Repairing the Healthcare System

You Cannot Lead Without A Posse

 

Stanley Feld M.D.,FACP,MACE

Paul Ryan has been one of a few Republicans that has demonstrated the belief in what is right rather than what is politically expedient. I thought the Republican caucus understood his budget plan and were behind it.

Republicans cannot talk about being fiscally responsible and act frightened.  They are acting frightened by  Democratic Party *“Demagoguery

It looks as if Paul Ryan has been left without a posse. The Republicans should be explaining what would happen if the status quo on the Medicare entitlement spending remained. They should be explaining how the Ryan plan will save entitlement from default.

The Democrats are not explaining how Paul Ryan’s Medicare plan will destroy Medicare.

Two important events occurred this week to further scare the Republican caucus from acting responsibly.

The first was the election of a Democrat in a traditional Republican stronghold in upper New York State.  The Democratic candidate used scare tactics saying the Ryan plan and hence the Republicans are going to destroy Medicare.  She never offered an explanation of how it would destroy Medicare. The Ryan plan is designed to save Medicare.

Neither the Republican candidate nor the Republican caucus stepped up to say why this is false. The Republican candidate deserved to lose. The Democrat won by default.

The second event this week was the Ryan Plan, which passed in the House, was defeated in the Senate. Worse is that six Republican Senators voted against the proposal without public explanation.

“Republicans voting against proceeding to the GOP proposal had raised concerns about the Medicare reform or other provisions -- Sen. Scott Brown of Massachusetts, Sen. Lisa Murkowski of Alaska and Sens. Susan Collins and Olympia Snowe of Maine. Sen. Rand Paul of Kentucky said the proposal did not make steep enough cuts.”

Horrifying to me was the smirk on Harry Reid’s face as he pretended to be the savior of middle class seniors. Nothing could be further from the truth.

  

The truth is Medicare is unsustainable in its present state. There hasn’t been an economist or government agency that has disagreed. President Obama has ignored these predications in forcing the passage of his Healthcare Reform Act. Medicare will collapse and disappear.  There will be restricted access to care and rationed care.

Seniors must be empowered to be responsible for their own healthcare either independently or by the government. Consumers must drive a market driven healthcare system.  

Seniors can control the onset of the complications of their chronic disease. They can do it with early behavioral changes such as stopping smoking, stopping alcoholic intake, losing weight, exercising regularly and adhering to medical treatment regimes. The government cannot legislate changes in behavior. It can motivate and incentivize behavioral change.  

"Their Republican, radical proposal would end Medicare as we know it," said Sen. Patty Murray (D-Wash.), the chairwoman of the party's campaign committee. "We're not going to stop talking about this in states across the country."  

It is not funny. There is agreement that Medicare is not fiscally sound. Senator Patty Murray is saying Democrats do not want a fiscally unsound Medicare program to be changed.

Senator Patty Murray is saying in effect, Democrats, are going to beat the Republicans in 2012 because we are going to support this ongoing unsound Medicare program until it will bankrupt America.

Isn’t this an insult to the intelligence of the American people.  Democrats must really think Americans are stupid.

President Obama wants to win reelection. Obamacare is unpopular. He could lose on this issue alone. He is cleverly trying to distract Americans from his unpopular program and make Paul Ryan’s plan unpopular. He has no facts about any defects in Ryan’s plan. He is using scare tactics.

Paul Ryan has a different view. He thinks Americans are smart. Americans want an opportunity to be responsible for themselves. They do not trust government to make their healthcare decisions.

I believe Americans can understand complicated facts. The government has an obligation to today’s seniors and future seniors to put Medicare on a sound financial footing.

Paul Ryan’s You Tube of May 25^th says it all. I know the American people can understand it. I hope the traditional media gives him and other Republican an opportunity to explain his plan.

I hope Republican politicians are not frightened away by the spin misters and their influence on polls.

Paul Ryan needs a posse!!

 

 

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

“We're Saving Medicare Not Destroying It”

 

 Stanley Feld M.D.,FACP,MACE

The week Paul Ryan replied to the Democratic Party’s spin misters and to the bias of the traditional media.   

Everyone will agree America has an unsustainable increase in deficit spending during the Obama administration. It has amounted to 4.7 trillion dollars. America has raised the debt ceiling at least three times in the last two anda half years. China is buying our debt at a very low interest rate. China can force us to raise our interest rate by selling our bonds and moving the cash to higher yielding assets. If the interest rate increases the cost of borrowing will be higher and our deficit will be even greater.

The government must decrease spending. There is tremendous waste in government spending. President Obama has not done much to decrease duplication of agency spending or decreasing entitlement spending. He has ignored the recommendation of his own deficit reduction committee.

President Obama’s Healthcare Reform Plan increases entitlement spending not decreases it. The action he has taken in his Healthcare Reform Act has increased costs and decreased efficiencies already. The CBO has warned us of the need to be fiscally responsible.  

“President Obama has been ignoring the warnings.  Medicare is carrying $24.6 trillion in unfunded liabilities through 2085, and chief Medicare actuary Richard Foster says even that does "not represent a reasonable expectation for actual program operations." 

Our major entitlement programs, Social Security and Medicare and Medicaid are fiscally defective in different ways. These programs have to be made fiscally sound in somehow.  Their percentage of America’s GNP grows yearly and is unsustainable.

