Repairing the Healthcare System

Getting Around The Rules: Hospital Readmission Rates

 Stanley Feld M.D.,FACP, MACE  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Eyes Wide Shut

Stanley Feld M.D.,FACP,MACE

 

I cannot believe the results of the Presidential election.

All of President Obama’s policies have failed so far. All have served to inhibit economic growth or make it worse.

Yet the majority of Americans voted for President Obama. Why could this occur when many of the structural ideas and ideals representative of the United States are being dismantled?

This is a great county. Americans accept the winner and move on.  They continue to speak to their neighbors who had the other guy’s sign in their front yard.

On the other hand it amazes me to see that the electorate ignores the real issues and votes for the  personality. Marshall McLuhan was correct. The media is the message. Why the media is ignoring the facts is beyond me.   

It is disappointing because Americans are also ignoring the obvious coming unintended consequences that are going to be the result of their voting decision.

The devil is always in the details. I have presented my views of how the medical care system is going to be destroyed by Obamacare. It is only a matter of time.

The healthcare system is becoming too expensive, unsustainable, impersonal, rationed. The result will be a denial of access to medical care for many Americans. 

Obamacare’s effect will become the opposite of what President Obama intended and  promised.

I have also stated that his strategies for change have been misguided.  

President Obama’s advisors are all ivory tower professors and bureaucrats. They have no understanding of what is happening in the street at the interface between patients and physicians.

Ideologically they want to make medical care better for all. President Obama does not understand the pressures and the reality of the real practice interactions between physicians and patients or physicians and their communities.

President Obama believes that healthcare should be an entitlement and not an individual responsibility. Healthcare entitlements will never solve America’s problems with obesity and chronic diseases.

In the process of making healthcare an entitlement, President Obama is devaluing the skills of those practicing medicine.

Many physicians have quit practice because of adverse conditions. The result will be a decreasing physician workforce in an increasing covered population. This is not a good equation.

Most physicians do not accept Medicaid and many have stopped accepting Medicare.

This will shift the burden of higher cost of medical care to seniors and poor people.  

Bob Doherty is Senior Vice President of Governmental Affairs and Public Policy, American College of Physicians. His blog at The ACP Advocate Blog is reprinted below. It deserves a wide audience.

Bob Doherty has dealt with the socioeconomic concerns of Internists and Internal Medicine Sub Specialists for at least 30 years both at the American Society for Internal Medicine and later after ASIM merged with American College of Physicians.

Bob Doherty wrote this article discussing the effects of Obamacare on the practicing physician. He presents practicing physicians’ complaints about  Obamacare.

This article should be read carefully. President Obama should pay attention to physicians’ complaints.

 “The micro level of health reform cannot be ignored”

by BOB DOHERTY on November 5th, 2012in POLICY

 

Much of what passes for debate on health care during this election year is focused on the macro side, on big issues like how do we cover the uninsured or restructure Medicare and Medicaid financing.  But for all of the talk about vouchers and block grants and insurance mandates, the candidates are missing the micro issues that really matter most to doctors and their patients, which is how health care policy directly affects the quality of the patient-physician encounter.

Talk to physicians around the country, as I regularly do, and these are some of the issues that have them most concerned:

1. Will anyone do anything about the oppressive burden of paperwork and red tape?
2. Will the candidates’ “macro” proposals for reforming healthcare and entitlements result in more or less paperwork and red tape?
3. I already don’t have enough time to spend with patients but now I am expected to counsel them on preventive care, lifestyle choices, and the effectiveness of different treatments?   How is this possible?
4. Electronic health records, great concept, but they don’t really streamline the process as advertised, if anything, they just make things more difficult, and besides, they still don’t communicate with other systems.
5. Everyone wants to measure me, but the measures don’t agree with other, they measure the wrong things and they are difficult to report on.   And who is measuring the value and effectiveness of the measures themselves?
6. Okay, I am supposed to practice cost conscious care, but who is going to stop a lawyer from suing me if I don’t give a patient the test they asked for?
7. Why is my cognitive care paid so little while procedures and drugs are paid exorbitant rates?
8. Payers and government keep imposing more penalties, for not e-prescribing, for not converting to ICD-10, for not meaningfully using my electronic health record, for not complying with their pay for performance schemes.  By the time they get done fining me for noncompliance, I will have had to shut my office. Then who will take care of my patients?
9. And who has the time to keep track of all of these mandates, incentives, rules, and penalties?  I would have to hire a full-time person keep on top of everything. Who is going to pay for that?
10. So I am supposed to transform my practice?  Well, we all want to do our part, but who is going to pay for that?  Besides, my patients seem to think my practice is just fine as it is

Now, I don’t really expect Obama and Romney to come out with plans to address these micro health policies.  But it is reasonable to hold their macro proposals to a standard of whether they will make all of these aggravations and intrusions better or worse.  And at some point, policymakers–no matter their political leanings and plans to reform healthcare at the macro level, need to pay attention to what is happening at the micro patient-doctor encounter level.  After all, the boldest of big ideas won’t make healthcare better if it makes it harder for physicians to give their patients the care they need.

Physician advocacy organizations also need to pay attention to the micro issues.  ACP prides itself on taking on the big issues like controlling health care costs and allocating health care resources rationally.   But the College puts at least as much effort into the micro issues, from objecting to the latest EHR mandates to offering alternatives to ICD 10 coding to advocating for higher payments.

The goal must be to fashion public policies that improve care at the macro level — universal access to coverage, spending health care dollars more wisely, and improving healthcare delivery systems — while also removing barriers at the micro level that intrude on the patient-doctor relationship.  Both are equally important.

Bob Doherty is Senior Vice President of Governmental Affairs and Public Policy, American College of Physicians and blogs at The ACP Advocate Blog.”

 

Bob Doherty has been an advocate of Obamacare in the past. He has highlighted the idealist principles of Obamacare. I am happy that he is starting to realize the unintended consequences that will occur as a result of  Obamacare.

Healthcare is only one area of life that President Obama is affecting adversely. I believe the majority of the population will start realizing soon that re-electing President Obama was a mistake.

Hopefully it does not become an irreversible disaster.

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

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It Is Time To Listen To Physicians

Stanley Feld M.D.,FACP,MACE

Physicians are getting tired of being blamed for the rising healthcare costs. There are starting to realize that they have to take action to preserve their professional integrity. In fact, six out of ten physicians said they would quit medicine in a recent study by the Physicians Foundation.

I believe physicians will have a hard time quitting because they love practicing medicine. I do believe physicians in their early 60’s are contemplating quitting. Many physicians are looking for viable exit strategies to avoid quitting.

The Physicians Foundation commissioned an extensive survey of nearly 13,575 physicians. Meritt Hawkins, the physician search and consulting firm, conducted the survey.

 “The survey found that 60% of physicians would retire today, if given the opportunity—an increase from 45% in 2008. And it's not just disgruntled and tired Baby Boomers who want to abandon their healing work. At least 47% of physicians under 40 also said they would retire today, if given the opportunity.”

The survey pointed out many major problem areas.

Two specific issues consistently agreed to were malpractice concerns and the need for tort reform as well as the lack of cohesive leadership among all physician groups to represent the vested interests of physicians and their patients.

This is an excellent and detailed survey that has heightened the awareness of physicians’ practice problems.

The Massachusetts Medical Society survey pointed out the scope of defensive medicine. I extrapolated findings of the society’s survey to the nation.

My conclusion was that $500 billion to $700 billion dollars a year is spent on defensive medicine testing in the nation.  Tort reform would serve to decrease this defensive testing.

President Obama and his advisors have ignored tort reform and defensive medicine as an insignificant cost. Ezekiel Emanuel M.D. one of President Obama’s advisors thinks defensive medicine only raises the cost of the healthcare system between $26 billion dollars a year. Dr. Emanuel feel this is an insignificant number to deal with in a 2.7 trillion dolloar healthcare system. His metrics are wrong. This is a misguided bias.

The Physician Foundation survey notes that many policy makers, academics, and others identify fee-for-service reimbursement as a key driver of health care costs. Physicians believe that "defensive medicine is a far more important cost driver."
 
40.3% of the physicians surveyed said "liability/defensive medicine pressures" was the least satisfying aspect of medical practice.

The survey also reveals that doctors see as a major cost driver of healthcare liability/defensive medicine.

69.1% of physicians said defensive medicine is the "number one ranked factor" driving up healthcare costs. The survey described the ordering of tests, prescribing of drugs, and conducting of procedures done "partly or solely to drive a wedge against potential malpractice lawsuits."  

"Medical malpractice lawsuits are common, adding an additional layer of paperwork, expense, and stress in virtually every physician's work day," the report adds.

The government ought to be listening to physicians practicing medicine every day rather than ivory tower professors who have never practice a day in their lives.

"Physicians understand to some degree that's the cost of doing business, but the defensive medicine goes deeper than that, in the ordering of extra tests, doing the extra procedures, and extra scans to protect [oneself] against a malpractice suit.”

Medical malpractice is at the heart of overspending in American healthcare. President Obama and Obamacare have ignored it. Some states have addressed it and the cost of care has been decreasing slowly. I believe it will take time in those states.  If anyone was sincere about bending the healthcare cost curve they have to take defensive medicine seriously. 

According to the survey physicians felt that there is a lack of a forceful cohesive voice representing them.

"There is a systematic, endemic series of problems," Walter Ray M.D. vice president of the Physicians Foundation, says. "Everywhere their defensive medicine, regulation issues, reimbursement issues. We are all in the same boat. But physician representation is balkanized. There is not a national organization that represents a majority of physicians."

When the survey asked which best describes their feelings about the current state of the medical profession, only 3.9 percent of physicians used the words “very positive,” while 23.4 percent of physicians indicated their feelings are “very negative.”

