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All items for June, 2006


Hey Kinky Friedman Give Us a Hand:The Posse is Growing !

Stanley Feld M.D.,FACP, MACE

Below is a comment made to my son, Brad Feld, on his blog, when he asked everyone following his blog to join his dad’s Posse.

Kinky Friedman is running for governor in Texas. We have our own Arnold Schwarzenegger and Jessie Ventura combined. Kinky Freidman is the Texas Jewish Cowboy Country Music Star and Author.

Denise ——- wrote

Dear Brad

I would like to join your dad’s posse. Here is a letter I wrote to Kinky about healthcare. If your dad’s interested have him contact me. I’ve been researching healthcare on my own for the last 4 years.

Here’s the letter, they never responded to it.

Dear Kinky,

Please excuse my boldness, but I am writing this to help with your platform on healthcare.

I like the leave no teacher behind, bio-fuels and the I’ll sign anything but bad legislation; however that is not enough to get my vote and the thousands of Texans who are either un-insured or under-insured.

It is not just about covering the poor. I have found out how a middle-class person can quickly become poor without insurance or with inadequate insurance.

The Problem
First I want to make you aware of a few problems in healthcare costs:
The un-insured are charged at least 10 times the amount charged to insurance companies.
A blood test called CA125 cost me $198.50 when I was un-insured and only $22.50 when I got insurance. The $22.50 was before my deductible was met! I could give you more examples but you get the idea.
A person cannot get prices before purchasing healthcare services.
o I had to have major surgery after my health insurance was canceled. So like I do with any large purchase I tried to shop around and called different hospitals to get an approximate price. Impossible! I called 4 hospitals; one hung up on me thinking it was a prank call, two didn’t know what to tell me and would call me back, which they didn’t; and one called me back and told me $15,000 which of course was way above what an insurance company would pay.
A hospital official was quoted saying,” We have to charge the un-insured more to make up for the discounts we give health insurance companies.”
o Does this seem like common sense to you?
Doctors are not allowed to give a discount to the un-insured or under-insured.
If I could have paid the rates given to health insurance companies I wouldn’t have lost all my savings, I could have stayed in the middle-class.
Where does pricing come from?
o One ENT I saw charged over $2,200.00 for a Limited CT scan of the sinuses while another charged over $600.00. Since I had insurance at the time each cost me $210.00, again this is without my deductible met.
o So how much does a Limited CT Scan and other procedures really cost? What is a fair price?

The Solution (maybe not THE solution but an idea)

Allow the un-insured to pay the same fees for procedures given to the Federal Government under Medicare.
This would cost the taxpayers nothing. It would simply be a Medicare Discount Card.
Allow doctors to give the un-insured discounts
Price transparency-have doctors, dentists, labs, pharmacies state their prices up front.
At the very least make no interest loans or credit cards available for medical debts.

So in conclusion I have another campaign slogan for you:

Leave no Patient behind!

I would love to hear something back from your campaign or from whoever reads this.

Give me some healthcare hope and Ill give you my vote; and campaign my friends and family to vote for Kinky.

Dear Denise

You are now an official member of the Stanley Feld M.D. ,FACP, MACE Repairing the Healthcare System Posse. Enclosed is an official membership card. Your letter to Kinky is great. You hit the nail on the head. You are talking about transparency of prices. You are also talking about leveling the playing field for all patients, insured and the uninsured.
I think Kinky Friedman will listen. He might not know what to do. Through my Posse,I plan to tell him and every other elected official what needs to be done to Repair the Healthcare System

We need about 10,000 Texans sending Kinky this kind letter detailing their experience. If he responded appropriately he could get elected in Texas as Jessie and Arnold got elected in their States. I sent him your letter and a detailed explanation of the letter’s importance. His public relations people have not yet answered.

Wouldn’t it be fabulous if two people from Texas could start creating the Tipping Point that would Repair the Healthcare System.

I would like to request that you send this note to your entire email list and invite them to visit my blog and subscribe. They, too, need to be members of the Posse and learn what to do to Repair the Healthcare System. The time has passed when we can leave it to someone else to fix things for us. If the politicians want to be our surrogates, they should know what the we want them to do to earn our vote.