The fact that 50% of the population pays no taxes and consumers most of the entitlement spending means our population is becoming poorer and that the redistribution of wealth is becoming greater.

The middle class is the real victim.

Paul Ryan and his budget reduction plan has been attacked again this week by none other than Newt Gingrich.  Mr. Ryan’s reply was “With friends like this who needs enemies.”

Newt made a big mistake. I do not believe he understands the Ryan Plan. He has been back pedaling all week.

President Obama, Democrats in congress, liberals and the traditional media do not want to understand Paul Ryan’s plan. His plan is common sense. If only the public was given the opportunity by the traditional media to understand it they would agree.

 I do not believe Republican congressmen and women and the Republican National Committee has the courage and the skill to neutralize Democratic demagoguery*. The Republicans are afraid of losing the election in 2012. They are afraid the public believes they are “destroying Medicare.”  Paul Ryan’s plan is  not destroying Medicare. The Republican Party should be helping the public understand the facts and the advantages of the Ryan plan. It is a plan that will save Medicare not destroy it. 

 

*“Demagoguery  is a strategy for gaining political power by appealing to the prejudices, emotions, fears, vanities and expectations of the public—typically via impassioned rhetoric and propaganda, and often using nationalist, populist or religious themes.  

Paul Ryan said on Meet The Press last week,

“If I can put it in a nutshell, we're saying: Don't affect current seniors,” Ryan told host David Gregory of his party's Medicare-reform plan. “Give future seniors the ability to deny business to inefficient providers. As a contrary to that, the president's plan is to give the government the power to deny care to seniors by empowering a panel of 15 unelected bureaucrats to put price controls and rationing in place for current seniors.”

Paul Ryan has hit the nail on the head.  Obamacare is destined to fail as I have pointed out in this blog over and over again. We are seeing this failure even before complete implementation of the act. We have seen over 1300 waivers, almost 300 new bureaucratic agencies, and tremendous increases in healthcare insurance premiums. Seniors are starting to see a decrease in access to medical care.

 Paul Ryan went on to point out,

“So I would argue that the opposite is true: We're being sensible, we're being rationale; we're saving this program. And you cannot deal with this debt crisis, David, unless you're serious about entitlement reform. And unfortunately, I think we're going to have ‘Mediscare' all over again, and that's unfortunate for the country.”

David Gregory said he has heard privately from Republicans that they're “scared to death” about the politics of what Ryan is proposing, and that he is handing over a huge issue to the Democrats.

“Of course people are scared of entitlement reform,” Ryan said. “Because every time you put entitlement reform out there, the other party uses it as a political weapon against you.”  

Paul Ryan said we must get serious about the drivers of our debt.

 “And the irony of this is all: If we don't fix these programs, people who rely on these benefits are going to get cut the first. They're going to be hurt the worst under a debt crisis. We're saying if we fix this now, we can keep the current promise to current seniors and people 10 years away from retiring. If we allow politics to get the best of us, if we allow demagoguery to sink in, and do nothing, then we will have a debt crisis and current seniors will get hurt.”

 Paul Ryan is absolutely correct. I hope the Republicans do not chicken out. The Democrats are trying to scare them. Remember, the Democrats and bureaucracy got us into this mess in the first place.

 

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

 

 

 

 

 

The Failure Of The British Electronic Medical Record

Stanley Feld M.D.,FACP,MACE

 The development and use of an electronic medical record is extremely important for communication, rapid diagnosis and clinical decision making, increasing efficiency in working up patients, decreasing the cost of duplication of testing and time delays in medical care and treatment.

 There are many other advantages of using a functional electronic medical records. A person could be anywhere in the world and have his medical information immediately available. The results of all testing should immediately be communicated to the treating physician. All imaging studies should be digital.

Patients’ physicians could immediately read and use them for their clinical decision making.

These are only a few of the advantages of the electronic medical record.  During an office visit the physicians’ cost of removing a chart from the shelf, dictating a notes and pasting lab results into the chart is $7.75. Instant automatic noes and laboratory testing delivered to the chart by electronic medical record cost nothing.

Dr. Don Berwick the head of CMS loves the English system. England has a  a single party payer system of socialized medicine. The healthcare system is controlled by the taxpayer-funded National Health Service (NHS). The NHS committed itself to installing a fully functional electronic medical record in 2002 with the goal to have it completed by 2005. 

“Not one of England’s 250 hospitals has a full electronic records system in 2011. A rollout promised for 2005 will not now be complete by 2015.”

It is easy for government to visualize the value of a fully functioning EMR. The execution of the EMR has proven to be nearly impossible even in Britain’s homogenized healthcare system.

“Of the original big four suppliers, only BT, which is responsible for London and a few hospitals in the south, would remain.” 

 

 “Richard Bacon, a Conser­vative member of the Commons public accounts committee, told Mr. Cameron that the programme, which is years behind schedule, would “never deliver its early promise” of a record for all 50m patients in ­England.”

Of the £11.4bn budget, some £4.7bn is still unspent, he said, and, rather than “squander” it, a better way had to be found to spend it.

Only 44 of 250 big hospitals have received a partially functioning new electronic medical record system after trying for 8 years.  While the installed systems have contributed some functionality they are not fully functional. They cannot fully exchange information.

“The US-owned Computer Sciences Corporation – which is responsible for installing the system in two-thirds of the country but, by a mile, holds the programme’s record for missed deadlines.”