The majority of physicians – 68.2 percent -- described their feelings as either somewhat negative” or “very negative,” while only 31.8 percent of physicians described their feelings as “somewhat positive” or “very positive”.

A "least satisfying" aspect of practicing medicine included dealing with Medicare/Medicaid/government regulations (27.4%) and reimbursement issues (27.3%).

 
The American Medical Association (AMA) represents only 15% of physicians, according to the Physician Foundation report. One of the reasons for the low enrollment is that physicians feel the AMA does not represent their vested interests.

 Sermo is another physician organization. It is an Internet social network. In less than 2 years Sermo had as many members as the AMA.

Sermo originally concentrated on socioeconomic issues. It also discussed difficult clinical cases.  

The socioeconomic activity has recently faded. Sermo’s power was using the social network to do instant surveys expressing physician’s opinions on healthcare policy and patient care hassles.

These surveys were quickly disseminated to the public as media stories of physicians’ opinions. It was done through public service announcements and daily press releases.

Physicians were able to let the public know how they felt about an issue instantly. It was very attractive. Somehow the initial vigor stalled. Physicians are now left without a vehicle or organization to express to express their feelings.

Government, the healthcare insurance industry and the hospital systems have little desire to listen to the concerns of practicing physicians. It is more important to tell physicians what to do. It will not work long term.

The Physicians Foundation Biennial Survey is valid and accurate. However it is not dynamic or evolving. Neither has it gotten much attention. It is a must read along with the Massachusetts Medical Society survey for those interested in physician concerns and behavior.

Patients’ problem with the healthcare system gets less attention. The government and insurance companies tell patients what they can and cannot do

Repair of the healthcare system will only happen when the American healthcare system evolves to a consumer driven healthcare system with individual responsibility and individual control by the patients of their healthcare dollars.

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

 

The PSA Fiasco

Stanley Feld MD.FACP,MACE

It is common knowledge that prostate cancer is a slow growing cancer. It is also believed that something happens and suddenly this slow growing cancer becomes aggressive and then metastatic.  

As the cancer increases in size, the Prostatic Specific Antigen (PSA) value increases. It is obvious that a baseline PSA should be obtained. The PSA’s value should be followed yearly to see if it is increases over time. 

The United State Preventative Task Force’s (USPTF’s) conclusions are incorrect. There are problems with the studies reviewed leading to its conclusions.

The media sensationalism of the USPTF’s conclusions was an indictment of PSA testing and urologists’ judgment.

"The USPSTF concludes that there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harm," the report stated.

“The U.S. Preventive Services Task Force said in a report that the PSA test is too inaccurate, creates needless anxiety for patients, and can lead to costly and potentially harmful follow-up procedures”.

Clinical judgment by physicians is ignored by the USPTF. The PSA increases as prostate cancer progresses. How are you going to know if the PSA is increasing, if you do not have a baseline PSA?

The nation's leading urology associations are fuming over a USPTF report  that discredits the widely used prostate-specific antigen-screening test for prostate cancer.

 "It's an absurd recommendation. It is ill-researched and ill-conceived," Sanford J. Siegel, MD, a board member with the Large Urology Group Practice Association, told HealthLeaders Media. "This will only do damage to all the great work that has been done for prostate cancer awareness and to control the deaths from prostate cancer."

The USPTF should have at least had an urologist on its task force to evaluate the literature of PSA testing.

The USPTF is a “non-government agency” that will be used by the administration to ration medical care.

How can the government say it advocates preventing cancer when it’s setting us up to restrict access to care (prevention)?

American Urological Association President Sushil S. Lacy, MD, said in prepared remarks that he was "outraged" by the report. "It is inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations such as African-American men," Lacy said. "Men who are in good health and have more than 10-15 years life expectancy should have the choice to be tested and not discouraged from doing so."

 The American Association of Clinical Urologists issued a similar statement  week,

“The AACU called the USPSTF recommendations "misleading and harmful."

The major urological associations say the USPSTF ignored new studies supporting the value of PSA tests, and that the panel refused to address concerns they raised about the conclusions during the comment period. In addition, the urologists complain that there were no urologists or oncologists on the panel.  

The major urological groups said,

 "It is just a screening test, one of several things we look at when we decide whether a man needs a biopsy or not," he says.

"Yes, it is true that many men can live with this disease their whole life. That is why active surveillance has become a treatment option," he says. "If we knew in advance who would and who wouldn't advance in the cancer, that'd be great!"

"There is no question that men get prostate biopsies that obviously in hindsight shouldn't happen.  But we are looking at improving PSA testing and other testing to help us find out which men will progress with more advanced prostate cancer."

The problem is that no one has yet come up with an alternative to determine which patients will develop advanced prostate cancer

There is case of a famous Texan who yearly had normal PSAs. His physicians told him it was not necessary to get further PSA test since he had been normal all these years. He was now past 80.   

At 86 he presented with severe bone pain.  Laboratory studies and a bone scans revealed a sky-high PSA (over 100) and widely metastatic prostate cancer.

If his PSAs were monitored the rising PSA would have been detected perhaps early enough to cure him. Prior to the bone pain this man felt perfectly well.

Urologists have many of these same stories.

The USPTF conclusion might aid clinical judgment. However, it should not trump clinical judgment.

Obamacare is getting set to make committee judgments about healthcare policy and clinical care while ignoring physicians’ clinical judgment.

 About 250,000 men are diagnosed with prostate cancer each year. The diagnosis is made by physical examination and PSA measurement. The final diagnosis and decision for surgery or radiation is made after a fine needle biopsy of the lesion.

A prospective double blind study does not exist to predict the grade of cancer that will be cured by surgery, radiation or no treatment.

Nor is there a study for the USPTF to grade about quality of life post op compared to the quality of life during progression of disease. Until then the USPTF conclusions on the basis of the studies they did review are relatively meaningless.

The incidence of 250,000 new cases of prostate cancer a year has been stabile over the last 30 years. 

With early detection the number of males dying per year from metastatic prostate cancer has dramatically fallen from 48,000 per year to 28,000.

 The USPTF statement does not seem correct,

“It could find no evidence to support claims that PSA tests are responsible for "reduction in all-cause mortality."

"Many more men in a screened population will experience the harms of screening and treatment of screen-detected disease than will experience the benefit."

The USPTF report ignores the dramatic decrease in deaths from prostate cancer over the last several decades.

Dr. Marc Siegel, a practicing urologist for 30 years, said,

 When I started training, 40% of African-American men at that time presented with metastatic disease. Now that number is miniscule," Siegel says. "Tell me how that happens without early screening? How do death rates go down from 48,000 when I trained to 28,000 now? How do you explain that without screening? You can't! It's impossible!"

I believe the defect in the USPTF conclusions have to do with the specificity of the PSA and not its clinical value. A more accurate PSA test needs to be developed.

The USPTF’s conclusions will save President Obama a little money in the short run.

However, the cost of care for prostate cancer along with the morbidity and mortality will cost Americans greatly in the long term. 

 The USPTF has to re-examine its premises and methodology.

 

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

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A Genius Wrote

Stanley Feld M.D.,FACP,MACE

Todd Siler is a famous artist and scientist. He is much more that. He is a genius. He has written many books about visualizing and solving problems. The most famous is “Thinks Like A Genius”.

For many years he created “Truizms” for the Rocky Mountain News. These Truizms deserve a publication of their own. His Truizms’ are insightful and inspiring. Todd sent me some Truizms to help me illustrate the points I am trying to make.

It is an honor to have Todd become a great friend. He is extremely perceptive and a phenomenal teacher, in addition to being a wonderful human being.

Todd wrote a great response to my last blog “Lets (Not) Do Physicals.”    

Stanley, the frustrating situation you've accurately described here invokes Joseph Heller's classic novel Catch-22:

"There was only one catch and that was Catch-22, which specified that a concern for one's safety in the face of dangers that were real and immediate was the process of a rational mind. Orr was crazy and could be grounded. All he had to do was ask; and as soon as he did, he would no longer be crazy and would have to fly more missions. Orr would be crazy to fly more missions and sane if he didn't, but if he were sane he had to fly them. If he flew them he was crazy and didn't have to; but if he didn't want to he was sane and had to. Yossarian was moved very deeply by the absolute simplicity of this clause of Catch-22 and let out a respectful whistle. (p. 56, ch. 5)...."Catch-22 says they have a right to do anything we can't stop them from doing." 

Quoting my blog , Todd wrote,

“It is not enough for the Obama administration to say it is interested in prevention of disease when it restricts access to prevention measures.

It is not right to restrict access to steps needed to prevent the debilitating or deadly complications of hip fracture.   

“The USPSTF concludes that, for men, evidence of the benefits of screening for osteoporosis is lacking and the balance of benefits and harms cannot be determined.” 

To me the trend to reduce physical examinations and lab screening is a ridiculous trend. The present spending on physicals probably should be modified some but not discontinued.” 

I agree!

Todd

One of Todd’s insightful Truisms’’ follws

Our bureaucratic society with its multiple and conflicting rules does not permit us to honestly do the right thing for Americans, especially when money is involved.

President Obama says the right things, but he does not do the right things.

The Healthcare System’s policies should let consumers decide on what is logical for them after listening to the advice of their physicians.

Consumers should control their healthcare dollars with financial incentives  provided for them to stay healthy, become educated about their diseases,  and control their chronic diseases.  

The evidence medicine debate should be between the medical community and the USPTF without creating a media circus.

Healthcare insurance should be a high deductible first dollar coverage plan that would cover everyone.

I covered how this would work in my blog “The Ideal Medical Saving Account is Democratic.

America’s healthcare system is at the home in a “Catch 22”.