  • Claiborne Booker

    Dr Feld —
    Your blog is most interesting and informative. I had the good fortune to meet your son Brad last week and we touched on your Posse and its similarities to something Jean-Francois Rischard suggested in his book “High Noon: 20 Global Problems, 20 Years to Solve Them”. He proposed Global Issues Networks around each of the problems, to be comprised of concerned citizens, government officials, and experts. Your Posse already benefits from two of these groups; adding Kinky and other public officials will no doubt help. I’m happy to join the New Mexico contingent anytime!
    Dear Clairborne
    Attached is an official Repairing the Healthcare System Stanley Feld Posse Membership Card. Brad sent me a copy of Rischard’s book 2 weeks ago. I am in the middle of it and plan to model the approach around some of Rischard’s thoughts.
    Someone has to do it. It is not going to be the policy makers or critics. Everyone writes about the problem. No one does anything because they know without doing multiple corrections at once the system we become more distorted. The only way to reach the tipping point of constructive change is through People Power, in my view
    You can help by getting all of your friends and colleagues to subscribe to the blog. They need to get engaged in first understanding the mistrust that has develop by all the stakeholders. They, then have to participate in being part of the solution. Actually, they must be the driving force in the solution. Let us put together a New Mexican team.
    Thanks for the comment
    Stanley Feld M.D.,FACP,MACE
    Repairing the Healthcare System

  • gabriela

    Good luck ,Great post,love you!Thanks for the info it had cleared out too many things in my mind. Your recommendations are really good.

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The Demise of the Patient-Physician Relationship: Price controls do not work!



A few days ago I received an email comment about my successful 43 years of marriage.  I answered the email in the comment section. However, I feel the answer deserves publishing in the main body of the blog. The answer can serve to illustrate the development of problems in the healthcare system and the Demise of the Patient-Patient Relationship.



Wanted to let you know that I have been reading your blog from the start, keep up the good work! On a personal note, happy 43rd to you and Mrs. Feld. Whatever your secrets to a long and happy marriage, we should try and bottle that, we could all use some. Also, Happy Father’s Day!



Thanks for the comment.

The key to our successful marriage is mutual respect, mutual trust, and love.


One can also look to this answer as a definition of the therapeutic effect of the Physician-Patient relationship. The therapeutic effect is a positive physician-patient relationship. In my opinion, the patient-physician relationship has been destroyed by the attempts of policy makers to fix the healthcare system. The actions catering to the facilitator stakeholders have only made the this relationship vanish.

Price controls do not work in any industry in my view. Intelligent people always seem to figure out how to get around price controls.

In medicine, the price controls imposed by Medicare in the early 1980’s, led to physicians seeing more patients in a less of time. Physician offices started to rely on physician extenders to relate to the patients as well leverage the physicians intellectual property. Physicians were forced to distant themselves from this important therapeutic effect. One of the most important healing factors in medicine, in my opinion, is a positive relationship with the patient. If physicians have no time to relate to the patient this all important effect erodes.

As a result of Medicare price controls, price shifting was occurring. The private insurance industry was happy because more money flowed through the system resulting in more profit. However, the insurance carrier started to delay payment and in many cases reduce payment to the physicians. Physicians did not notice the reduction in payment. Their financial information systems were not very efficient or effective.

Physicians noticed they were working harder, seeing more patients and taking home less money.

When they realized their fees were cut by the insurance companies, they were very angry at the insurance industry. The physicians’, then, billed the patient many months after the service was performed. Patients’ became angry at physicians and at the insurance companies. Physicians were angrier at insurance companies because patients became angry at the physicians. Employers were angry at the insurance companies and the physicians. Everyone is mistrusted, and everyone disrespects each other. The demise of the physician-patient relationship. In fact the demise of any relationship.

Hospital stayed very quiet as they steadily raised their rates. Hospital pricing is a topic of a future blog. The hospitals did not experience the firestorm the physician community experienced. The rate of increase of hospital rates were higher than physicians’ or insurance companies’. However, the hospitals had an advantage. Only 5% of patients are hospitalized. Ninety five percent(95%) of potential hospitalized patients have no idea of the fees charged in the hospital. In fact, at least 60% of physicians do not know what the hospitals charge. One has to be pretty sick to be put into the hospital in these days. If you leave the hospital with all the scary media news about hospital acquired infections, medication errors as well as such things as amputating the incorrect arm, the former hospitalized patient is grateful to be alive. They do not have the energy to complain. They simply pay the bill, if they can. If they can not they are usually more stressed by the hospital system pursuing the payment. This collection drill also stress the hospital system and is costly. The remaining 90% of us, thank god, so not experience hospitalization. We are able remain detached from the fees the hospital is charging and choose to ignore the problem.