 The installations of EMRs have frequently led to initial chaos in hospitals. There are reports of lost patients, lost records, an inability of hospitals to be paid for the care they provide.

The scope of the program for developing a functioning EMR has been decreased as a result of cost overruns and missed deadlines.  New EMRs for ambulance services and doctors offices have been eliminated.

 In April 2010, the minister then in charge – Labour’s Mike O’Brien – admitted that it would never now   deliver the promised comprehensive solution

Nowhere in the world has found the creation of an electronic patient record easy. Denmark, which has a publicly funded health system, is reckoned by many to be as far ahead as anyone. But even that small country after 20 years still has hospitals that use paper records.

There have been many unintended consequences, too numerous to list, in trying to implement the NHS’s goal for a functional EMR. The NHS has accomplished a few of its goals.

1. The NHS was the first in the world to replace X-ray film with digital images for scans and X-rays.

     2. Half the country’s general practitioners, or family doctors, can now transfer at least some of              their records electronically to another practice when patients move.

     3.Electronic transfer of prescriptions to pharmacies is finally proceeding at pace.

     4. Six million out of 50 million patients now have a summary care record. It contains a limited list of         allergies and current medications. It makes emergency room care significantly safer.  

The NHS has a long way to go and lots more money to spend if they continue the present course.

What is the solution?

1. Create incentives for patients to obtain their clinical information. Scan the clinical information into a thumb flash drive and carry the data on a key chain.
2. Create incentives for hospitals and doctors to open the thumb flash drives and use the data.

This would be an instant solution to a difficult problem. The system would reduce the cost of retesting.

EMR are too expensive for U.S. physicians. Physicians are experiencing reimbursement cuts. A fully functioning system costs more than $60,000 per physician. There are additional costs such as service and upgrade fees.

If a satisfactory EMR was available the government should buy it. They should put it in the Internet cloud. Upgrades should be installed as necessary. A single integrated healthcare system wide EMR would result. Physicians should be given incentives to use the EMR. They would be charged by the click. The cloud EMR must be integrated into a physicians’ present non functional legacy systems.  

This process was used while converting to electronic billing in the 1980’s. It should be done with the EMR now. It will save everyone time and money and increase the ability to diagnose and treat patients rapidly.

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

 

 

 

 

 

 

 

War on Obesity: Part 18

 

Stanley Feld M.D.,FACP,MACE

 There are many perverse economic incentives causing obesity in our society. A cultural change toward food has to occur in America in order to decrease the ever-increasing obesity epidemic. Obesity leads to chronic disease. Chronic disease leads to increased healthcare costs. Eighty percent of the healthcare dollars are spent on the treatment of the complications of chronic disease. 

It is time for action to neutralize the barriers that exist for people to overcome obesity in America. 

I do not believe therapeutic tricks work. I know short-term diets do not work. We tried a very low calorie diet program at Endocrine Associate of Dallas P.A. in 1985. The program combined behavior modification along with a very low calorie diet for obese Type 2 Diabetics. It worked short term but failed long term.  We discontinued the program.

I do not believe medication to decrease appetite works. Many of the medications are harmful to one’s health.  A shift in society’s thinking about food is necessary.

Mrs. Obama has planted a garden in the White House’s back yard. She has started a public service program that focuses on obesity in children. Her program should focus on the entire population because adults’ behavior influences childrens’ behavior. 

 http://youtu.be/ZR3HMo-vzjE  

Mrs. Obama’s initiative falls short. There has been no visible continuous follow-up. The media is the message. As our TV addiction grows so does our exposure to junk food advertising. It can be overcome by continuous news about her initiative.  

Mrs. Obama’s message also has some scientific errors. Her message pushes fresh vegetables only. Fresh frozen vegetables are just as nutritious as fresh vegetables and cheaper. The diet should contain food from all food groups.

In order to lose weight you have to eat fewer calories than you burn or burn calories more than you eat.

The public has to be taught the caloric value of food. The public has to be taught to evaluate the number of calories they burn with exercise in terms of calories. The public must learn that in order to loss 2.2 lbs. one has to burn 9,000 calories more than one eats. In order to loss 22 lbs. one needs to burn 90,000 calories more than one eats.

The solution to obesity is to get all Americans to do more and eat less. They must understand the relationship of calories in to calories out.

My son, Daniel Feld, sent me this You Tube from a TED meeting in San Jose presented by Chris Wang of Ideo. His idea is innovative.   

It is actionable solution. It can be fun. It could start a national trend.  It has educational potential. It is an enjoyable video. 

 http://youtu.be/rvqcS6-7tNc 

Unfortunately, few know that a baked potato contains 100 calories. The same potato made into French fries has a caloric value of 450 calories. Water is boiled out of the potato and replaced by fat. Fat contains 9 calories per gram.  Water has zero calories per gram.   

My son, Brad Feld, and the Foundry Group invested in the Fit Bit Company.  I thought he was nuts. He sent me a Fit Bit to critique and I became a Fit Bit fan. 

My first impression was it was an overgrown pedometer. It turns out it is much more. It provides an education that puts individuals in control of their intake and output. It is easy to underestimate intake and overestimate output. 

 Fit Bit also has a chance of creating the educational trend necessary to help conquer obesity. 

 Technology is the future!