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

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Medicare Coding Is Becoming More Complicated Under Obamacare

Stanley Feld M.D.,FACP,MACE

Physicians make coding errors. These errors result in decreased reimbursement.   The denied claims might not be noticed for months by the physicians’ office.

In a busy practice the details of all the changes in coding rules are sometimes impossible to understand.

An entire coding industry with coding professionals taking certification examinations has developed with a great increase in the cost to the healthcare system.  

President Obama’s healthcare reform act is trying to institute a completely new electronic claims system. It is called 5010. It will replace claims system 4010.

As far as I can tell the goal is to obtain more data on physicians’ practice patterns. The goal of the new system is to determine the “quality” of physicians care. If the quality is poor, reimbursement will be reduced. Claims will be denied. Its execution looks confusing and expensive.

5010 was suppose to be in place and required for all to use by January 1, 2012. Apparently, it was not fully installed or tested by enough healthcare organizations to be validated. The date of full implementation was moved to March 31, 2012. Last week full implementation was moved to June 30, 2012.

The other complicated “innovation” of Obamacare is ICD 10 coding system.  This new coding system replaces ICD-9. It has increased the number of codes from 18,000 to 68,000 for coding in-patient and out-patient care. Effective implementation of these codes will be very difficult.

The implementation of these two “innovations” will add billions of dollars to the cost of healthcare.

 It will increase physicians’ paperwork. It will result in more mistakes. It is questionable whether the new systems will increase the quality of care.

It is adding more complexity to an already dysfunctional system.

It is impossible for physicians to keep up with all the new regulations the Centers for Medicare and Medicaid Services is about to impose on them.

Most physicians do not have the time to study the new regulations and their implications. They hope their professional organizations will pick up the important ones and point out the problems in plain English.

Many times one regulation contradicts another regulation. The administrative service providers (healthcare insurance industry) for CMS interpret the regulations the way they want. There is often a lack of consistency from state to state.

The Texas Medical Association recently informed us of an error related to submission of measure No.235, Hypertension: Plan of Care for the 2012 Physician Quality Reporting System.

 The Texas Medical Association sent the following message to all Texas physicians. I challenge anyone to understand this message.

The Centers for Medicare & Medicaid Services (CMS) has identified an error related to the submission of measure No. 235, Hypertension: Plan of Care, for the 2012 Physician Quality Reporting System (PQRS). Hypertension: Plan of Care is a claims/registry measure with G-codes that are inactive due to an error. Consequently, Medicare carrier TrailBlazer has rejected or denied claims containing the G-codes associated with the measure.

The following is a note I received from a physician.

“I thought I went to medical school to learn how to take care of sick patients?”

“I did not go to medical school to deal with complicated and impossible rules and regulations daily. These regulations interfere with my ability to help sick patients”

Physicians are faced with these confusing rules daily. I do not believe that these rules promote quality care for patients. These rules serve to irritate physicians. The rule changes result in a non-user friendly Medicare system.  I predict it will ultimately result in non-cooperation by physicians.

The TMA goes on to tell us what CMS is going to do and what we can do to obtain reimbursement for treatment given using CMS’ rules.

 CMS will reactivate the codes G8675, G8676, G8677, G8678, G8679, G8680, and 4050F with its next update of the HCPCS code data in April 2012. For 2012 claims-based reporting, PQRS requires at least three measures be reported at a 50-percent reporting rate.

In the interim, if you had intended to report this measure via claims for the 2012 PQRS, consider doing the following:

• Report additional measures to substitute for measure No. 235, Hypertension: Plan of Care.
• Hypertension: Plan of Care is a per-visit measure, which requires reporting for 50 percent of eligible patient visits. Therefore, you could report the measure on more than 50 percent of eligible visits from April through December 2012 to increase the likelihood for successful reporting of the measure.

As an alternative to reporting PQRS quality measures via claims, physicians can report using a qualified registry (PDF). TMA endorses two such vendors. Or, practices can submit measures using a qualified electronic health record (PDF).

Published March 16, 2012

Is it any wonder the Medicare and Medicaid System have tremendous bureaucratic cost overruns?

There has to be a better way?

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

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Where Is The Healthcare Money Going?

Stanley Feld M.D.,FACP, MACE

In reviewing Ezekiel Emanuel’s New York Times article I thought of an interesting question. In Dr. Emanuel’s view it is not worth having tort reform or healthcare care insurance reform. He claims these reforms are an insignificant burden to the cost of the healthcare system.

I have demonstrated that the evidence for tort reform and reform of the healthcare insurance industry proves him wrong.

The question then is where is the $2.5 trillion dollars the U.S. healthcare system spends going?

President Obama and Dr. Emanuel think it is going to physicians. President Obama’s idea to control healthcare costs is to reduce physician reimbursement.

Physicians have the weakest expression of its vested interests among all the stakeholders because of lack of effective leadership. 

Simple arithmetic reveals that reducing physician reimbursement will yield an insignificant reduction in healthcare costs.

Never the less on January 1^st Medicare is going to decrease physicians’ reimbursement by 27%. This decrease is the result of the application of the government’s Sustainable Growth Rate (SGR).

The Sustainable Growth Rate (SGR) is a complicated and defective formula intended to contain the overall growth of Medicare spending for physicians’ services.  The intent was to keep physicians’ reimbursement in line with the nation’s ability to pay for that medical care.  The SGR formula uses the gross domestic product per capita in a complicated and inaccurate way. 

In 2008 the Bureau of Labor statistics published a report that there were 661,400 physicians in the United States.

 The report’s findings are summarized in the table below.

 

Projections data from the National Employment Matrix
Occupational Title	SOC Code	Employment, 2008	Projected  Employment, 2018	Change, 2008-18		Detailed Statistics
				Number	Percent
Physicians and surgeons	29-1060	661,400	805,500	144,100	22	[PDF]	[XLS]
NOTE: Data in this table are rounded. See the discussion of the employment projections table in the Handbook introductory chapter onOccupational Information Included in the Handbook.

Let us assume that 161,400 of the 661,400 physicians in the U.S. work in private medical related industries such as the healthcare insurance industry, the pharmaceutical industry, the physician executive industry and government services.  These physicians are not involved in direct patient care and do not generate direct patient costs to the healthcare system.

 The number of non direct patient care physicians is probably higher (185,192 in other non practice positions and 476,208 in direct patient care). My assumption uses 500,000 physicians involved in direct patient care for all types of insurance to inflate physicians’ reimbursement. 

The Bureau of Labor report states,

 Physicians and surgeons held about 661,400 jobs in 2008; approximately 12 percent were self-employed. About 53 percent of wage–and-salary physicians and surgeons worked in offices of physicians, and 19 percent were employed by hospitals.  .

 

Let us also assume that physicians’ overhead is 50% of total collections. Therefore physicians’ take home salary is 50% of collections. Fifty percent is a fairly accurate assessment whether the physicians are self employed or hospital system employed.  

 “According to the Medical Group Management Association's Physician Compensation and Production Survey, median total compensation for physicians varied by their type of practice. In 2008, physicians practicing primary care had total median annual compensation of $186,044, and physicians practicing in specialties earned total median annual compensation of $339,738.”

 If we round off the salaries to $190,000 for Primary Care Physicians and $340,000 for Specialists and round off the number of Primary Care Physicians to 300,000 (actually 375,000) and 200,000 in Specialties (actually 125,000) and do the math, physicians’ salary comprise only 5% of the total $2.5 trillion dollars spent in the healthcare system.

The Math:

 $190,000 per year per primary care physician x 300,000 physicians= $57,000,000,000 ($57 billion dollars for primary care physicians).

 340,000 per year per specialists x 200,000 specialists= $68,000,000,000 ( $68 billions dollars a year for specialists).

 $57 billion + $68 billion= $125 billion per year for the costs of physicians salary for direct patient care.

 $125 billion (125,000,000,000)/ $2.5 ($2,500,000,000,000) trillion per year = 5%

 If you double the physicians’ collections to include physicians’ overhead costs ,  physicians receive 10% of total dollars spent on healthcare system.

Improvements can be achieved in decreasing physicians’ overhead by having more integrated healthcare systems. Presently, most communities do a fair job.

Integrated electronic medical records could achieve a further decrease in the 5% of the total healthcare cost spend by physicians for overhead.

The government is spending billions of dollars on building bureaucracies, creating regulations, developing a IRS physicians fraud squad and creating committees trying to reduce 5% of the healthcare costs.

President Obama is approaching the problem of escalating healthcare system costs using the wrong premises. It will result in increasing healthcare system costs. Obamacare already has increased the costs of the healthcare system even though it is not fully implemented.

 "IF REALITY DOESN'T match your expectations, perhaps it's time to re-examine your premises."

 

Where is the other 90% of the healthcare system costs going?

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

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Getting Closer To The Ideal Electronic Medical Record

Stanley Feld M.D.,FACP,MACE

Over 70 % of physicians use smartphones. Physicians are not resistant to learning how to use an iPhone or one of the Android smartphones. The network speed is the irritation. Networks are confusing the public with 3G and 4 G network speed. They should just do it!

We are rapidly approaching the time when a smartphone will be an appliance. The best applications will survive. Medical applications will become fully functional.

Most individual physicians and group practices have had at least one electronic medical record (EMR). None has fulfilled its promises. None has been fully functional. The price paid for the EMR was high in the era of decreasing reimbursement.

Most practices need a fully functioning EMR. The practices are hesitant to endure the pain of conversion once more.

President Obama’s multi-billion dollar subsidy program is bogus. The amount of the subsidy is well below the cost of the EMR and its continuing service and upgrades. I believe the program will have little impact on adoption of EMRs.

If President Obama provided the ideal electronic medical record along with upgrades and service to physicians for a monthly fee, physicians could afford to sign up. They would not worry about an unaffordable capital expense. Physicians would be charged by the click just as MasterCard charges by the usage.

