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All items for August, 2006


Physicians Have the Same Problems Patients Have!

Stanley Feld M.D., FACP, MACE
Physicians have the same problems. Dr David Westbrock’s knee story is chilling. Recently I received an email from a Clinical Oncologist. From the physicians point of view treating patients with chemotherapy in the office is more efficient and cheaper than sending them to the hospital for treatment. It provides one stop shopping for the convenience of the patient and generates Centers of Excellence in physician’s offices. It also promotes the physician-patient relationship.
The government is worried that physicians are going to cheat their patients by over ordering tests. Laws been written to “protect patients from their physicians.” The government laws figure that all physicians are crooks and will take advantage of their patients. Who is going to protect the patients from the hospital? The hospital charges for chemotherapy are three times the charges for the same treatment in the physician office. However, both fees are opaque. The physician fees are a little less opaque than the hospital fees. Many times the add on complications and procedures raise the price further in the hospital. Patients make little personal contact with anyone in the hospital. When the patient gets the very expensive bill who does he get angry at? The person he had contact with. His physician. This does not help the patient-physician relationship at all. I think about 50% of the therapeutic effect of treatment is the patient-physician relationship a relationship that is eroding at a rapid velocity because of the conditions of practice. Patients want to know why we are recommending a certain therapy. Instead today the patient get a call from the physicians nurse being told that the doctor wants you on this medicine and she will call in a prescription. The patient-physician relationship is not a commodity!
The following is John’s (the Clinical Oncologist) letter to me.

The two tier reimbursement system visa a vie community services and hospital services is enormously pervasive and threatens all community outpatient delivery. As an example, hospitals are paid and charge several times the fee that community oncologists are paid and charge for cancer chemotherapy drugs. All the drugs purchased by the hospitals and community physicians cost essentially the same dollar amount. Most hospitals get the benefit of somewhat lower drug prices. Have you ever seen a hospital charge sheet for cancer drugs? The patients treated have. It’s mind boggling. This healthcare policy is forcing community oncologists to send patients to hospital outpatient departments. In this very personal physician-patient relationship, this healthcare policy is destroying the physician-patient relationship that is critical to the care of the patient, with cancer.

Getting a hospital charge and Medicare reimbursement is a totally different thing. Seen inconsistently and usually when the patient wants to question this or that about a hospital stay. This, of course, is one of the issues. Very opaque. A patient cannot go to a hospital and ask the charge for 75 mg Taxotere. What Medicare or some commercial insurer will pay is also not available to the patient because what they charge and what is paid is totally disconnected. The patient can ask my office and I will tell them all the prices.”

As physicians we have the same problem patients have. The hospitals and insurance industry want to keep us blind to their charges and payments. In studying DRGs, I discovered an additional problem. When the patient receives an Explanation of Benefits (EOB) from Medicare or the Insurance Company one has no idea what was done to you in the hospital, or what medication you received.(see Dr. Augus Deaton letter). A patient told me that he received all generic drugs in place of his prescribed brand named drugs while in the hospital. I would suspect the hospital wanted to save money. However, was that DRG charge built on generics drugs as opposed to the brand name drugs ordered? I would suspect it was on the price of the brand named drugs although I will never know.
Remember Denise’s story. Denise had no power to negotiate anything. She paid retail for everything.
It is up to us to demand that opacity does not evolve to semi opacity to appease us. Semi opacity is worthless and does not help the consumer with prices. The system must go directly to real and accurate Price Transparency. Consumers (patients) have to be in a position to negotiate price. If they can not they can walk with their feet . This is the definition of “Patient Power.” Why are Americans buying Toyotas and not Ford, GM or Chrysler cars? We own the purchasing power. We figure out how purchase the best buy giving the best value for our hard earned dollar. My goal is to help you figure out how to do the same in healthcare.

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Consumer-Driven Healthcare Will Fail Without REAL Price Transparency!