The therapeutic effectiveness of the physician patient relationship deteriorated rapidly during this period of anger toward physicians. Patients expressed some of this anger by suing the physician.

Malpractice suits increased markedly. Media coverage of medical errors did not help. The fact that some of the media coverage was disinformation was immaterial. The excessive law suits served to increase the price of care. Premium cost had to be passed on somehow. The government should have taken action at that time, but did not do anything. The government should have set or define liability limits as well as rules to discourage frivolous law suits. Limits on liability would have acted as a deterrent to plaintiff attorneys who saw easy money.

The physician extender market was escalating. The insurance industry saw an opportunity to devalue physicians. They categorized physicians, nurse practitioners, and physician assistants as Healthcare Providers thus implying an equality of value and therefore an equality of fees.

The mounting distortions resulted in physicians adjusting to the distortions. They ordered more physician visits and more procedures. The increase in malpractice suits lead to more defensive medicine. The result was more testing and more expensive treatment to avoid a malpractice suits.  The increase in the delivery of medical care led to higher Medicare payments and private sector payments as well. As a result the total gross Medicare and private sector payment obligations increased markedly over the next few years.

The major take home point of these examples is that price controls do not work. Price controls simply distort a free market system even further.

Everyone was in pain. The patients, physicians, government, and employers are all suffering. The insurance industry was prospering, but they feared they were losing their customer, the employer and can not keep up with their crazy insurance billing and payment practices. The lawyers were prospering at the expense of cost effective medical care (defensive medicine). The major stakeholders, the patients and the physicians were suffering because of the quality of care, the cost of care and the access to care. Interesting enough the facilitator stakeholders were starting to suffer as well.

What came next was even a sharper blow than previous blows to the effectiveness of our healthcare system.

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People Power plus Political Power is the Key to the Repair

Stanley Feld M.D.,FACP,MACE

The following email was recieved. I feel it is important to post this email on the main page because some of you might not read the comments. I thank Walt for his comment.

First we need Patient Power and Political Power will follow!

Dr. Feld,  I believe you’re on the right path.  By getting a posse rounded up and engaged in the hunt for a solution through sharing of information, insights, and observations of constraints, we may be able to get the political ‘help’ needed to effect change.  Are you working with Newt’s group here in Atlanta (


Dear Walt

I know Newt and he knows me. I have presented my ideas on Disease Management to Newt when he was speaker of the house. His response was this is a "BIG IDEA" .

He was then at a Human Resource and Information Technology meeting at Delta Airlines a few years later, after he left congress, where I gave a presentation. He loved my presentation and summarized it for an hour. He then invited me to visit him at his office in Washington. We went over the presentation in great detail. It was still a BIG IDEA in his mind. He told me he has quoted me often. However, I have never had followup from him nor have never been able to make contact with him since.

I have sent him the blog information. However, I suspect he has a fortress of  people creating blockades between him and the ordinary people like me, and they do not know me.  This information has probably never gotten on his screen.

If you know him please direct him to the site. He is a nice guy. I am convinced the concepts I am presenting will excite him. He theoretically understands the problem about the dysfunction of the healthcare system in my view. 

I am trying to get to the main stakeholders, the patients and future patients, in mass to appeal to people like Newt.  Newt could help greatly if he became engaged in my effort.

However, it is going to take "People Power" to turn this boat around, and not simply talking about turning it around. Coming from one person, the "BIG IDEAS" that will be presented in this blog will have little impact, unless people understand the problem and act. Anyone involved personally in the healthcare system or has a relative involved has felt the pain of the dysfunction. I am convinced we have the power to fix it and align everyones incentives.  One can not be passive anymore and simply make judgements to disconnected sound bites.

I believe the media has failed us. They have not provided real information in systematically connected way. I also believe connecting people in a systematic way with the same vested interest, protecting our health, and fixing the healthcare system is the power of RSS and the blogosphere. 