Instantaneously, the system proposed, would result in America’s physicians converting to a government certified fully functional EMR at minimal cost or risk.

Patients’ data could be kept on a hard drive in the physicians’ office to maintain patient privacy. Physicians would have to agree to release certain data to be used for educational purposes without compromising patients’ privacy.

Instead, President Obama’s new agencies are going to use inaccurate claims data to judge physicians’ care and impose penalties on physicians.

With the increasing development of cloud computing, President Obama could provide the software in the cloud with servicing and upgrading. It would cost the government less and the government would have created an income generating business.

Electronic medical records software producer ClearPractice has developed a SAAS (software-as-a-service application) for the Apple iPad to help doctors manage their workflow, from scheduling to prescribing to billing.

A fully functioning EMR can be developed with physicians using the functionality of an iPad and upcoming Android tablets.

I have not had the opportunity to study ClearPractice’s product. ClearPractice has the right idea. Its Nimble EMR cloud product is the first comprehensive EMR application designed to run on the iPad.

I think its distribution and storage model needs refining. It also should build iPad applications to interface seamlessly with an Android system Pad.

The software can be accessed from the cloud. Patient data files can be accessed from the physicians server using a Pogoplug. This would permit physicians to be in control of their patients’ data.

“In designing Nimble, ClearPractice tackled the slow implementation of EMR software, which costs physicians time and money and disrupts their workflow. "Traditional EMR systems slow down busy doctors."

A tablet can easily keep physicians connected to their patients’ data in their office, in the hospital and at night in their home.

ClearPractice claims its software-as-a-service application has scheduling, tracking in-patient rounds, prescribing, lab review/ordering and messaging applications. It also connects to the physicians’ billing system to automatically capture and submit charges for payment.

Nimble does not sound fully functional. The software must have the ability to connect financial outcomes with clinical outcomes to be appealing to physicians. Physicians must be able to use the data they generate to augment their value to the patient. They are hesitant to submit data to a third party that will use it to devalue their worth.

ClearPractice’s fee schedule is vague. Nonetheless, ClearPractice is on the right track. President Obama could save his subsidy money if he would start listening to physicians. He is going to ahead and will waste the money from the stimulus package. He will not make progress toward the goal of developing universal use of fully functioning electronic medical records.

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

Patients Own Their Disease.

Stanley Feld M.D.,FACP,MACE

It is important to listen to what physicians are saying. An article appeared in SERMO, a physicians’ social network, which expressed a physician’s frustration.

It is appropriate to publish some of that physician’s thoughts.

“I first heard this statement over twenty years ago, when I was an intern in general surgery, struggling to find my professional self.”

“My chief resident said; “The patient owns the disease,” “You’re not trying to make them suffer, you’re trying to help. They’re sick, you’re not.”

“The human body is unpredictable.  Disease complications happen.”

The author thought his chief resident was heartless and callous. In a way, he was but he was getting at the heart of the matter. What is the patient’s responsibility in the evolution of disease?

This physician took everything that happened to his patients personally.

The patient owns his disease. The physician does not own the patient’s disease. Lifestyle plays a large role in the cost of the healthcare system.

President Obama’s healthcare reform law ignores the central role patients play in the therapeutic equation.

Day after day in the Emergency Department, people who take no responsibility for their health confront me.  They smoke, they drink, they do drugs, they don’t take their medicines, they drive impaired and crash, and yet they expect me to make them well.

They visit at their convenience, complain about the wait, want their medicines for free, and then don’t pay their bills.

The concepts of health insurance, family doctors, and preventive care have been completely lost.  Everybody except the patient owns the disease.

There was a time that patients knew they owned their disease. They knew they were partners with physicians in the treatment of their disease. Patients had to do the best they could under their physicians’ guidance.

“Somewhere, somehow, things got turned around.  The patients no longer own their diseases.  They’ve given them to us – physicians and society at large.

We are held responsible for everything that happens to a person, regardless of how they conduct their lives or follow our instructions.

  The weight on our shoulders is crushingly real, and forcing many good physicians to walk away from the thing they love most – taking care of others.”

He goes on to say;

I’m still shocked when a patient says, “You have to ….”  It’s endless – “refill my blood pressure and diabetes medicines, even though I don’t know their names or the dose. Patients demand I order an MRI for their two years of knee pain.”

“Say no, explain why, try to educate, offer alternatives, and the reply is  “If you don’t do it and something bad happens, it’s your fault.”

“You can’t tell someone that his or her symptoms are due to obesity, smoking or drinking – that’s judgmental.”

The author’s examples are endless. One last example sums up the dilemma facing healthcare in America.

“I once believed that every time I gave in to a patient’s pressure for an antibiotic for a viral illness, I was contributing to the emergence of super-resistant organisms.

“I believed that I could control the run-away cost of health care by judiciously ordering advanced studies only when absolutely necessary.  I tried to convince people that they owned the disease, that they had responsibilities to meet, that they couldn’t just demand everything be given to them.  And now I’m labeled a “disruptive physician”, because I generate too many complaints.

The increasing prevalence of obesity is a concrete example of the need for patients accepting responsibility for their disease.

Obesity is the cause of many disease processes. Obesity is not a random occurrence. It is linked to eating more than you burn. Potential patients are responsible for their obesity.

When obesity leads to the onset of Diabetes Mellitus, patients are responsible for controlling their blood sugar so they do not develop the complication of Diabetes Mellitus. The complications are heart attacks, hypertension, strokes, blindness, or kidney failure.

The government must provide and promote public education about obesity. Somehow, the appeal of overeating must be squashed and the virtues of exercise promoted.

Physicians and their healthcare teams are responsible for teaching patients how to control their blood sugar.

Eighty percent of the healthcare costs are the result of the complications of chronic diseases. Physicians must be encouraged, not forced, to set up systems of care to help patients become responsible for their chronic disease.

Where is the motivation for physicians in President Obama’s healthcare reform law? Where is the motivation for patients to become serious about intensively controlling their blood sugars in President Obama’s healthcare reform bill? New agencies are being set up to penalize physicians for not using resources to set up systems of care, resources which are uncompensated.

President Obama’s healthcare reform law does not promote patients taking responsibility for their diseases. The law contains nothing that measures patients’ performance. The law contains a lot of proposals that will falsely measure physicians’ performance

The law uses the term preventive care. It is meaningless without providing details. Prevention is immediately defined as providing vaccinations. Vaccinations do not define preventive chronic disease management.

If we are going to decrease the acute and chronic complications of chronic diseases, patients must comply with their physician’s recommendations.

Systems of care for chronic disease management have to be taught to patients and physicians. Medical schools have taught physicians how to treat diseases after its onset. President Obama should focus on setting up systems of public education before the onset of chronic disease.

President Obama’s healthcare reform act puts the burden of successful outcomes on physicians. Physicians do not own their patients diseases.

He should focusing on where money is wasted not building an infrastructure that will waste more money.

“Somewhere between the past paternalistic model of the physician-patient relationship and today’s give-them-what-they-want system, there has to exist a better paradigm.

As doctors, we need to resist the external pressures to make every one happy.  We must legitimize our expectations and have the backing of hospital administration when appropriate.

We should be empowered to refuse unnecessary, expensive, and often harmful demands. We cannot continue to abdicate the responsibility of our education and profession to political correctness.”

The Sermo physician’s statement demands physician leadership for constructive change. He says just say no.

It is difficult for most physicians to say no when they will be penalized by their hospital administrator or get sued under present malpractice laws.

Patients must own their disease!

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

The Electronic Medical Record (EMR) Stimulus Fiasco: Part 3

Stanley Feld M.D.,FACP,MACE

 

President Obama’s goal for healthcare reform is to increase the quality of medical care, increase efficiency of medical care and decrease the cost of care. The goal is admirable. The route he is taking is wrong. In the process he might destroy the medical workforce.

The route the electronic medical record (EMR) stimulus package should take should be flexible and educational for patients and physicians. It should use modern software technology instead of subsidizing old inflexible technology that is set up to be punitive to physicians and patients to the advantage of the government and the healthcare insurance industry.

The term "quality medical care' is used loosely. It has not been appropriately defined. The practice of evidence based medicine has been used to define quality medical care. The problem is evidence based medicine is changing daily.

A better definition should be the best clinical outcome with the most efficient financial outcome. It is assumed that practicing evidence based medicine will lead to the best clinical outcome at the most efficient cost.

Clinical guidelines are defined by “experts” interpreting evidence based medicine. I am/was one of those experts and appreciate its short comings.

Some guidelines are essential and should be inflexible. Others are ever changing and must be flexible. In bureaurocratic systems it is difficult to create flexible rules. Also, all patients are different. Clinical judgment plays an important role in treatment.

Physicians should not be penalized for using clinical judgment. Nonetheless, physicians are penalized in a pay for performance evaluation for deviating from inflexible clinical guidelines. Since some clinical guidelines are always changing the weakness of the approach is obvious.

An example of an inflexible clinical guideline is the need for rules to have a sterile operating room with sterile gowns and tools to avoid surgical infection.

An example of a need for a flexible clinical guideline should be a physician’s approach to a patient with hypertension. The goal should be to normalize the blood pressure. The goal for lowering the blood pressure to normal is to avoid heart attacks and stroke. However, if the patient’s blood pressure was elevated for a long period of time and was severe enough to compromise the renal (kidney)) blood flow, lowering the blood pressure too quickly could result in the patient having a stroke from a relatively low blood pressure. This is an example of the value of clinical judgment.