Stanley Feld M.D.,FACP,MACE

If we are going to be able to Repair the Healthcare System REAL Price Transparency is a must. There is a lot of noise about Price Transparency by hospitals and the insurance industry but it is all pretend. I suspect there is going to be little change in policy until the patients, future patients and physicians as well demand REAL Price Transparency.

Augus Deaton an economist at Princeton tried to be a well informed consumer. In his “Letter from America, Trying To Be A Good Hip Op Consumer” he points out the problems he had seeking good value in his health-care and being an informed consumer. It is a worthwhile read if you want to see what the American consumer of healthcare is up against. Consumer driven healthcare is just talk and will fail unless we want to walk the walk. He points out the lack of available appropriate information and the total opacity encountered when information is limited.

President Bush “Bush Seeks Better Health Care Cost Information” and the people at CMS seem to really want to do the right thing. They will not get better information. Their problem is they are up against a powerful vested interest lobbying machine that has been successful at contaminating every good idea that might hurt them. There is a total resistance to change. The fact is the change might help the vested interest stakeholders. The change would certainly help the consumer of healthcare. President Bush’s only chance will be if we create a public opinion outcry. Once again who is responsible? Unfortunately, we are because our surrogates have let us down.

Medicine is big business and the facilitator stakeholders want to keep control of the big business of Medicine. Checking on quality care was impossible for Augus Deaton. Understanding his potential financial liability was an even bigger chore. Surprise billings were ubiquitous. He could not even know what he was covered for until after the service was rendered. This lack of transparency is ubiquitous in Medicine and not getting any better. Aetna claimed a Price Transparency initiative in 2005. It affected a small group in Ohio and covered only 23 services. This sort of Price Transparency is a relatively meaningless gesture and will not help repair the system. The initiative did generate a lot of sound bite publicity for Aetna at a small cost.

Ohio announced that it is going to publish their hospital DRGs. However, they will not be ready for more than a year. Publishing DRGs does not tell you what the insurance company or Medicare is going to pay for or how much. Wisconsin published their DRGs. It is enlightening but meaningless because you as a consumer can not do anything about the price.

Is this right? My answer is no! We, the people are responsible for making the demand, and demanding it now in an election year. If we are going to be purchasers of healthcare with our own dollars we need to know what we are buying.

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Look At This? Have You Heard It Before?

Stanley Feld M.D.,FACP,MACE

Last week I had a post entitled “Medicare backed off maybe?” Medicare announced it was delaying changing the ineffective DRG system established in 1983, to a system that reimburses on hospital cost rather than charges. I said maybe they have back down. I have been to this movie before. They never seem to back down even if there are defects in the new system that can easily be corrected. The policy usually gets instituted using another route.

The front page Sunday New York Times had a story entitled “Hospitals Grew with Medicare Paying the Way” exposes the abuses of the DRG system by St. Barnabas Hospital System. There is naturally a lot of disinformation in the story. However, the abuse is the result of defects in the charges based on the old DRG system. I asked previously; ‘how the various hospital systems have so much money to build, redecorate and buy hospitals?” I suggested; “hospital systems might have a special deal with the government”. One could start connecting the points after this Sunday’s NY Times story. The CEO also made a salary of 4.7 million dollars in 2003. I guess good help is hard to find.

“In 1998, Mr. Del Mauro received $613,000 from SBC, according to documents on file with the I.R.S. His compensation was $4.7 million in 2003, the last year St. Barnabas received the huge Medicare overpayments. In 2004, it was $4.2 million.”

However, St Barnabas is not the only hospital system in the country involved in the federal investigations of abuse. Some might remember when HCA was called “Columbia Healthcare Systems”. Columbia was expanding rapidly and investigated by the Federal government for Medicare abuse. The result was a penalty and reorganization.

“The episode at St. Barnabas, whose legal problems are not over, is part of a wave of Medicare fraud investigations that, according to a federal report, have reached more than 450 hospitals nationwide. Experts said the money involved could exceed $6 billion. “

“The way the system has operated, it’s almost irresponsible corporate governance for hospitals not to cheat Medicare,” said Patrick Burns, an analyst at Taxpayers Against Fraud, a leading watchdog organization.