If you can help, it will be greatly appreciated

Stanley Feld M.D.,MACE

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Healthcare System vs. Medical Care System:Lighten up Dr. Feld

Download new_yorker_cartoon.jpg

Stanley Feld MD,FACP,MACE

Healthcare System vs. Medical Care System

A very impressive and thoughtful blog Procurement Central said today “I highly recommend Dr. Stanley Feld’s blog for those interested in a deep dive on this important area.”

I very much appreciate the recognition from Procurement Central.

My goal is to get every thinking person that is affected or will be affected by the healthcare system working toward the solution of the healthcare systems problems. Every stakeholder is involved. In order to understand the solution one needs to take a “deep dive” into the factors that created the problem. Only then can one buy into the solution that will align every stakeholder’s incentives. It must be remembered that the “Patient is First”. Please do not think of my blog as a “deep dive”. This can scare you away because you might not have the time for. I have gotten this reaction from a person in organized medicine that runs the socioeconomic department of that organization. I imagine the same thing happens in insurance companies’ managers, and with government officials’, hospital systems officials’ and physicians’ office administrators. Everyone is very busy going to meetings.

Please think of my blog as an intellectual exercise that can be transformed into action. Everyone has a responsibility to understand what needs to be done for your health and well being in the future.

You will notice I always use the term healthcare system and not medical care system. Physicians’ deliver medical care. Medical care is excellent for acute illness and for correcting the complications of chronic disease. In my opinion, and the Institute of Medicine as well, we are not very good at preventing the complications of chronic disease. However, physicians all over the country are trying to learn. The distortions in the healthcare system have to be corrected in order to improve our excellent medical care delivery system. If the repair of the healthcare system is done correctly, the repair will reduce price of care, cure the problems of access to care, and correct the 45 million uninsured problem.

Lighten up

Both my wife Cecelia Feld a world class artist (www.Studio and my son Brad Feld (Feld Thoughts) have told me to lighten up a little. So here goes.

Father’s Day was great. We stayed at Brad and Amy’s house over the weekend. You need to understand that Brad was my tech support person from the time he was 13 years old until the time he was 30 years old. In 1977, he bought the first of the Apple II computers with his Bar Mitzvah money. I had to make an additional $1500 contribution for all the accessories we, absolutely, had to have. It was clearly the best investment I ever made. I not only received tech support for 17 years free, but Brad has blossomed into an information technology wizard. In the last 10 years it has been difficult to get tech support from my son. We have joked about it often. His standard answer has been, “he did not know how to do what I needed help with”. Incidentally, I never believed him but pretended to not get the message.

This Father’s Day was special. Brad is rooting for me and my blog. We sat for 1 hour going over details on how to improve my blog presentations. As some of you might know Brad is a master blogger with a huge audience. Amy found the following cartoon while reading the New Yorker during our tech support session. The cartoon is a riot!


The caption reads " For Father’s Day, I’m giving my dad an hour of free tech support."


Dear Stanley:

A new comment has been submitted to your weblog "Repairing the Healthcare System," on the post "Do Complications of Chronic Disease really absorb Eighty Percent (80%) of the Healthcare Dollar?."

Great post.
Here’s my question.
Can the market be allowed to solve the problem? What if the cost scale for insurance was weighted based on the amount of preventative health steps one took?
What happens then?

The answer is the market can solve the problem! The government can not! The patient is the primary stakeholder and should make the market decision. However, they need to know what decisions to make and how to make them. There is enough information on the web presently to use as a resource if appropriately selected. I have given you a few clues to the solution already. I will put all the steps together as we get go along. The goal and purpose of the blog is to teach patients and futures patients what to do to fix the system. I hope the blog will also teach all the others stakeholders what to do, and how to stop spinning their wheels.

I need to have as many patients, future patients and physicians subscribe so that they understand the problem how we got here, and then understand the action they need to take toward the solution. Please encourage everyone you know to subscribe.

Thanks for your email Eric

Stanley Feld MD,FACP,MACE

  • Sam Garmon

    I think those New Yorker cartoons are protected under US copywright law

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Do Complications of Chronic Disease really absorb Eighty Percent (80%) of the Healthcare Dollar?



I received the following email a few days ago.

Could you please provide a reference that supports the 80% statistic ("Fixing the complication absorbs 80% of the healthcare dollar")?  I am not questioning this number, but I would like to read more about it.  Thanks!