 Meal Snap is an IPHONE application that estimates how many calories are in a meal. All you do is snap a picture with your IPHONE of the meal and Meal Snap estimates the calories in the meal.   

So how do you get started going from overweight to healthy,

Leo Babauta in his blog Zen Habits covers it well.

Essentially it is the same way one would eat an elephant. “One bite at a time.”

You need to make slow changes silently with full awareness of intake as opposed to output. I have described some innovative tools that can be used. Decreasing obesity can lead to healthier living.

It is the individuals’ responsibility to  “just do it.”  Incentive must be provided by the cultural change in society to help individuals make their own good choices.

President Obama’s healthcare reform act does not accomplish that. 

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

 

 

 

 

 

 

 

 

 

 

 

Organized Medicine Is Out Of Touch With Practicing Physicians.

 

Stanley Feld M.D.,FACP,MACE

There is a widespread discrepancy between the opinions of organized medical group leaders in the American Medical Association (AMA), the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), and  practicing physicians.  AMA, AAFP, and ACP are part of organized medicine.

These organizations supported the healthcare reform law in 2010 and continue to support the legislation. I believe they have taken this position because they want a seat at the table as implementation of the legislation moves forward. President Obama has not paid attention them so far and there is little evidence that he will in the future.

In March of 2010, Speaker of the House Nancy Pelosi famously said, "We have to pass the [health care] bill so that you can find out what is in it."  

Most physicians are starting to realize the implications of President Obama’s Healthcare Reform Act (ACA) (Obamacare). They are terrified about the implications for the practice of medicine.

Organized medicine is still not disenchanted with President Obama’s Healthcare Reform Act. Charles Cutler, MD, chair of the ACP Board of Governors said recently,  "The medical community recognizes that so much of the ACA is good."

Dr. Cutler is out of touch with the thinking of the practicing community. It is important for the public to know what practicing physicians are thinking.

In a January 2011 poll of practicing physicians conducted by Thomson/Reuters and HCPlexus. “Seventy-eight percent of physicians said the ACA (Obamacare) would negatively affect their profession, 74% predicted that the law would make physician reimbursement less fair, and 58% believed it would hurt patients care.”

President Obama’s healthcare team does not want to recognize that the shortage of primary care physicians become worse as a result of Obamacare. The Healthcare Reform Act makes no attempt to decrease the present shortage. Sixteen million new enrollees in Medicaid will not be able to find a physician.

A recent membership survey by the Texas Medical Association (TMA)  of Texas physicians reports that “59% of Texas physicians have an unfavorable opinion of Obamacare. Texas physicians described their feelings as disappointed (78%), anxious (74%), and confused and angry (62%).

A nationwide survey conducted by The Physicians Foundation last fall produced the same negative results.

Physician disapproval of President Obama’s Healthcare Reform Act is consistent among all medical and surgical specialties. Practicing physicians know it cannot work. 

The Thomson/Reuters and HCPlexus survey showed that only 11% of primary care physicians thought Obamacare would have a positive impact on their profession. Only 14% of pediatricians and psychiatrists were optimistic. The optimism for success among cardiologists and surgeons was at 3% and 4%, respectively.

Organized medicine should at least try to hear what practicing physicians thinking.

Forty-eight percent of the  general public disapproves of President Obama’s healthcare plan. I believe it will equal the disapproval ratings of physicians once the public experiences the full impact of this terrible law.  

President Obama has tried to maintain public support by increasing benefits in the first two years of implementation of Obamacare before the 2012 elections. After 2012 the impact will be felt. It will be too late by then. The infrastructure will be built and money will be wasted. In 2013 and 2014 there will be increased taxes, decreased access to healthcare and decreased choice of care as a result of the Healthcare Reform Act.

President Obama promised a bonus to primary care physicians. The reality is the bonus is insignificant. I suspect with a 29.5% decrease in reimbursement scheduled to go into effect on January 1,2012. It will not only offset the bonus but decrease reimbursement significantly.  

President Obama promised organized medicine a “Doc Fix.” Most believe the promise is bogus in light of the budget pressures.

No one is talking about the upcoming debate to make participation in Medicare a condition for renewal of medical licensure. President Obama is going to create a larger physician shortage than already exists with this move. 

Accountable Care Organizations(ACOs) introduces another avenue of uncertainty. The process for providers to qualify for ACO status is costly. ACOs are going to increase the cost of healthcare rather than decrease the costs. ACOs will put physicians at risk for patient outcomes. Physicians will be penalized if outcomes are poor. Physicians know that clinical and financial outcomes not only depend on their care of patients but also the patients care of themselves. Few physicians are interested in assuming the patients’ responsibility for this risk. ACOs will fail.   

The burden of mandated insurance is a clear attack on the states’ sovereignty and budgets. It is also a clear attack on individuals’ freedom to choose. I believe it is unconstitutional. It will be a few years before the Supreme Court rules on the issue. Mandated insurance only increases the uncertainty and ability to maintaining a medical practice.

Just as the federal government is supposed to be a government by the people for the people and not ignore the will of the people, organized medicine should not ignore the will of its constituents.

 

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

 

 

 

 

 

 

 

 

It Will Not Work!

 

 

Stanley Feld M.D.,FACP, MACE

“The media is the message.” It does not matter if the policy has failed previously.  All that is important is the effectiveness of the policy’s presentation and its ability to manipulate the polls. 