Physician performance should not be evaluated on static measurements. It must be evaluated on physicians’ medical judgment. Clinical judgment is a function of a physician’s ability to relate to his or her patients. (patient physician relationship)

On the other hand, if a patient felt poorly as a physician tried to lower the blood pressure to normal the patient might stop his medication without telling the physician. The physician’s workup might have been perfect and his choice of medication may have been excellent. This physician might get an excellent mark on his performance but the patient had a stroke because the patient did not comply with treatment. The patient might not have complied because he was not taught to be a professor of his disease. Healthcare is a team sport. The patient physician relationship failed but was not measured. .

The poor performance was missed by the static digital healthcare evaluation imposed by an inflexible EMR. The importance of the patient physician relationship and not including patient responsibility in the clinical outcome should be part of any performance measurement. A performance measurement should be a measurement of both the patients’ and physicians’ performance.

Now that the federal government plans to spend $50 billion to spur the use of computerized patient records, the challenge of adopting the technology widely and wisely is becoming increasingly apparent.

There is no question we should have universal electronic medical records. It should be a teaching tool for patients and physicians. The EMR should be inexpensive and flexible. It should not a tool to judge and penalize clinical performance. President Obama is being ill advised. His EMR stimulus program is going to result in a waste of $50 billion dollars.

“In a “perspective,” Dr. Kenneth D. Mandl and Dr. Isaac S. Kohane portray the current health record suppliers as offering pre-Internet era software — costly and wedded to proprietary technology standards that make it difficult for customers to switch vendors and for outside programmers to make upgrades and improvements.”

The software the government is going to spend $50 billion dollars on is going to be too expensive, inflexible and not widely distributed.

“Instead of stimulating use of such software, they say, the government should be a rule-setting referee to encourage the development of an open software platform on which innovators could write electronic health record applications”.

EMR software platforms in the cloud should be developed. This link by Christopher Barnatt  is an excellent utube explanation of cloud computing. I suggest all watch it.Amazon uses the cloud to sell books. www.Salesforce.com’s business model tracks sales force activity at a minimal cost to the company. It is flexible and maintenance free.

“Such an approach, they say, would open the door to competition, flexibility and lower costs — and thus, better health care in the long run. “If the government’s money goes to cement the current technology in place,” Dr. Mandl said in an interview, “we will have a very hard time innovating in health care reform.”

The rules can be immediately changed. The cost to a medical practice could be minimal. Its effectiveness is maximal. The cost to the government using modern software technology could be between 1-10 % of what the stimulus is proposing to spend. If it is fashioned as an educational tool to patients and physicians the payback will be maximal, quality of care will improve and the cost of care will decrease.

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

President Obama; If You Really Want To Reduce Healthcare Costs, Effectively Reform The Medical Malpractice Tort System: Part 3

 

Stanley Feld M.D.,FACP,MACE

President Obama, the details of the Massachusetts Medical Society Defensive Medicine survey have profound importance in explaining trends in the delivery of medical care. Unfortunately, only meaningless sound bites have been given by the media. The survey’s significance has not had the impact on policy it should.

The authors state that the dollar estimates do not include the diagnostic procedures, hospital admissions, specialty referrals and consultations or unnecessary prescription by physicians in specialties not included in the study.

The eight specialties surveyed represent only 46% of the physicians in the Massachusetts. The real costs to the healthcare system from the practice defensive medicine in the state of Massachusetts are much higher. The authors estimate the real costs could be twice the $1.4 billion dollars per year they estimated.

I believe the costs of defensive medicine in many other states are much higher because the cost of litigation in many states is lower and the malpractice awards are higher encouraging litigation.

“This survey clearly shows that the fear of medical liability is a serious burden on health care,” said Dr. Sethi. “The fear of being sued is driving physicians to defensive medicine and dramatically increasing health care costs. This poses a critical issue, as soaring costs are the biggest threat to the success of Massachusetts health reform efforts.”

Defensive medicine is definitely a threat to the success of the Massachusetts healthcare reform efforts. President Obama, defensive medicine is a big burden nationally to the healthcare system. Its costs will undermine any attempt at healthcare reform unless you take medical malpractice liability reform seriously. There has to be a fundamental change in the structure of adjudication.

The survey’s findings must be studied carefully. The physicians surveyed estimated their percentages for defensive medicine testing to avoid law suit. I think their estimates are low. The real percentages must be studied objectively using data mining techniques. Nonetheless the current estimates reveal unsustainable waste in our dysfunctional healthcare system.

Radiological imaging is one tool overused by physicians defensively to avoid litigation. Physicians feel they must test everything even if the probability of a positive result is insignificant.

“Plain Film X-Rays: An average of 22% of X-rays were ordered for defensive reasons.”

“CT Scans: An average of 28% of CT scans were motivated by liability concerns, with major differences among specialties.”

About 33% of scans ordered by obstetricians/ gynecologists, emergency physicians, and family practitioners were done for defensive reasons.

The total number of unnecessary CT scans needs to be calculated along with its costs in order to understand the significance of the percentage presented. The health policy solution should not be to lower the reimbursement for CT scans. The solution is to fix the medical malpractice liability system.

MRI Studies: An average of 27% of MRIs were ordered for defensive reasons, with significant differences by specialty.

The highest rates were reported by obstetricians/ gynecologists, general surgeons, and family practitioners, with the lowest rates by neurosurgeons and emergency physicians.

Ultrasound Studies: An average of 24% of Ultrasounds were ordered for defensive reasons. Orthopedic surgeons (33%) and obstetricians/gynecologists (28%) reported the highest rates, with neurosurgeons (6%) and anesthesiologists (9%) the lowest.

I believe neurosurgeons are underestimating their use of radiologic procedures in order to look good. Neurosurgery is one of the specialties with the highest malpractice rates. Please note that obstetricians/gynecologists take no chances and order the most procedures for defensive purposes.

Laboratory Testing:

An average of 18% of laboratory tests were ordered for defensive reasons, with emergency physicians (25%) reporting the highest rates and neurosurgeons (7%) the lowest.

Specialty referrals, consultations and hospitalizations are overused the most for defensive reasons. No one wants to take a chance and send the patient home even if the indication for hospitalization is small. Hospitalization is also the most costly overused element in defensive medicine.

Specialty Referrals and Consultations:

“An average of 28% of specialty referrals and consultations were motivated by liability concerns, with significant differences by specialty. Obstetricians/gynecologists reported that 40% of their referrals and consultations were done for defensive reasons, and anesthesiologists and family practitioners said that 33% of their referrals and consultations were done for the same reasons.”

Hospital Admissions:

An average of 13% of hospital admissions were motivated by liability concerns, with surgical specialties reporting lower rates than the other specialties.

The percentages of defensive procedures are admitted by practicing physicians. The cost of defensive medicine is high and wasteful. President Obama, defensive medicine is not the minor problem that the malpractice attorneys want you to believe it is. It is time for definitive action now.

 

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

Is Barack Obama Any Different Than Other Politicians? Part 1

 

Stanley Feld M.D.,FACP, MACE

No! He is not.

In the weeks to come I am going to point out the deficiencies in both candidates thinking about healthcare. It is clear that neither has received input from practicing physicians. Please click on the highlighted phrases for more details on each subject.  

I will start with Barack Obama because the Democratic convention is first.

I am astonished by the lack of scholarship and thoughtfulness on the part of either Presidential candidate. The issues have been reduced to sound bites. The pronouncements are picture words that generate false hope. Neither political party is confronting the real issues and the necessary repairs. If any of their proposals are passed into law it will simply be a patch. In the process the proposals will destroy the vital and good elements of our entire healthcare system.

Both the Medicare and the Private Healthcare Insurance system have failed. They have neither decreased costs nor improved medical outcomes. They have been both economic and medical care disasters. The United States can no longer afford the present course. Academically the reasons for the disaster are clear.

1. Price controls do not work!

2. Price transparency is essential to create a free market economy!

3. There are too many monetary incentives in the healthcare system to maintain an inefficient system for all stakeholders. (primary and secondary stakeholders)

4. Punitive measures directed at the weakest stakeholders (primary stakeholders) to correct inefficiencies do not work and lead to greater inefficiencies.

5. The healthcare system must be constructed and run for the benefit of the primary stakeholders.

6. The primary stakeholders must drive the healthcare system for their medical and financial benefit. (Consumer driven healthcare).

7. Secondary stakeholders should be facilitators for the primary stakeholders. (patients).

8. Profit derived from the system should be the result of efficiency and not the result of political influence to protect secondary stakeholder vested interests.

9. Consumers as the primary stakeholders must be responsible for their health, and medical care. Appropriate government subsidy must be provided, if warranted.

10. The government must set up rules to protect the consumer from the healthcare insurance industry, hospital systems, drug companies and physicians

10. Actions should be taken by government across all areas of society (War on Obesity) to educate consumers to decrease the incidence of chronic disease.

The consumer must fix the healthcare system. None of the other stakeholders has been successful. In fact, in the last 30 years the healthcare system has been made worse by the insurance industry, government and policy makers.

All their systemic changes have failed because they have, for the most part, been to the advantage of the facilitator stakeholders and not the primary stakeholder, the patient. Facilitator stakeholders’ profits have soared, insurance premiums have skyrocketed while access to care has plummeted. Patients, physicians, hospital systems and the government have adjusted to changes to the detriment of patients. The facilitator stakeholder adjustments have resulted in further dysfunction in the healthcare system.

Presently, employers and all the stakeholders except for the insurance industry are in pain. However, the stakeholder most at risk is the consumer. Only 20% of the population is sick and interacts with the healthcare system at any moment in time. 80% of the population does not interact with the healthcare system. They think everything is fine. However, the entire populations’ health and well being is at risk! If we stay on the present course, I predict the system will break down completely. Access to care will be limited and rationed. Access to life saving medical advances will vanish. Future advances in medical care will disappear.