There are many articles in the literature to support the 80% rule. Our focus is on Diabetes Mellitus a disease that cost society about $150 billion dollars.

The best recent reference is published in a story in the LA Times on June 19, 2006 entitled “Medicare Looks to Boost Seniors’ Use of Preventive Care.”

Mark B. McClellan Medicare administrator said in an interview “If you take a big step back and look at Medicare spending, 90%-plus of what we are spending is going for the complications of chronic disease.” He goes on to say “We can get healthier beneficiaries and lot lower costs related to complications if we can get more prevention.”

Medicare’s budget is $336 billion dollars a year. In some diseases, you can reduce the complication rate by 50% or more as shown by the DCCT (Diabetes Control and Complications Trial) NEJM 1993.

If we spend 90% of the healthcare dollar on complications of disease for persons over 65, and we can reduce the complication rate by 30% rather than the 50% or the theoretical 100%, the cost saving would be $90 billion. If we could reduce the complication rate by 50%, the savings to the Medicare system would be $168 billion. Then Medicare would not have to solve their increasing cost of care problem by reducing payment to physicians yearly, and restricting patient access to care.

Since Medicare is the payer of last resort, physicians have finally gotten the governments attention about the “Power of Prevention”. The 2007 Medicare handbook will focus on preventive care. Medicare will finally start paying for preventive care.

Complications of chronic diseases take a long time to develop. It has been estimated that Diabetes mellitus takes 8 years to discover from the time of onset of disease and the onset of complications even longer. Many times a high blood sugar is discovered when the patient is in the Cardiac Intensive Care Unit after having a heart attack. Coronary artery disease is the most common complication of Type 2 Diabetes Mellitus. If the blood sugar was controlled by intensive self management this complication could have been reduced 30-100% depending on the control of the blood sugar. There are many other complications in other chronic diseases states that the “Power of Prevention” will stop.

The private insurance industry has been very slow to pay for prevention of chronic complications. I imagine the thinking is “we pay for some things that are broken”. If something becomes broken, we will pay but raise the insurance premium or not offer the employers insurance next year. If you are self employed, simply getting older and at greater risk for disease might make it impossible to buy insurance.

How do we motivate the private insurance industry to pay for a future event that will not happen on their watch? A clue is that every State has a State Insurance Board that licenses the insurance company to sell insurance in that State. We, the people, have to do is educate our politicans, policy makers and State Insurance Boards and demand coverage for chronic disease from the insurance company in order for them to sell health insurance in our state.

There are many other things we, the people, will have to demand. We will get to them in time.

The LA Times article goes on to state that “some of the results have been disappointing to Medicare officials. 2% of eligible seniors have taken advantage of the physical examinations that are paid for. “Only 54% of male beneficiaries get Prostate Specific Antigen, or PSA blood test- prostate cancer screenings that are free."

Why is that? The presentation of the information is confusing to the elderly. The patients are afraid to be checked for fear of discovering an unknown illness. Patients do not understand the Power of Prevention. Patients lack economic incentives to participate in prevention.  Chronic disease management is not a strong card in the Primary Care physicians’ deck as I have stated previously. However, we, the medical profession, are trying very hard to improve the Quality of Care for Chronic Disease.

I will cover my opinions for the reasons for all of the above and more in future blogs.

The article is worth reading completely.    

  • electronic medical records

    This is a very interesting article on the new stimulus package including healthcare. I was actually very happy to hear about it and also believe in the innovations and upsides as well. But as I was blindsided and I think Obama was as well, the immediate reaction from this was the healthcare stocks dropped dramatically. It is kind of like a downward spiral for our economy. I truly hope that everything pulls together as we all are equal and we should all have decent healthcare as well.

  • Electronic Medical Records

    Many people with potentially life-threatening conditions cannot afford to buy the medications and supplies that keep their illnesses under control

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Where would you rather be sick?

Stanley Feld M.D.,FACP,MACE

A few days ago I wrote about USA Today article “Study: Canadians Healthier than Americans.” The take home message of the article was socialized medicine in Canada is better that the medical system in America. I pointed out that the article had many defects in study design. The data derived from the study was poor. The study did not prove anything. It did however simply add noise to the debate.