The government’s purpose is to work for the people who elected it. It does not seem to be working that way at present. Bureaucrats create rules or regulations as they interpret the laws made by congress and the president. Regulations are controlled by the administration’s ideology. Many times the regulations in one area nullify the intended effect in another area.  

Regulations and bureaucracy inhibit the use of common sense in policy making for the benefit of the people.

The people did not have an outlet to express their opinions or frustrations until blogging came into its own seven years ago.  

Americans do not like President Obama’s healthcare reform act. They also do not like Dr. Don Berwick’s apparent disrespect for their intelligence and his infatuation with the British healthcare system.

“I am romantic about the NHS (British National Health Service); I love it. All I need to do to rediscover the romance is to look at health care in my own country.”

 Dr. Berwick’s comments about redistribution of wealth and taking freedom of choice is scorned by many Americans.
 

“Dr. Berwick complained the American health system runs in the ‘darkness of private enterprise,’ unlike Britain’s ‘politically accountable system.’ The NHS is ‘universal, accessible, excellent, and free at the point of care – a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just’; America’s health system is ‘toxic,’ ‘fragmented,’ because of its dependence on consumer choice. He told his UK audience: ‘I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.’”

The NHS is failing. Prime Minister Cameron has declared he will change the system. The British healthcare system has resulted in long waits for treatment and rationing of treatment.  If past experience is any indication, generic drugs and expert commissions have done little to lower healthcare costs.

“As the United States prepares to introduce the massive new health-care program known as Obamacare, Britain’s Conservative Prime Minister David Cameron said on Monday that he plans to significantly reform his country’s state-run health-care system due to the program’s massive cost and lackluster performance”. 

Theodore Dalrymple wrote a critique of the British Healthcare system in the Wall Street Journal on April 16, 2011. Theodore Dalrymple is the pen name of  Anthony Daniels, an English physician.  

He is echoing the sentiments of many practicing physicians in Britain.

Dr. Anthony Daniels’ perception contradicts Dr. Don Berwick’s perception. One of them is wrong.  My bet is Dr. Berwick is wrong. 

Dr. Daniels’ practical experiences are:

“1. All attempts to reduce bureaucracy increase it, and the same goes for cost. Such, at any rate, has been my experience of the British health care system.”

“2. In Britain we have been prescribing generics for years; I cannot remember a time when I personally did not. Our National Institute for Clinical Excellence (NICE) has done cost-benefit analyses of drugs and procedures, often very sensibly, for years. But despite its best efforts, our system has been highly inventive in finding other ways of wasting immense quantities of public money.”

I suspect this is a result of the administrative costs associated with the increased government bureaucracy and regulations.

“3. Don Berwick wants to move from a fee-for-service system, which gives doctors an incentive to perform expensive and doubtfully effective procedures, to one in which doctors are rewarded for preventing diseases that are so expensive to treat.”

“4. On paper, prevention always seems much cheaper than cure. Health-care economists prove it very elegantly and convincingly over and over again.”

“5. Unfortunately, the world always proves to be more complex and refractory than the theories of even the best economists”.

“6. For a long time, a physician was paid a capitation fee: He received a certain amount per patient per year from the NHS, irrespective of what the doctor did for the patient or how many times a year the patient was seen.  The physician could not increase his income except by private practice.”

“7. Needless to say, private practice was most extensive in the better-off areas, so that the system ended up reproducing the very social divisions in health care that it was designed to abolish.”

“8. In the poorer areas, doctors had no incentive—at any rate, no financial incentive—to improve their practice. It was rather the reverse. The worse the facilities they offered, the higher their income.”

“9. In the 1990s, Family doctors began to be paid to undertake preventive measures. The experts hoped that this would save money because the cost of preventing diseases would be more than offset by the savings from not having to treat the diseases that they prevented.”

“The costs of prevention were decidedly real, while the savings were inclined to be imaginary.”

a.     “The bureaucratic costs of setting and monitoring health-improvement targets—which were often highly arbitrary—were far greater than anticipated, bureaucracies having an inherent tendency to increase in size and spending power.”

b.    “Many doctors started to be paid for procedures that they were already doing for no charge, like taking their patients' blood pressure.”

c.     “Screening procedures turned out to be highly equivocal in their efficacy.”

d.     “Thus the overall benefit was much less than anticipated.”

e.     “Some of the more common ills that had been targeted, such as strokes and heart attacks, were in marked decline anyway because of increase in effective technology.”

f.      “Worse, much of the expenditure on the treatment of disease proved intractable.”

g.     “Technology inexorably increased costs; and even if the health of the population improved rapidly”

h.     “The increased proportion of older people in the population meant that the proportion of people ill with expensive chronic diseases increased.”

i.      “Procedures such as hip replacement have gone from being relatively new-fangled and exotic to being routine, precisely at a time when there are more people than ever who can benefit from them.”

j.      “ Osteoarthritis is no doubt hastened by obesity, but no medical means has yet been found for the prevention of that particular condition.”

“It is true that in Britain we have had our own peculiar reasons for the spectacular rise in the cost of our health-care system.”

“The British system is now capable of absorbing infinite amounts of money with minimal benefit to the health of the population, though with great benefit to the pocketbooks of those who work in it.”

“It is an occupational hazard for politicians to think that they and their ilk know best.”

“I have seen a hundred schemes of cost reduction.”