Isn’t it bizarre? A facilitator stakeholder (hospital systems) take advantage of a defect in the system the government created (DRGs). Then the government sues the organizations that take advantage of the defect in the system that they created at a huge cost to both the hospital systems and the government. Who do you think pays for the legal fees? You bet. We do (the people.) Who do you think is wrong? The answer is both the hospital and the government. Shouldn’t the government do it right the first time? Shouldn’t we demand that the government does it right the first time? Shouldn’t someone ask the practicing physician and the patient what they think the right thing to do is? You bet! Are they? No!

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Déjà Vu All Over Again

Stanley Feld MD,FACP,MACE

I have stated that all of the stakeholders are at fault in creating a dysfunctional healthcare system. Most of the media articles are critical of the defects in the system, as well as the stakeholders abusing these defects in the healthcare system.

The last few weeks have highlighted a few defects. The defects have resulted in corporate abuse by the facilitator stakeholders. The government is trying to take steps to correct the abuses. However, no one in the media is trying to connect the points. It seems to me when something happens, it is reported. The public gets upset. Newspapers are sold. The story then blows over.

I believe the power of the internet, along with blogs and the development of topic specific search engines will be the vehicle that allows us to connect the points. We will understand the significance of the media stories. Understanding problems usually leads to populous pressure in America with a resulting change.

A few weeks ago HCA went private for 31 billion dollars. The result, the best I can tell from the internet financial information about a public company and the buy out terms reported, was the Frists walked away with about 8 billion dollars in cash and reinvested between $800,000 million and $1.6 billion dollars. Their ownership position went 40% to 14%. There is a great advantage to be a private company in the present healthcare system environment. The principle advantage is their financial position can become more opaque compared to the level of opacity presently. The problem is they have $25 billion in debt to service and pay verses 11 billion dollars before the leveraged buyout. The government cleared the way for the buyout

There only seem to be two ways to pay off debt. One either sells of assets or raises prices. Today, HCA announced that is selling a money losing hospital in West Virginia to CAMC Hospital Care System. The sale will stop the $2.4 million bleed since 2005 and add $19 million to its bank account.

This is occurring in an environment where Medicare is supposed to be calling for transparency in pricing. Price Transparency should benefit of the patients and the cost of medical care. The goal of Price Transparency is for patients to be informed healthcare consumers. They can then make responsible healthcare purchases at an affordable cost while being in control of their healthcare dollar.

Before the ink on the deal dried HCA raised their fees to the insurance industry. United Healthcare plan and HCA were very far from a contract in Denver. The 800,000 patients (the primary stakeholder) with United Healthcare insurance will have to find other hospitals and physicians in the Denver area if agreement can not be achieved by August 30. If they do not change hospitals and physician they will be liable for complete retail payment of fees. Yesterday, it was announced that HCA raised the price in the Florida market. United Healthcare has refused to accept the price increase on the grounds they can not afford the increase.

The question in the supposed environment of Price Transparency for the consumer (patient) is; “what is the justification for HCA’s price increase? I bet we will never know.
I suspect as each new contract comes up, we will see isolated small media stories about the price increases state to state and insurance vendor to insurance vendor. However to the nation, this will not be new news and will not be picked up by major media outlets. The problem will fade away. No pressure will be applied to solve the problem.

My guess is the best thing United Healthcare Insurance Company can do is drop HCA. In the Denver area, United has 800,000 people insured presently. Many of who use HCA’s hospital system for care. With HCA’s tremendous debt service and brick and mortar expenses, HCA’s prices will come down to manageable levels or the HCA hospitals will close as HCA loses contracts.

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My First Call for ACTION !

Stanley Feld MD, FACP, MACE

Every time I visit my sons and their families in Boulder I am asked to less write intensely in my blog. It is difficult for me. I feel a sense of urgency to precipitate action immediately before the system fails and medical care is destroyed.