On June 15, 2006 the Wall Street Journal published and article “Where would you rather be sick?” This article was to be the answer to the Canadian study. The article pointed out some of the defects in the Canadian study. The article then went on to state the survival rates for treating illness is far superior in the U.S than in Canada. Therefore when one becomes ill it is much better to be ill in the US under our system of healthcare than it is to get ill in Canada under their system of healthcare.

For the students of my blog, the facts in the WSJ article have nothing to do with the defects in our system. These defects must be repaired. A system that has 45 million uninsured, restricts access to care, daily creates more and more economic strain on every stakeholder in the system, and has the key element of the system (patient care and the physician patient relationships) deteriorating has problems that have to be fixed immediately.

As stated previously, we, physicians, know how to fix things that are broken better than any country on the planet. The healthcare system must learn how maintain health before complications occur. Fixing the complication absorb 80% of the healthcare dollar. Our fixing the complication of disease is what is bankrupting the system. The system has not been set up to maintain health. It is trying slowly but we are not even close.

We can not get distracted by noise or “Fooled by Randomness” fooled by random data. We must state focused as we work our way to the solution. In order to do this we “the patients and potential patients” must think critically and dismiss the noise we are exposed to daily.

The Weekend

Cecelia and I came to Boulder, to celebrate our 43rd Wedding Anniversary and Father’s Day with my two boys, Brad and Daniel, their wives, Amy and Laura and our granddaughter Sabrina. It has been a fabulous weekend. Forty three years feels like yesterday and the ride gets better each year. We are tremendously proud of our kids and their families.

Cecelia rented a PT Cruiser convertible. We drove all around Boulder like two teenagers the entire weekend. Our kids were and are great to us. Thanks for the wonderful weekend!

Thanks Brad

I want to thank Brad to plugging my blog in Feld Thoughts. You can all help by sending the blog information to you email lists and asking everyone to subscribe. When I get into “what to we do to fix the system? ", I will need as many people from all walks of life as I can get to act to repair the healthcare system.

Thanks in advance for participating and helping !

  • BuddhaMouse

    Could you please provide a reference that supports the 80% statistic (“Fixing the complication absorb 80% of the healthcare dollar”)? I am not questioning this number, but I would like to read more about it. Thanks!
    Dear Buddamouse
    Here is a link to an article where Mark McClellan CMS Director calculated that 90% of the medicare cost is for chronic disease. This is a more recent figure than the 80% figure calculated by many previously.
    It is a gigantic problem and a gigantic opportunity to save the healthcare system
    Stanley Feld MD,FACP,MACE
    This is a good start. Search the Institute of Medicine site and you will get additional confirmation.,1,3824435.story?coll=la-headlines-nation&track=crosspromo

  • David Kelton

    Hi Dr. Feld,
    I’m in my residency in Canada and look forward to see where this blog takes you and your ideas!
    I will try and comment when I have time in between on-call duties. I thought I’d add two early comments in this note.
    The first is that I agree with your philosophy about personal empowerment in healthcare. Many years ago the providers were about 6-degrees of kevin bacon away from the patient. New concepts such as ‘patient-centered care’ are shifting that toward 2- or 3-degrees from true informed consumers of healthcare. I think the huge reforms will be seen as we get in the 1- or 2- degrees of separation between patient and healthcare – ie they make the informed decision to balance insurance costs/interventions/lifestyle etc.
    The second point that all these academic articles (and newspapers like USA Today) fail to consider the question, Who drives health innovation? The answer is clearly the US. Canada and other single payer systems operate on a stall and defer investment until public outcry/tragedy. The US churns through various models pretty quickly (with many ill side effects), but does select for true innovations in delivery of care which is so different than the areas of biotech, devices, etc.
    As much as Canada dislikes admitting it, we import all our health models after years of watching American experimentation in open delivery.
    I would argue without an open model, the world would be decades behind in health innovations (public school comparison here?).
    Just some early thoughts. Good luck!
    ps – i also write some of my thoughts about health care IT on (i love learning about healthcare startups)

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When will you Pronounce the Solution to the Healthcare System

Stanley Feld M.D., FACP,MACE

I received the follow email a few days ago.


These episodes are very good. To whom are they written? Public at large, I suppose. I am waiting for the final scenario in which you pronounce the solution!