“ I have never seen any reduction in costs, or at least any that lasted more than a few months. I can't remember a single health minister who did not promise more efficiency at less cost, or a single one who actually managed to achieve it.”

“The long-term solution, I imagine, is the same for health care as it is for pensions: to pay for it with the income generated by dedicated savings accounts, which can be transferred to the next generation after death.”  

President Obama is setting up a healthcare system in America that has been proven not to work in Britain. The healthcare reform act should be reconsidered.

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

 

It Is Easy To Forget

 

Stanley Feld M.D.,FACP,MACE

President Obama’s healthcare reform act is a little over one year old.

It is easy to forget the negative components and unintended consequences of the bad legislation. It will not solve our healthcare systems problems. It is making the problems worse. 

America is facing a tremendous budget deficit. There are many causes for the deficit. The Medicare and Medicaid entitlement programs are two of the principle causes of the mounting deficit.

President Obama’s goal is to provide universal healthcare coverage at an affordable price with an increase in quality. The healthcare reform act is going to change the payment structure without changing incentives for consumers of healthcare.

The result will be a disaster for everyone.

John Fleming is an M.D. and a member of congress. He wrote a note to his constituents revealing how the President Obama’s healthcare reform act has failed to deliver on costs, premiums, spending and preserving American’s existing healthcare coverage. He wants to repeal the healthcare reform law.

Several of the law’s initial provisions have taken effect. The effects of newer provisions are being anticipated. This anticipation has created havoc. Waivers granted to unions have generated cries of favoritism. The law’s initial provisions have already resulted in American families and businesses facing higher costs, economic uncertainty, and loss of their current healthcare insurance coverage.  None of these effects has been helpful to our fragile economic state.  Dr. Fleming has listed some of the issues and unintended consequences that will cause President Obama’s healthcare reform act to fail.   1.  In 19 states parents can no longer buy child-only insurance policies as a result of the law. 2.  30 states suing to block the law from taking effect, or requesting waivers from its requirements 3.  51 percent of American workers who will lose their current health coverage by 2013, according to the Administration’s own estimates. 4. A $2,100 increase in individual insurance premiums due to Obama care, according to the Congressional Budget Office. 5. $2,500 premium reduction promised by candidate Obama “by the end of my first term as President” will not occur.  6.  7,400,000 reduction in Medicare Advantage enrollment as a result of Obamacare, resulting in a loss of choice for seniors and millions of beneficiaries losing their current health plan. 7. $118,000,000,000 in new costs imposed on states to implement Obamacare's budgetary costs that will lead to reduced services for other state programs like education or to higher state taxes 8. $310,800,000,000 projected increase in health costs due to Obamacare, according to the independent Medicare Trustee. This list is only the tip of the iceberg. There are many effects of the legislation that will add waste and increase cost to the healthcare system. It is hard to keep track of these effects. Painful consequences are “easy to forget” as President Obama’s spin machine keeps telling us how wonderful his healthcare reform act will be for America. The massive bureaucracy being formed with all its waste and paperwork is discounted by the administration. 1.   1,270 for new bureaucrats requested by the Internal Revenue Service to implement the law this year 2.   6,578 pages of new regulations issued implementing Obamacare through March 14, 2011 2. 800,000 reduction in the American labor force due to Obamacare provisions that “will effectively increase marginal tax rates, which will also discourage work,” according to the CBO 3. 2,624,720 total individuals in 1,040 plans granted waivers thus far exempting them from the law’s insurance mandates; nearly half of whom participate in union plans 4. 40,000,000 firms subject to the health law’s new 1099 reporting requirements, which the National Federation of Independent Business called a “tremendous new paperwork compliance burden actuary", who called its promise of lower costs “false, more so than true” 5. $552,200,000,000 is the amount of higher taxes Americans will pay if Obama care remains in place, which will be imposed on all Americans in varying degrees. 6. A  $1,390,000,000,000 increase in federal spending on new entitlements during fiscal years 2012-2021 according to the CBO, a 48 percent increase from an earlier estimate Dr. Fleming’s  DIAGNOSIS:  The new health care reform law is the prime example of how the Democrats’ tax hikes, spending spree, and heavy-handed government policies are hurting our economy and making it harder for small businesses to create jobs.     Removing these barriers will provide the businesses that create new jobs with the certainty they need to hire new employees and get our economy back on track. I remain committed to reducing healthcare costs by providing access and choices for every American, protecting the patient-doctor relationship, and keeping the government out of the exam room.  I will work aggressively in Congress to repeal what I firmly believe to be an onerous and unconstitutional health care reform law and support market-based solutions to our health care needs. Sincerely,  JOHN FLEMING, M.D. Member of Congress Bravo Dr. John Fleming. More congressmen should be repeating the facts about President Obama’s undeclared waste and hidden taxes. It is hard for the public to remember all the facts.

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

 

 

How To Win A War; Don’t Show Up

 

Stanley Feld M.D.,FACP,MACE

A reader responded to my last blog, Why ACOs Will Fail, with the following comment.

"Stan

Let's keep our objections as simple as possible, so we can explain them better. The ACO's are a form of capitation. Why should doctors be at any financial risk for performing a service that the government and the public feel is absolutely necessary? 

Sincerely

 R.M. M.D."

The point I made was that the only way to repair the healthcare system is if patients are responsible for their healthcare dollars and for the maintenance of their health. Patients with the appropriate education with will force the healthcare system to be competitive (Consumer Driven Healthcare).