However, during dinner one night, we were talking about the fact that I finally got an ice cream maker. I am a lover of chocolate ice cream. I have searched the world for the best tasting chocolate ice cream. So far the winner is Vivoli in Florence, Italy.

My wife and I are part of a supper club in Dallas called the Gourmet Group. The five couples have met every 6 weeks for the last thirty four years. Last month the meal was at our house. Cecelia assigned one couple to make Maida Heatter’s recipe “Doris Duke’s Bittersweet Chocolate Ice Milk.”

I discovered that I did not have to travel all over the world for the best chocolate ice cream. I had it in my dining room during Gourmet Groups dinner.

I have a fantasy that I can become a Chocolate Ice Cream Making Superstar. I then could have great ice cream any time I want. However, I need your help.

The Call for ACTION is:

If any one out there has an outstanding recipe for chocolate ice cream, please send it to me. I will make it in my new electric ice cream maker. I will make judgments about the quality and taste and then share the recipes and rating with all of you out there. I will also do some innovative things to the recipes to try to create the best chocolate ice cream ever made. Thanks for your help.

Stanley Feld M.D.,FACP,MACE

  • Neil Simon

    Glacier — in Boulder — has a chocolate flavor that is a knockout. Best I’ve ever had.
    From their website: “Death By Chocolate – Our homemade soft chocolate chunks mixed in a double dark chocolate base with a homemade hot fudge swirl.”
    Maybe they can give you some hints on the recipe.

  • Lori Tsuruda

    How did you ice cream experiments go? Did you like the chocolate pudding ice cream recipe?

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Why am I writing this Blog? Part 2

Stanley Feld M.D.,FACP,MACE

I was very moved by Ayn Rand’s Atlas Shrugged in 1957. I reread it in the late 1990’s. I listened to it on tape in 2000. Each time I read the book I saw more similarities to the events going on in our world today. I believe Ayn Rand recognized patterns very astutely. Her teachings are equally as fresh and pertinent today as in 1957. Societies have doers and moochers. Industries have been built on taking advantage of our current system of bureaucratic public administration.

Let us assume that the government is for the good of the people and directed by the people. Let us also assume that the current process oriented public administration of our healthcare system has mutated into an inflexible system on the brink of bankruptcy. One can not make minor modifications to marginally improve the system. Minor modfications can make the system a little better or a lot worse. The pressure to sustain the status quo by the bureaucracy, the advantaged stakeholders and the media is overwhelming. Change only occurs when we are all overwhelmed by the burden of the status quo. In healthcare we are almost at that point. Presently, all the stakeholders are hurting as medical care charges and prices are spinning out of control and out of the reach of all of the stakeholders. Even the moochers are hurting.

My son, Brad Feld, said to me a few months ago; “Dad if you think you have something to say then say it though RSS (Real Simple Syndication) and create a blog.

Songwriter Kris Kristopherson wrote in “Beat the Devil”: “he has a stomach full of empty and a pocket full of dreams” An old man at a bar buys him a beer and borrows his guitar. The old man then sings this verse;

“If you waste your time a talking to the people who don’t listen to the things that you are saying who do you think is going to hear. And if you should die explaining how the things that they complain about, are things they could be changing, who do you think is going to care. There were other lonely singers, in a world turned deft and blind, who were crucified for what they tried to show. And their voices have been scattered by the swirling winds of time because the truth remains that no one wants to know.”

Kristopherson goes on to say: “When no one stood behind me but my shadow on the floor.” “Lonesome is more than a state of mind.” “I didn’t beat the devil but I drank his beer for nothing and then I stole his song.”

He concludes:

“And you still can hear me singing to the people who don’t listen to the things that I am saying , praying someone is going to hear. And I guess I will die explaining about the things that they complain about are thing they could change hoping someone is going to care.
I was born a lonely singer, and I am bound to die the same, but I have got to feed the hunger in my soul. If I never have a nickel, I will never die ashamed because I don’t believe that no one wants to know.”