Unfortunately, the solution is not a sound bite! It can not be pronounced. The solution must to be understood in the context of the problems evolution. My goal is to activate the public. The people need to demand control over their insurance dollar as part of the solution.

I believe strongly in individual responsibility and individual freedom. Individual responsibility and individual choice will be the driving force to the Repair of the Healthcare System. An activated public willing to put some skin in the game, and pressure on the politicians, hospitals, and insurance companies will fix the system. I need a large number of people to bang pots and make some noise that is focused toward a proper solution. No one will be interested in doing this until they know what has happen to their most valuable resource, the healthcare system, over the past 30 years. I suggest one reread the Preamble and the Introduction to the blog for hints about the solution.

Unfortunately, the healthcare system is almost beyond repair. When it collapses everyone will suffer. However, the people who will suffer most will be the patients and the medical profession, the system most important stakeholders.

This blog is an attempt to get patients and physicians motivated to step out and demand the proper solution. A patch that will benefit facilitator stakeholders will not do. Patches have been tried in the past and have failed. I plan to outline what patients, future patients and physicians need to do with explicit instructions down the line.

However, I need a posse’. You can help by emailing my site address to all the people you know and ask them to subscribe. I want to get people (physicians, patients, and future patients to read the blog, and buy into the solution. Our most precious possession is our health. We need to protect it. Barriers of Repair to the Healthcare System have developed, because all of the major stakeholders had to adjust to changes in the healthcare system in the past. All the stakeholders are good people just trying to make a living. However, their adjustments have led to a misalignment of incentives and further dysfunction.

Politicians look at numbers and public opinion. I call it the “Fax machine phenomenon”. One day no one had a fax machine and by the end of the month everyone had a fax machine.

Since all the stakeholders are in pain because of the dysfunction in the healthcare system, I am writing to everyone that could be affected by the system. Remember, I said no one ever ask the practicing physician or practicing patient how to fix the system.

I know your question is on the mind of many others reading the blog. Many want the solution so they can be the judge. As judge you can accept or reject the proposed solution without necessarily understanding the facts behind the solution. Most people understand we are the victim of a broken healthcare system. The usual comment made when I express my goal to fix the system is “Good Luck”. There is a lack of engagement by the only people who can really fix the system, the people affected presently and in the future by the system.

This can only happen if the people understand how the system got into this pickle. Only then will they become actively engaged in getting us out of the pickle. I will try to develop the story quickly so we can concentrate on the solution. I believe in any problem you must know how you got there in the first place. Only then can you know where to go. I also believe that people have tremendous power; they simply need leadership, inspiration and hope.

The blogosphere can democratize ideas to a great number of people and produce constructive action. I would appreciate if you would help.

Please send a blind copy to everyone in your email address book who would be interested in becoming engaged in the solution. .

Thanks for you kind praise. I hope you will help.


Stanley Feld M.D.,FACP,MACE

  • Walt Carter

    Dr. Feld, I believe you’re on the right path. By getting a posse rounded up and engaged in the hunt for a solution through sharing of information, insights, and observations of constraints, we may be able to get the political ‘help’ needed to effect change. Are you working with Newt’s group here in Atlanta (
    Dear Walt
    I know Newt and he knows me. I have presented my ideas on Disease Management to Newt when he was speaker of the house. His response was this is a “BIG IDEA” .
    He was then at a meeting at Human Resource meeting and Information technology meeting at Delta Airlines a few years later, after he left congress. He loved the presentation. He invited me to visit him at his office in Washington. We went over the presentation in great detail. It was still a BIG IDEA. He told me he has quoted me often. However, I have never had followup from him nor have never been able to make contact with him since.
    I have sent him the blog information. However, I suspect he has a fortress of people creating blockades between him and the ordinary people like me, and they do not know me. This information has probably never gotten on his screen.
    If you know him please direct him to the site. I am convinced the concepts will excite him. He theoretically understands the problem about the dysfunction of the healthcare system in my view.
    I am trying to get the main stakeholders, the patients and future patients, in mass to appeal to people like Newt. Newt could help greatly. However, it is going to take people power to turn this boat around. Coming from one person, the BIG IDEAS that will be coming will have little impact.
    If you can help, it will be greatly appreciated
    Stanley Feld M.D.,MACE