The goal of the healthcare system should be;

1. To provide patients

a. with access to good quality care
b. with education to judge quality care
c. with incentives to be motivated to be responsible for their medical care
d. with the freedom to judge and select the physician of their choice
e. with the information from their healthcare providers that is truly portable
f. with choice of healthcare insurance vehicles that are affordable
g. with education vehicles to become “Professors of their Chronic Disease” and be truly responsible for their care
h. effective and affordable drug coverage designed to enhance patient compliance with treatment

2. To provide physicians

a. with a precise definition of the meaning of quality care for various chronic diseases
b. with incentives to provide quality care for both acute and chronic disease
c. with the educational opportunity and motivation to improve the quality of care they deliver.
d. with an actual vehicle developed by their peers to prove that they are delivering quality care.
e. with a mechanism for delivering care at a transparent price
f. with the ability to effectively communicate with patients electronically.
g. with the ability to improve the patient physician relationships
h. with the ability to enable patients to practice effective self-management techniques to prevent costly complications of chronic disease
i. with the ability to improve communication and access to patient information so as to reduce the cost of redundant evaluation and treatment

3. To decrease the overall cost of the system

4. To eliminate the 47 million uninsured

5. To align stakeholders’ incentives

6. To provide satisfactory profit margins for hospitals, pharmaceutical companies, insurance companies, and physicians.

These are ambitious goals. Processes must be changed in order for the United States to deliver effective health care to the population now and in the future.

Consumers can not leave it up to the facilitator stakeholders and policy wonks to fix the system. Their policies have distorted the healthcare system in the past to serve their vested interests. Patients today and in the future must drive the process of change through appropriate demands on our politicians in order to repair our healthcare system and install an effective consumer driven healthcare system.

Did You Know The United States Could Have A Prescription Drug Shortage!

 

Stanley Feld M.D.,FACP,MACE

China is determined to present a favorable impression to the world during the Olympic Games. Beijing is extremely polluted. It is desperately trying to decrease the pollution in the city and its surroundings. The pollution could affect the athlete’s performance and health. Many countries have expressed concern.

In order to clean up the air quality for the Olympic Games athletes, Beijing has taken extreme measures shunting down many large commercial plant operations in its vicinity. Many chemical plants in and around Beijing produce ingredients for both generic and brand named drugs. These plants are dirty plants producing significant pollution. The closing of these chemical plants before and after the Olympics will result, at least, in large increases in drug prices globally and, at most ,in life threatening shortages of vital medications throughout the world.

“The expedience of reducing particulate pollution has prompted officials to temporarily shut down chemical production in and around Beijing prior to the Olympics. This crackdown is likely to include pharmaceutical production.”

The Chinese government has been trying to relocate polluting industries and power generating plants away from its large cities. Cleaner plants have already been built in less populated areas. However, the production of particulate matter (microscopic particles toxic to lung tissue) is still twice the admissible level recommended by the World Health Organization. Pollution from particulate matter produces both acute and chronic pulmonary disease. Chinese government officials have temporarily shut down chemical production for two months prior to the Olympics and one month post Olympic Games to decrease particulate matter in the air.

This crackdown affects pharmaceutical production. China is the largest producer in the world of bulk pharmaceuticals known as active pharmaceutical ingredients (API)

“China is the largest producer of bulk pharmaceutical chemicals, also known as active pharmaceutical ingredients (APIs), which are made into drugs that supply the world. With India it supplies 40% of the API used in U.S. pharmaceutical production, an amount predicted to increase to 80% by 2020. China provides at least 20% of the APIs used in making Indian generic drugs, as well as about 75% of the intermediate products Indian firms require to synthesize the final products they sell.”

These APIs are used for the production of both brand named and generic drugs. The U.S. press has not discussed the source of production of U.S. brand named drugs.

“For the next two months Western and Indian companies will find it difficult to import most chemical substances including bulk drugs and intermediates from China. This could prove costly to patients and especially costly for the Indian generics industry, because their companies are so reliant on Chinese inputs.”
The price of APIs has increased at least 50% over the past six months."

This is putting pressure on the pharmaceutical industry’s profit. The increase in price for APIs has been blamed on the increase in the price of oil as well as the decrease in China’s production. This is certainly going to be reflected in the increase in drug prices shortly at all levels.

“Given that many of China's bulk API manufacturers operate around Beijing product prices will still increase drastically over the next few weeks as supply is constricted from Beijing alone.”

I predict we are going to see the impact of China’s decreased production on the United States drug supply in the next few weeks. I suspect we are going to see life threatening shortages.

One must wonder about this perverse effect of “globalization” on our ability to deliver appropriate medical care if it results in significant shortages of vital medication.

The other perverse effect of globalization is the inability or lack of desire on the part of multinational companies operating throughout China in joint ventures with the Chinese government to protect the environment of the country to the detriment of its citizens in order to product “cheap” medication for the United States and the rest of the world.

“It is impossible to calculate how many lives will be lost because drug prices are rising,”

It is easy to feel that the wheels are coming off the global economy as indiscretions are being tolerated by government. As these indiscretions are revealed one has to wonder if the present direction of globalization is a good idea.

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

It Is Not Only Older Physicians Who Are Discontent: Part 2

 

Stanley Feld M.D.,FACP,MACE

 

The administrative difficulties in the physicians’ work environment are increasing physician discontent.

“In a survey last year of nearly 2,400 physicians conducted by a physician recruiting firm, locumtenens.com, 97 percent said they were frustrated by nonclinical aspects of medicine. The level of frustration has increased with nearly every survey.”

The important point is that it is our younger physicians who are complaining about the burdens of medical practice.

“Dr. Bhupinder Singh, 42, a general internist in New York, sold his practice and went to work part time at a hospital in Queens. When he decided to work in a hospital, he figured that there would be more freedom to practice his specialty.”

Recently, he confessed, he has been thinking about quitting medicine altogether and opening a convenience store. “Ninety percent of doctors I know are fed up with medicine,” he said.

Many healthcare policy makers dismiss these complaints as the failure of managed care. Managed care was a system policy makers developed to manage costs. It is a system that has failed to manage care and manage costs as well.

“It is not just managed care. Stories of patients armed with medical knowledge gleaned from the Internet demanding antibiotics for viral illnesses or M.R.I. scans for routine symptoms are rife in doctors’ lounges. Malpractice worries also remain at the forefront of many physicians’ minds, compounded by increasing liability premiums that have forced many into early retirement.’

Physicians are discouraging their children and their friends’ children from becoming physicians. The opposite was true in past generations.

In surveys, increasing numbers of doctors attest to diminishing enthusiasm for medicine and say they would discourage a friend or family member from going into the profession.

Practicing physicians are not stupid. They are adjusting their practice to decrease practice burdens. Some Ob-Gyn physicians have stopped delivering babies because of the malpractice burden and decrease in reimbursement. They are only practicing gynecology. The adjustments in medical practices are to the detriment of patient care.

“Doctors are working harder and faster to maintain income, even as staff salaries and costs of living continue to increase. Some have resorted to selling herbs and vitamins retail out of their offices to make up for decreasing revenue. Others are limiting their practices just to patients who can pay out of pocket.”

“There are serious consequences to this discontent, the most worrisome of which is that it is difficult for doctors who are so unhappy to provide good care.”

I have said over and over again that healthcare policy makers do not listen to or ask physicians for advice. The end result will be a severe physician shortage. Physician shortages are here already. The central problem is quality care for patients and not the healthcare insurance company’s bottom line. I hope policy makers are listening.

“Another is a looming shortage of doctors, especially in primary care, which has the lowest reimbursement of all the medical specialties and probably has the most dissatisfied practitioners.”

Last year, residency programs in family practice took only 1,096 graduating medical students, the fewest in the last two decades. The number increased just slightly this year. “For me it’s an endless amount of work that I can never get through to do it properly,” said Dr. Jeffrey Freilich, 38, a primary-care physician on Long Island. “I’m a bit compulsive. There is no time to do it all in a day."

“On top of all that, there are all the colonoscopies and mammograms you have to arrange, and all the time on the phone getting preauthorizations. Then you have to track the patient down. And none of it is reimbursed.”

The only services primary care physician have to sell is their time and clinical judgment. Both services are undervalued in the present healthcare system.

Once a patient is hospitalized the primary care physician loses track of the patient. Hospitalists take over. Hospitalists call many specialists for consultation and advice.

“The upshot is that the doctor who knows a patient best is often uninvolved in her care when she is hospitalized. This contributes to the poor coordination and wanton consultation that is so common in hospitals today.”

“Years ago you had one or two doctors,” a hospitalized patient told me recently. “Now you’ve got so many people coming in it’s hard to know who’s who.”

Medicare is going to cut payments to physicians 10.6% in July. Why? It is easier to cut physicians who utilize 20% of the healthcare dollar than to cut the stakeholders that absorb 80% of the healthcare dollar. Why? Physicians are not organized! They are also cheapskates and do not support lobbyists. They do not have the powerful a lobbying infrastructure that the healthcare insurance industry and the American Hospital Association.

A 10.6 percent cut in Medicare payments to physicians is scheduled to take effect on July 1. Further cuts are planned in coming years. Many doctors have told lawmakers that if the cuts go through, they will stop seeing Medicare patients.

Unfortunately, politicians do not understand the problems physicians and patients have in the healthcare system. It is going to be up to patients and physicians make these problems clear to politicians in order to Repair the Healthcare System.

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

Do You Think Politicians Want To Hear From You?

Stanley Feld M.D.,FACP,MACE

The answer is “NO”. Cecelia and I wanted to contact John Cornyn and Kay Baily Hutchison about their vote on HR 6331. Their two votes defeated the House of Representatives proposal to cancel the Medicare cuts.

It is an impossible task to send them an email. Just try to find an email address. We have concluded the best way to contact a congressperson is to send him or her a fax. Actually, many fax’s and break their fax machine. Maybe then you will get their attention.