It is naïve to assume that physicians and hospital systems are interested in taking risks for patients’ behavior.

HHS head,Kathleen Sibelius, does not think I am correct according to her news release;

“Changing the way we pay hospitals will improve the quality of care for seniors and save money for all of us,”

Under the ACO initiative, Medicare will reward hospitals that provide high-quality care and keep their patients healthy.”

 Dr. Donald Berwick CMS chief wrote in a Wall Street Journal op-ed;

“We announced another effort that will reduce costs by improving care: a proposed set of rules for doctors, hospitals and other providers who want to work together as Accountable Care Organizations, or ACOs. ACOs will coordinate better care for patients, improving communication and reducing duplicative tests and procedures that hassle patients and do them no good at all.

The ACOs will be held to a strict set of quality standards to ensure that they aren't lowering costs by cutting necessary care.”

The initial results from Medicare’s one year pilot studies of 10 Medicare Physician Group Practice sites and five Dartmouth/Brookings sites demonstrate the majority of the savings occurred from outpatient services and not inpatient services.

The sites in the pilot have not achieved the level of saving to share with Medicare.

CMS hopes 75 to 150 groups will apply and qualify as an ACO. The startup investment and first-year operating expense for a participant in the Shared Savings Program is estimated by CMS to be about $1.75 million per ACO. Many say this estimate is low.

CEO of the large hospital systems and group practices are starting to understand the financial trap ACO’s represent.

 “I think there’s a very high bar that’s set in these regulations,”  says Thomas Graf, MD, chairman of Community Practice Service Line for Geisinger Health System in Danville, PA.

 “They’re very detailed, and somewhat prescriptive, although there’s a mention that if there’s an alternate idea, and you can show how your proposed alternative meets these goals, they would consider it.” 

The Geisinger Health System, one of the 10 Physician Group

Practice demonstration sites plans to stay with the PGP model for another two years, especially since the new rules for the second portion of that program were just released.

Dr. Graf also notes that some organizations will have to endure a

25% withhold, which means that in order to make sure new ACOs

are able to manage any losses, they’ll retain one-quarter of shared

savings. “To the extent you’re a startup ACO, you have to put in

costs now, presumably something to improve the care that you’re

delivering on both the quality and cost side. You incur costs on

Day 1”.

Dr. Graf explains: “Let’s say that in the first year, you qualify for

shared savings of $2 million. [CMS says] we’ll pay you $1.5 million

and we’ll retain half a million in case in the second year you have

$300,000 of losses, which will come out of the $500,000.” 

 CEOs are realizing that an effective plan must include smaller organizations. Local markets must be represented because all medical care is local. The hospital system CEOs also are beginning to recognize that patients must be central to determining their own healthcare needs. Consumers must be responsible for their own care for a healthcare system to be effective.

Craig Samitt, MD, president and CEO of Dean Health System in Madison, WI. says, 

“There are many complexities and process-based requirement in ACO s.”

Large investments will be needed for most organizations to be high-performing ACOs”

Some don’t think ACOs equitable or practical. ACOs will not

know which Medicare beneficiaries they will be judged on until at

least a year after the program is under way.

Many have expressed concern that there just isn’t enough time between now and Jan. 1 for the final regulations to come out. There is not enough time for them to apply and be approved. It will be impossible for them to have all the pieces in place for a highly functioning ACO.

Chris Van Gorder president and CEO of Scripps Health expressed that concern, among others. “The government is trying to put a politically correct managed care

system of healthcare together requiring the hospitals or the ACO to assume both financial and quality responsibility for patients without even letting them know who those patients are prospectively.”

Chris Van Gorder says “he’ll hold his system back from applying for

Medicare ACO status unless the regulations undergo significant

change.” “Frankly, I was surprised. I thought there would be more

carrots, not so much stick.”

He emphasized that rather than this flawed ACO model, CMS would get better results by expanding bundled payment incentives to include hospital care. “That will get faster and maybe better results than by trying to push the ACO too fast.”

He also says that “he was quite surprised the regulations

impose a penalty for lack of performance on cost controls “right

at the beginning of this grand experiment. That was expected

over time, but [not] for a startup program that is extremely

complicated and far-reaching. One would have thought the

feds would have done all they could to attract and incentivize

healthcare providers and suppliers to take this risk.” 

That sentiment was echoed by Richard A. Hachten II, president

and chief executive officer of Alegent Health in Omaha, NE.

“It’s appropriate that we’re going to be managing people’s

health differently going forward; it’s the financial risk part of it

and not being able to do that as effectively as one could if you

knew which patients you were working with, and could do a more

effective job in coaching the use of healthcare resources,” he says.

“So we think there’s a significant amount of unmanageable risk

built into the way it’s set up currently.”

Jay Cohen, MD, executive chairman of Monarch Healthcare in Orange County, CA says;

The negatives on the flip side outweigh the positives in the proposed regulations, and may prevent his organization from opting to be an ACO. “The way the proposed regulations are written will not work.”

 

George Halvorson, chairman and chief executive officer of

Kaiser Foundation Health Plan and Kaiser Foundation Hospitals,

which has 8.8 million members nationally, says his system does

not plan to apply and will stay with prepaid Medicare Advantage.

Kaiser, he says, already has a much more advanced team approach to care that goes beyond the four walls of the system. “We’re already there and we’re giving great care. We’re cutting the number of heart attacks in half; we’re cutting the number of broken bones in half.” 