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The Next Step in Intensifying the Healthcare Systems Problems

Stanley Feld M.D.,MACE

A bizarre circumstance was beginning to occur in hospitals using DRGs (Diagnosis Related Guidelines). Patients with multiple diagnoses were being assigned multiple DRGs. The physician was required to sign the chart indicating multiple diagnoses. Each DRG had a fixed payment assigned to it. The payment for each DRG was unchanged, even if the diagnosis used excessive resources for that particular patient. This bit of irrationality occurred during the attempt to quantitate the value of care. Physicians developed the ability to give better care using more complex procedures. However, the physicians care was being limited due to the restriction of payment from the DRG system unless that cost of care could be compensated for by using multiple diagnoses and multiple DRGs. The DRG coding profession was born. People were trained to extract multiple diagnoses from the documentation in the chart. The more DRGs you had as a patient during a hospital admission, the more the hospital payment the hospital received.

Physicians reacted to the increase in documentation, surveillance, as well as the difficulty in getting pre-approval for care. The pre-approval of care limited the patients’ access to care. The paperwork was overwhelming. The paper work necessary to complete a claim, at times, was longer than the patient-physician encounter. If there was the slightest entry error in the claim, payment was delayed. Hospitals were more organized than physicians. The hospitals already understood the changing systems and processes. As a result, paperwork did not bother hospital nearly as much as it did physicians. They somehow compensated for the increased cost of processing claims. I will get into the compensation for increased cost of claims in more detail in the future.

A spending cap was placed on Medicare. The fees for visits and procedures continued to rise in both the private and Medicare sector. The physician had to learn to document and quantitate outpatient visits and procedures
The cost of delivering care continued to rise due to inflation and technology. The government permitted moderate increases in fees along the way. The phenomenon of cost shifting was becoming intolerable to the employers (Business) who were still providing first dollar coverage medical insurance for their employees.

Despite the price cap and spending cap, the cost to the government was getting further out of hand. The insurance industry was happy. It was the broker and collected 6% of the money spent in the system the more they collected for their fee. The private sector face 10-20% increases in insurance rates each year. The more money the system generated, the more the insurance industry charged the employer. The physicians and hospitals were becoming unhappy. Even though there was more money in the system, collecting the money became more costly and difficult. Their information systems could not keep up with the changes. The result was less profit. Business was becoming extremely unhappy because the cost of insurance for their employees was approaching 18% of their gross revenues.

What happened next served to intensify the healthcare system’s problems even further.

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What is Price Shifting(Cost Shifting)?

Stanley Feld M.D.,FACP,MACE

In the early 1980’s, the government made an effort to control its costs by regulating prices for encounters, procedures and diagnoses. We had terms such as Evaluation and Management codes (EM codes), ICD-9 coding, CPT codes and DRGs. The goal was to quantitate services and unify prices for each diagnosis. This was very confusing and complicated for the practicing physician. We went to hours of dull, descriptive lectures to learn what these terms meant. We tried to figure out how to participate legitimately. Quite simply, a system of price controls was imposed upon us. Price controls, in my opinion, never work no matter what the industry. These price controls set into play many of the serious economic misalignments all the stakeholders suffer in our healthcare system. Price shifting occurred. Hospitals had more money and more administrators than physician practices. The hospitals figured out what was going on and how to get around it before the physicians did.

Price shifting was simply the phenomenon of increasing the price of a service to another payer (Private Insurer) to compensate for the reduction in fees imposed by the initial payer (Medicare). If the institutions’ or physicians’ cost to provide the service was $75, they would charge the patient, Medicare, and the private insurer $100 and have a $25 profit. Medicare now said it would only pay $50. In order to compensate for the Medicare reduction in payment below the cost of the service, the fee for the service was increased to $150 to the private sector. The price charged did not take into account the institution’s or physician’s patient mix. Some hospitals and physician practices lost money because they had a high percentage of Medicare patients. Some experienced a windfall profit because of a high private pay population. The insurance industry did not protest because its revenue increased with the increase in revenue volume.

The plot thickens. I believe the solutions to the riddle are in the developing defects in the system.

  • Keith Sketchley

    You didn’t post my comment, but it appears that you sent me badly formatted email with links to articles (email had several insecure featurs).

  • new balance

    Success covers a multitude of blunders.

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