The next time I hear that a politician wants to hear from his/her constituents, I know he/her wants to seduce us to vote for him/her. He/her has no intention of listening to us.

It Is Not Only Older Physicians Who Are Discontent: Part 1

Stanley Feld M.D.,FACP,MACE

It has been said that the older physicians are the only physicians upset by the way they are being treated by the healthcare insurance industry. The claim is older physicians are spoiled by the golden days of medicine. My reply to that statement is nonsense. When a professional is treated as a commodity no matter what his age discontent is generated. The older physicians are products of the silent generation. When the younger physicians are pushed to the edge we will hear lots of noise and have lots of rebellion. The rumblings have started.

“I love being a doctor but I hate practicing medicine,” a friend, Saeed Siddiqui, told me recently. We were sitting in his office amid his many framed medical certificates.

Uwe Reihardt said it all to my surprise in a letter to the editor of the New York Times in May 2008.

“Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.

Besides, cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.

This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.

Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere.”

Many examples of discontent from younger physicians can be sited. As these physicians gain experience and understand that the healthcare system is a business to the facilitator stakeholders whose only concern is the bottom line the patient-physician rebellion will pick up steam. The facilitator stakeholders account for 80% of the healthcare dollar and add little value.

“A doctor in his late 30s, he has been in practice for six years, mostly as a solo practitioner. But he told me he recently had decided to go into partnership with another cardiologist; “Your days aren’t busy enough already?” I asked.

The waiting room was packed. He had a full schedule of appointments, and after he was done with his office patients, he was going to round at two hospitals.

He smiled wanly. “Just look at my eyes.” They were bloodshot.“This whole week I haven’t slept more than about six hours a night.”I asked when his work usually got done. “It is never done,” he replied, shaking his head. “See this pile?” “He pointed to five large manila packages on a shelf above his desk.” “These are reports I still have to finish.”

“As a physician, I could empathize. I too often feel overwhelmed with paperwork. But my friend’s discontent seemed to run much deeper than that. Unfortunately, he is not alone. I have been hearing physician colleagues voice a level of dissatisfaction with medical practice that is alarming.”

The discontent is building. Physicians are fed up with what they perceived as a loss of professional autonomy. They can not stand the unwarranted restrictions on their medical judgment. As demand for physician services increase we are experiencing larger and larger physician shortages.

Another physician complained. “I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.” Managed care is like a magnet attached to you.

A 42 year old physician complains that he continues to be frustrated by payment denials. “Thirty percent of my hospital admissions are being denied. There’s a 45-day limit on the appeal. You don’t bill in time, you lose everything. You’re discussing this with a managed-care rep on the phone and you think: ‘You’re sitting there, I’m sitting here. How do you know anything about this patient?’ ”

The endless abuse on professional integrity amazes me. A high school graduate sits in front of a computer screen deciding on what a physician can or can not do. Another healthcare insurance company assistant sits in front of a computer billing screen reducing reimbursement on questionable computer programming decisions. The appeals process is difficult and time consuming for physicians.

“Dr. Mark Linzer, an internist at the University of Wisconsin who has done extensive research on physician unhappiness, told me. “Fortunately, the data show that physicians are willing to put up with a lot before giving up.””

How long do you think young intelligent physicians will tolerate this abuse? How long do you think it will take to train another compliant work force? America has a physician shortage that is about to accelerate.

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

The Primary Care Physician Shortage Emphasized By Universal Coverage In Massachusetts

Stanley Feld M.D.,FACP,MACE

Medical students are choosing procedure oriented subspecialties rather than family practice or internal medicine (Primary Care). There has been a 50% decrease between 1997 and 2008. This trend resulted from the fact that it is difficult to make a living in a non procedure oriented practice. Cognitive medical care and positive physician patient relationships have been devalued. The government and the healthcare insurance industry have not adequately compensated cognitive medical care in an attempt to save money.

“Once they discover that she is Dr. Kate, the supplicants line up to approach at dinner parties and ballet recitals. Surely, they suggest to Dr. Katherine J. Atkinson, a family physician here, she might find a way to move them up her lengthy waiting list for new patients.”

“Massachusetts primary care practices like this one in Shelburne Falls have been trying to manage an influx of new patients. Those fortunate enough to make it soon learn they face another long wait: Dr. Atkinson’s next opening for a physical is not until early May — of 2009”

Positive patient physician relationships have an important therapeutic effect. The patient physician relationship is disappearing as primary care physicians have less time to relate to their patients. They have to see more patients in a shorter time in order afford their practice overhead.

“Modest reimbursement, medical school debt, an aging population and the prevalence of chronic disease have each played a role in primary care physician ".

The primary care physician shortage widens with increases in population, decreases in the uninsured in Massachusetts, overuse of the healthcare system by first dollar insurance coverage, increases in obesity and subsequently increases in chronic disease and the decrease in reimbursement to the primary care physician.

“Since last year, when the landmark law took effect, about 340,000 of Massachusetts’ estimated 600,000 uninsured have gained coverage. Many are now searching for doctors and scheduling appointments for long-deferred care.”

The result has been an unintended consequence leading to the realization that Massachusetts has a severe primary care physician shortage. It also has resulted in the state’s widening budget deficit. The solution to the problem is to change the approach to care. The primary care physician has to be taught to extend his intellectual property.

“It’s a recipe for disaster,” Dr. Sereno said. “It’s great that people have access to health care, but now we’ve got to find a way to give them access to preventive services. The point of this legislation was not to get people episodic care.”

Dr. Serno is right on target. There are not enough Clinical Endocrinologists to take care of all the patients with Diabetes Mellitus. There are not enough Clinical Cardiologists to take care of all the heart disease patients. There are not enough Clinical Pulmonologists to take care of all the lung disease patients. Primary care physicians have to install systems of care of chronic disease in their practices. They initially see most of the chronic disease patients. The complications of chronic diseases absorbs ninety percent (90%) of the healthcare dollar. These costs can be decreased by at least 50% with effective chronic disease management.

“Whether there is a national shortage of primary care providers is a matter of considerable debate. Some researchers contend the United States has too many doctors, driving overutilization of the system.”

It seems obvious there is a growing shortage of primary care physicians. Politicians always want to do a study. All they have to do is go into a typical physician’s office and observe the demands on the physicians and the problems the physicians have.

“But there is little dispute that the general practice of medicine is under strain at a time when there is bipartisan consensus that better prevention and chronic disease management would not only improve health but also help control costs.”

“With its population aging, the country will need 40 percent more primary care doctors by 2020, according to the American College of Physicians, which represents 125,000 internists, and the 94,000-member American Academy of Family Physicians. Community health centers, bolstered by increases in federal financing during the Bush years, are having particular difficulty finding doctors.”

There are many who say we have more primary care physicians than previously. I believe all of their arguments blur the issue. The truth is every community there is a shortage of primary care physicians.

“I think it’s pretty serious,” said Dr. David C. Dale, president of the American College of Physicians and former dean of the University of Washington’s medical school. “Maybe we’re at the front of the wave, but there are several factors making it harder for the average American, particularly older Americans, to have a good personal physician."

“Studies show that the number of medical school graduates in the United States entering family medicine training programs, or residencies, has dropped by 50 percent since 1997.”

Physicians are not becoming primary care physician because they can not afford to become primary care physicians. The Medicare reimbursement for a half-hour primary care visit in Boston is $103.42 while reimbursement to a gastroenterologist for a colonoscopy requiring roughly the same time would be $449.44.

"Dr. Atkinson, 45, said she paid herself a salary of $110,000 last year. Her insurance reimbursements often do not cover her costs, she said."

“I calculated that every time I have a Medicare patient it’s like handing them a $20 bill when they leave,” she said. “I never went into medicine to get rich, but I never expected to feel as disrespected as I feel. Where is the incentive for a practice like ours?”

The physicians’ goal is to help people get well. They also want to earn a reasonable livelihood for their efforts and intellectual property. Physicians have not done a good job arguing this point.

Organized medicine (AMA,AAFP,ACP) has not done a very good job of defending the physicians’ value.

As time passes the problems with the delivery of healthcare will escalate as the secondary stakeholders, the healthcare insurance industry, the pharmaceutical industry, and hospitals thrive making egregious profits while the primary care physician shortage intensifies.

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

What Does Chronic Disease Management Mean? Part 2

Stanley Feld M.D.,FACP,MACE

The responsibility for the control of the onset of the complications of chronic disease is the responsibility of the patient. Patients live with their disease 24 hours a day and need to learn how to manage it.

There are 20 million patients with Type 2 Diabetes Mellitus in America. This number is growing every day because we are experiencing an obesity epidemic. As I have previously discussed, this epidemic is the fault of our cultural conditioning.

The physician’s responsibility is to teach the patient how to manage his chronic disease.

Imagine you were told you have Type 2 Diabetes Mellitus. Think about your potential emotional responses. Think of all the bad things you have heard about diabetes mellitus. Think about the fantasies you would have about your future morbidity and mortality. These fantasies are the result of the media information and free public service campaigns various organizations have to heighten awareness about Diabetes Mellitus.

The complications of Diabetes Mellitus cost the healthcare system at least $150 billion dollars per year. At a July 4th party, I spoke to a diabetic patient who has had diabetes mellitus for thirty years. He became a professor of diabetes mellitus 28 years ago and has had his blood glucose levels under exquisite control. He has not suffered one complication of diabetes mellitus. There are many patients like this patient.

How does one start to teach patients to be the professor of their disease? I believe it is important for readers of this blog to understand what patients need to learn. It is also important for readers to understand how this process of self-management is a continuous learning project for both the patients and the physicians. The patients’ effort and responsibility in controlling this chronic disease is enormous, and can be very difficult.

