

Wal-Mart uses the same disintermediation principle with its effective use of information technology. Wal-Mart passes the saving produced by eliminating the middlemen on to consumers. Wall-Mart has revolutionized retailing.

Healthcare reform should include systems of care. It should also include a disintermediation system to bypass the healthcare care insurance industry. Disintermediation in the healthcare system can empower patients to control of their health and healthcare dollars.

President Obama wants to increase quality and decrease the cost of healthcare by increasing the efficiency of healthcare delivery.

Everyone has the same goal. President Obama’s route is wrong.

Our healthcare systems problems can be solved by combining Taylorism with Disintermediation.

This can be achieved with consumer driven healthcare and ideal medical saving accounts.

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

What Do The People Really Think?

Stanley Feld M.D.,FACP,MACE The political climate is changing in America. It is clear that politicians of each party are not paying attention to the will of the people. It is unbelievable that 500,000 people showed up at Glenn Beck’s 8/28 rally at the Lincoln Memorial. It is a sign of change. Our elected officials are only influenced by special interests and lobbying groups. They are the ones that make the donations to permit televisions ad that win elections. Dr. Don Berwick, Director of CMS, told us the people are not smart enough to understand the healthcare system. It is too complicated. It is up to the government to know what is best for the people. President Obama has acted as if he knows best despite the fact that every issue is getting worse. People are angry and frustrated. The Tea Party is a symbol of their frustration. The Tea Party might not yet have enough political clout but it is certainly an expression of how “People Power” can start to influence the political process. "Americans don't want to be governed from the left or the right," Scott Rasmussen tells the American Legislative Exchange Council, a conference of 1,500 conservative and moderate legislators. "They want, like the Founding Fathers, to largely govern themselves with Washington in a supporting—but not dominant—role. The tea party movement is today's updated expression of that sentiment." There are at least 14.5 million Americans searching for work. Two million have not found a job in 99 weeks. President Obama’s solution is to extend unemployment insurance. It is not going to create job. Employers with incentives and a certainty about the future will create jobs and not outsource them overseas. “Pessimism is on the increase, and people are losing confidence in the president. In health care, while 39% of people believe Barack Obama's performance is up to expectations, 55% say that he has fallen short. Regarding our economy, it is 29% positive and 66% negative. And the budget deficit? Only 25% of people think the government has done well controlling the deficit, while 67% believe it is too big and will not be cut. Neither Democrats nor Republicans get it. The Republicans have offered nothing creative or positive. Republicans have not shown Americans a common sense plan. All Republicans are saying is we must extend the Bush tax cuts. President Obama is not leveling the playing field for the middle class. His has not shown respect for middle class intelligence. Neither has either party. It is politics and political influence as usual. None of President Obama’s promises have been met. America did not sign up for the change he is providing. Cynicism is mounting. America does not need a bigger government to make bigger mistakes. Hayak said in the “Road to Serfdom”, “We do not need a government that controls our freedom we need a government that preserves our freedom.” Americans are getting ready to throw the bums out. Americans are not as dumb as our politicians think. A reader sent me this take off on Dr. Suess. It expresses the sentiment and cynicism mounting in the nation. I do not like this Uncle Sam, I do not like his health care scam. I do not like these dirty crooks, or how they lie and cook the books. I do not like when Congress steals, I do not like their secret deals. I do not like this speaker Nan , I do not like this 'YES, WE CAN'. I do not like this spending spree--- I'm smart, I know that nothing's free. I do not like your smug replies, when I complain about your lies. I do not like this kind of hope. I do not like it. nope, nope, nope! Go green-recycle Congress in 2010!

President Obama has asked us to change to green. We should listen to him..

http://online.wsj.com/article/SB10001424052748703579804575441330559553568.html?mod=djemEditorialPage_h

Another reader sent this video expressing the frustration of the people.

“Mr. Rasmussen has a partial answer for Mr. Emanuel's confusion, and it lies in a significant division among the American public that he has tracked for the past few years—a division between what he calls the Mainstream Public and the Political Class.”

Mr. Rasmussen did a survey asking three questions.

1. Whose judgment do you trust more: that of the American people or America's political leaders?

2. Has the federal government become its own special interest group?

3. Do government and big business often work together in ways that hurt consumers and investors?

Those who identify with the government on two or more questions are defined as the political class.

“ A majority of Democrats, Republicans and independents all agree with the mainstream view on Mr. Rasmussen's three questions. "The major division in this country is no longer between parties but between political elites and the people," Mr. Rasmussen says.

The political class overwhelmingly supported the bailouts of the financial and auto industries, the health-care bill, and the Justice Department's decision to sue Arizona over its new immigration law. Those in the mainstream public just as intensely opposed those moves.

President Obama insists he is doing what is right for America. The statement has a similar sound to Nancy Pelosi’s statement that “we will understand the healthcare reform bill after it is passed.”

One last reader comment.

Let me get this straight. We're going to be "gifted" with a health care plan we are forced to purchase and fined if we don't, written by a committee whose chairman says he doesn't understand it, passed by a Congress that hasn't read it but exempts themselves from it,

to be signed by a president who also smokes,

with funding administered by a treasury chief who didn't pay his taxes, to be overseen by a surgeon general who is obese,

and financed by a country that's broke.

What the hell could possibly go wrong?

There you have it. I suggest President Obama start listening to the people and stop ignoring the expression of their feelings.

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

President Obama’s Healthcare Reform Will Fail. What Should We Be Doing Next?

Stanley Feld M.D.,FACP,MACE

Dr. Don Berwick, Director of CMS, has stated that the Healthcare System is too complex for people to manage their own medical care. It must be left up to the experts in government. I believe 160 new government agencies will not succeed in managing individuals’ medical care very efficiently. The resulting system will be less efficient. It will also limit access to care.

The Massachusetts Healthcare Reform experiment has failed for reasons I have outlined previously.

President Obama’s Healthcare Reform Plan will also fail at a very high cost to the American taxpayer. His healthcare reform law follows the basic principles of the Massachusetts Healthcare Reform Plan.

Some readers misunderstand the two models I have proposed to Repair the Healthcare System. Those models are Consumer Driven Healthcare and the Ideal Medical Saving Accounts.

Regina Herzlinger the Nancy R. McPherson Professor of Business Administration Chair at Harvard Business School has been called the “godmother” of Consumer Driven Healthcare.

For those readers who skim blogs, I think it would be a excellent exercise for the reader to settle down and watch an entertaining “You Tube” by Dr. Regina Herzlinger describing the power of Consumer Driven Healthcare.

McKinsey consultants have claimed that administrative inefficiency of the healthcare system accounts for $500 billion dollars of excess cost per year to the healthcare system. I think it is closer to $250 billion dollars a year.

Eliminating inefficiency will not be achieved by adding 160 new bureaucratic agencies and over 800 new regulations.

The solution to the problem is easy. The social contract for medical care should be between patients and physicians. Consumers should owned their healthcare dollars. They should be given incentives to be responsible for their medical care and maintaining their health. Chronic disease complication rates would fall, obesity would be decrease and the cost of healthcare would decrease.

The role of government should be to empower consumers to control their medical expenditures and maintain their health. The government should level the playing field between stakeholders. It should provide education and subsidies to those who need it. The government should teach them how to control their healthcare dollars and maintain their health. Then government should get out of the way.

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