There you have it. “The Art Of War”. The healthcare organizations Dr. Donald Berwick was depending on are not going to show up to his ACO party.

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

 

 

 

 

 

Why Will Accountable Care Organizations (ACOs) Fail?

 

Stanley Feld M.D.,FACP,MACE

In an ideal world ACOs should work. There is no evidence that  untested and complex organizational structure of ACOs developed by Dr. Don Berwick (head of CMS) will improve quality of care and reduce costs

ACOs are supposed to provide financial incentives to health care organizations to reduce costs and improve quality. There are too many defects in the ACOs infrastructure to improve the financial and medical outcomes.

At a conceptual level, the incentive for ACOs would be to increase efficiency and avoid overuse and duplication of services, resources, and facilities. In this model, ACO members would share the savings resulting from the increased coordination of care.

I have said over and over again that excessive administrative fees and ineffective management of chronic disease is the main source of waste in the healthcare system. ACOs do not deal with these main drivers of costs.

The only stakeholders who can demand that this waste be eliminated are consumers/patients. Patients must control their healthcare dollars.  They will make sure there are competitive prices and will not permit duplication of services.

ACOs are not a market-based system. They do not put patients at the center of their medical care or permit them to choose their medical care. The government controls the healthcare dollars and is at the center of patients’ medical care decisions directly and indirectly.

In order to truly repair the healthcare system a system of incentives for patients and physicians must be created. There is no question that the processes of care for chronic diseases must be improved. More importantly, the medical and financial outcomes must be measured and not the process changes.

“In theory, ACOs provide financial incentives to health care organizations to reduce costs and improve quality. In reality, given the complexity of the existing system, ACOs will not only fail; they will most likely exacerbate the very problems they set out to fix.”  

ACOs are merely the latest in a long history of unsuccessful health policy innovations. Since the 1970s, Congress and successive administrations have tried a number of tactics to control rising health care costs.  The tactics tried have been:  

1. Payments for diagnostic related groups of services, or DRGs.
2. Health maintenance organizations (HMOs).
3. Preferred provider organizations (PPOs). 

They all failed. Consumers reacted negatively to the care provided. Healthcare costs continued to rise. ACOs are being promoted as the new structure that will address the lack of success of the past tactics.

“Under Obamacare, the Secretary of the Department of Health and Human Services (HHS) is charged with developing a method to assign Medicare beneficiaries to ACOs.”

“ Because the statute is unclear about the resolution of many vital issues, the crucial details will be supplied and refined by federal regulators—as is the case for so many other provisions of the new health law.” 

Congress has relinquished its power to the unelected portion of the executive branch of government to construct a system that will reduce the rising costs.

ACOs create a new organizational structure to remedy problems inherent in the existing healthcare system.  The complexity of the structure of ACOs will result in the same or similar types of unintended consequences that led to earlier failures. 

There will be consolidation of providers. ACOs will result in increased costs rather than decreased costs.  It might decrease duplication of testing. The resulting savings will be small. There is no evidence that ACOs will provide improved medical and financial outcomes. I believe it is Dr. Berwick’s naïve wish that it will improve medical and financial outcomes. 

The are at least 7 key deficiencies with ACOs

1. ACOs do not empower consumers to be responsible for their own medical care.  Healthcare should be consumer driven with consumers controlling their healthcare dollars. They will then make informed choices about their care and insurance coverage.

      2.ACOs create artificial incentives to improve quality and provider performance. Consumer driven           healthcare creates real incentives to promote price completion. Competitors are constantly           working to improve their products, attract consumers, and ultimately increase market share.  

Consumers have no part in driving that competition in an ACO system.

           3.Most physicians are reluctant to assume accountability for patient outcomes.  Physicians                           recognize that much of the outcome is directly under the consumer/patient behavioral control.

            4. ACOs remove the patient/consumer from being responsible or accountable for their medical                   care. ACOs undermine any attempt to create a truly accountable healthcare system that can                   drive down costs.

            5.ACO do not encourage provider accountability even though it seems that provider buy-in would            be integral to an ACO’s success with its shared savings incentive.  Many physicians believe the                  share savings incentive is bogus. 

            Providers continue to be paid for each service they perform until the government provided funds             run out. There are also grave uncertainties and practical complications of distributing production             and savings between the hospital system and physicians.

             6. ACOs create an unfair competitive advantage for large organizations that are hospital                 centric. Eligibility requirements are vague and ambiguous. The eligibility requirements                 suggest that larger organizations have an unspoken eligibility advantage.

                This is the reason hospital systems are trying to form ACOs. Hospital systems think they will                 make money. I think they will fail. Hospital systems will lose a lot of money. They will fight                 with their physicians over the distribution of government reimbursement. The cost of hospital                 care will then increase. The consumer will lose.

                7. Groups of independent practitioners as well as other types of small and mid-sized practices                     may lack the infrastructure, Internet technology, or other resources needed to qualify for                     ACO eligibility. They will be forced to join hospital systems. Hospital systems have a                     history of taking advantage of physicians and their skills and intellectual property. More                     tensions will be created. Hospital systems’ ACOs will crumble. The cost of medical care                     will continue to increase further.

I have presented some common sense observations. Common sense does not seem to prevail in the difficult world of repairing the healthcare system.

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