You have just been told you have Type 2 diabetes mellitus. If I describe what needs to be learned you can start understanding how this empowerment could result in better control of the blood glucose level. You could also understand how the information could extinguish your fantasies and anxieties about diabetes mellitus. The result would be a decrease in the complication rate of Diabetes Mellitus.

The teaching process has to be a coordinated effort between the physician and the Diabetes Care Team, the nurse educator, dietician, and exercise therapist. We start by teaching patients what Type 2 Diabetes Mellitus is,
why they got it, and how they can reverse Type 2 Diabetes or at least control the rising blood sugar. If patients understands the pathophysiology they know the enemy. They are not frightened about the consequences of the disease. Then a plan can be developed for patients to actively self manage their disease.

At least 20% of the population has the genetic tendency to develop Type 2 Diabetes Mellitus. The genetic defect is an underlying resistance to their own insulin. We have insulin receptors on every cell in our body. These receptors attract insulin. The insulin receptor/insulin combination permits our cells to absorb circulating blood glucose. Once in the cells the glucose gets metabolized to carbon dioxide and water. In the process, packets of energy (ATP) are stored in our cells.

Increasing weight, stress, decreasing exercise, and development of infection decrease the insulin receptors affinity to attack circulating insulin. In effect you have an increased resistance to your own insulin. These external factors are additive to the underlying genetic defect. The more weight gained, the less exercise done and the more stress one has the greater the insulin resistance. As the effective insulin receptors decrease (increased insulin resistance) our body produces more insulin to compensate for this increase in insulin resistance. Over time we can not compensate with sufficient output of insulin to overcome the insulin resistance and our blood glucose rises.

Diabetes Mellitus is defined as a fasting blood sugar of greater than 126mg% on two occasions. Patients can have fasting blood glucose of greater than 126 mg% for many years without symptoms. Many people, mostly men, do not have periodic blood glucose measurements.

High blood glucose levels are the cause of the complications of Type 2 Diabetes Mellitus. The complications are eye disease, kidney disease, neurological disease and heart disease. The average time from the onset to the diagnosis of Type 2 Diabetes Mellitus has been calculated as 8 years. The average time of onset of complications of diabetes varies with the height of the elevation in the blood glucose levels. If you do not recognize that your blood glucose is elevated because you are asymptomatic you can not appreciate that you are harming your body. Many patients first discover they have diabetes mellitus when they are in the Cardiac Care Unit after suffering the cardiovascular complication (heart attack) of Type 2 Diabetes Mellitus.

Why does a high blood glucose level cause eye disease, kidney disease, neurological disease and heart disease? I have observed that once people understand the concept they become motivated to control their blood glucose levels.

Understanding causality is simple. A graphic way of understanding the process is to know that sugar helps alter proteins. The process of converting cucumbers to sour pickles comes to mind. You mix water, vinegar, salt, spices and sugar together. Then add cucumbers to the liquid and put the container in the closet for two weeks. The cucumbers have turned to sour pickles because the proteins in the cucumber have been deformed.

One can think of a person with a high blood glucose level deforming all the proteins in their body. They are essentially pickling all the cells and vessels in their body. The blood vessels narrow because the cells lining the blood vessels are deformed. For example, If there is not enough blood supply to the eye, the body tries to compensate by making more vessels. These new blood vessels (neovascularization) float on the surface of the retina and are fragile. If they bleed, patients can become blind. This narrowing applies to the blood vessels around nerves resulting in neuropathy. As blood vessels narrow, nerve endings will fire ineffectively. Many times these nerve ending misfires are painful. Many patients lose feeling in their extremities as a result of misfiring of nerve ending.

The hemoglobin molecule carries oxygen to the cells of the body. Each red blood cell has a 120 day life cycle. If a red blood cell is born in a high glucose environment it gets deformed or pickled and rather than being a simple Hb molecule it is now a HBA1c molecule. The higher your HBA1c level is, the higher your average blood glucose level has been over the three month period of time. A normal HbA1c level is under 6%. The HbA1c is that high in normal people because after a meal a normal blood glucose can go as high as 160mg%. National laboratories have calculated that the average Type 2 diabetic has a HbA1c of 9.2%. This finding means that neither patients nor physicians are doing a very good job in lowering the HbA1c to normal.

The patient I referred to earlier with diabetes for 30 years has a HbA1c level of 5.5%

Next time I will describe how that goal of a normal HbA1c can be achieved by the patients. It is the essence of the principle of chronic disease management. Normalization of the HbA1c levels can reduce the complication rate of Type 2 Diabetes Mellitus by at least 50%. It can theoretically reduce the complication rate of Type 2 Diabetes Mellitus by 100%. Fifty percent of $150 billion dollars is not a shabby dollar amount toward the repair of the healthcare system. However, the necessary education process to empower the patients to control their blood glucose levels and prevent obesity is not supported by society, the insurance industry or the government.

What Does Chronic Disease Management Mean? Part 1

Stanley Feld M.D.,FACP,MACE

Ninety percent (90%) of the Medicare dollar is spent on the complications of chronic diseases according to CMS. Eighty percent (80%) of the healthcare dollars for all age groups is spent on the complications of chronic diseases.

I have stated that our medical care system is great at fixing things that are broken. Our healthcare system has not been good at preventing things from breaking. The medical care system has not been good at preventing the complications of chronic diseases once the patient is afflicted with the disease.

There are two reasons for our inability to prevent things from breaking. One, is that most of the abuse to the human body is a result of the patient’s behavior and lifestyle. An additional factor is the genetic predisposition patients have for a particular chronic disease. Physicians can do little to control genetic predisposition presently. Genomics represents a great hope for preventing the onset of chronic disease in the future. Inhibiting stem cell research seems foolish in the face of its potential benefit. Prohibiting the use of embryonic material that is going to be destroyed anyway to me is illogical. The controversy is a result of the science wars presently going on between theology and science. It is my belief once the public understands the potential of genomics and the illogical nature of the controversy, public opinion with turn on the foolishness of the argument and the controversy will evaporate. This is for the future and the prevention of the onset of chronic disease.

Once the patient has a chronic disease, there is much that can be done for each disease to slow or halt its progression and slow or halt the onset of devastating complications. If we were effective in preventing the complications of chronic disease after its onset, this would result in an improved quality of life for patients and a marked reduction in cost to the healthcare system. The present costs of the healthcare system are leading to an increasing number of uninsured as well as bankrupting the nation.

Presently, most studies demonstrate that, with adequate treatment, we can reduce the complication rate of most chronic diseases by 50%. The reduction to the cost of the healthcare system would be 800 million dollars. Theoretically, with perfect control of the chronic disease and perfect medical therapy we could reduce the complication rate by 100%. The result would be a 100% reduction of the 90% of the money spent by the healthcare system on the complications of the diseases.

Most healthcare economists, “healthcare policy experts” and politicians are starting to understand the math. What I have discovered is that they do not understand the process of chronic disease management and the importance of the patient physician relationship. They do not understand the pathophysiology of the chronic diseases or the origin of the complication of the diseases.

The chronic diseases we are talking about are cardiovascular disease and hypertension, diabetes mellitus, osteoporosis and muscular skeletal disease (arthritis and collagen vascular diseases, lung disease, AIDs, and cancer. We have a $2 trillion dollar annual healthcare system. The total cost of all chronic disease complications to the healthcare system is $1.6 trillion dollars per year.

A lot of brain power is going into trying to do something to reduce the healthcare system costs because we simply can not go on with ever increasing costs and ever increasing opportunities for facilitator stakeholders to increase there profitability while there are ever increasing number of uninsured persons.

We must have a universal healthcare system. However, universal healthcare does not mean a single party payer. I believe a single party payer system will add bureaucracy and impose rules that will stifle and inhibit innovation. The result will be increased inefficiency and increased cost. We all agree that what has made America is innovation by entrepreneurs and not rules by bureaucrats. I know that the physicians are not the problem. They are part of the problem. There is no reason to create a healthcare system that will methodically inhibit physician innovation. Even worse, drive a skilled labor force (physicians) out of business whose education we as a society subsidized.

Who is responsible for the complications of chronic diseases? It is the patient who lives with his disease and lifestyle 24 hours a day. The patient must learn how to control his disease to avoid the complications of the disease. The physicians can only be the coach or manager of the patients and modify their treatment plan through his experience and clinical judgment. Physicians must teach patients how to adjust to changes in the course of their disease. Physicians have to do this with their healthcare team with the patient being the most important person on the team.

Patients must be provided with education, incentive and financial reward for their successful adherence to treatment regimes. The promise of good health does not seem to be enough of a reward. Once patients understand that they are responsible for their self-management and the management of their health care dollar adherence to treatment will improve and outcomes of chronic diseases will improve. Physicians also have to be compensated for their effort. To help make the patients the professors of their disease is a very hard process. It is much easier for a physician to set a broken arm, fix a hernia, or even do bypass heart surgery. Yet the insurance industry does not value or reward this effort.

If patients owned their healthcare dollar and needed to spend their money wisely, they would become intelligent consumers of healthcare. This would force innovation by physicians and hospitals. They would force and increase the quality of chronic disease management at decrease the cost. This would also create a competitive environment for hospitals to control prices. They would produce a market driven economy as occurs in other areas of commerce. Healthcare is a not marketplace presently. Hospital prices presently have nothing to do with hospital costs. This is why we need the ideal medical saving account owned by patients and not the insurance industry. The Ideal Medical Savings Accounts would align all the stakeholders incentives to enable the best product at the best price in a truly consumer driven healthcare system.

In order to understand its complexity I will discuss the disease management concept of several diseases. Obesity is the worse epidemic we are experiencing at the moment. It leads to diabetes, heart disease and hypertension, each of which has devastating and costly complications. In my "War on Obesity" I have discussed some of its problems. I will integrate obesity into the disease management process.