Kris Kristopherson’s song explains why I am writing this blog. I believe people want to know. I want to get the people “madder than hell and not take it anymore”. The BIG IDEA is people taking personal responsibility for their medical care and medical care dollar. I want the people to direct their leaders to develop effective system, and not a series of patches that do not work.

Thank you Brad.

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Why am I writing this blog? Part 1

Stanley Feld M.D. FACP, MACE

I have been asked this question many times. Many friends and colleagues all over the country have said to me;
“It is hopeless!”
“There will be no solution in our lifetime.”
“Good luck.”
“You are wasting your time.”
“We are too far down the road to be able to save this puppy.”
“The politics and economics are out of the control of physicians and patients.”

All of the above may be true. However, I believe it is essential that the healthcare system be repaired. I also believe it can be repaired. Any contribution that can made to it repair will be gratifying to me.

What makes me think I can do anything about Repairing the Healthcare System?

• I did something like this when I joined the American Association of Clinical Endocrinologist steering committee. As Woody Allen said in one of his movies, 80% of it is showing up. I showed up and became the third president of a nascent organization of 26 Clinical Endocrinologists from all over the country. These Clinical Endocrinologists were totally focused on putting the Clinical Endocrinologist on the medical map. Before AACE, the Clinical Endocrinologist was not a household word. I, to my amazement, helped, put the Clinical Endocrinologist and Clinical Endocrinology on the medical care map. Clinical Endocrinology is a great subspecialty of Internal Medicine. It was not recognized by Medicare as an essential medical subspecialty. We helped change that by publicizing the services and special training of the Clinical Endocrinologist to organized medicine, the government, the insurance industry and the patients. Most of the Clinical Endocrinologists in the country stepped to the plate to help create this recognition of their subspecialty. If I could help fix that situation, then fixing the healthcare system should not be a problem. The method is all a function of heightening awareness, and capturing the imagination of all of the stakeholders. If we could all focus on a higher goal of excellent medical care at an affordable price rather than improving the financial results of constricted vested interests, all of the stakeholders could all flourish with the minimum of pain and maximum creativity.

• My wife says I am an eternal optimist in every area of my life. I believe optimism is healthy, and vital to constructive and creative change. It is the American way! Every problem can be solved, if we understand the components that created the problem.

• I was taught that when you see a pattern do not be afraid to describe it. When I was an endocrine fellow at Massachusetts General Hospital in Boston, I saw a case that was never described. My attending said, “If you see something no one else sees describe it. It may make a contribution to our knowledge base and improve medical care in the future.

• I have always tried to understand the “why” behind the symptoms rather than simply act to fix the symptoms. As knowledge increases the patterns of the “why” something happens has become obvious. I believe it is because of the constant search for “why” something happens and not simply responding to the event. You will note that much of the media discussion is about responding to events and not the search for the reason for the event.

• I believe that America is a land of great opportunity. Things beyond belief can be accomplished if you believe you can accomplish them. The freedom of life, liberty and the pursuit of happiness is the engine that has generated America’s phenomenal accomplishments over the past 230 years. I have often told my sons; “If you are not on the edge you are taking up too much space.”

• As our society and government have become more complex some of the parts of America’s freedom engine have become ossified by bureaucratic hierarchies. Other parts of our freedom engine are as frictionless as they were in 1776. We were founded by optimists, a pioneer outlook and an entrepreneurial spirit. The goal presently should be to recognized the ossified parts and oil or replace them. The American people have the will to do it, if they only knew what to oil or replace.

• We live in an era that promotes a short attention span. Most of our news media is delivered by sound bites. Much is the information is unscientific disinformation as describe in Fooled by Randomness. Marshall MacLuhan described it beautifully in the Global Village and The Media is the Message. I am convinced Americans are smarter than this. Unfortunately, the medical care system is about to collapse. We have to start concentrating on the facts beyond the sound bites and demand solutions.

• America’s optimism, pioneer outlook and entrepreneurial spirit, invented the internet and Real Simple Syndication. RSS is reinventing how we communicate. The internet makes all source materials available at our finger tips. I remember in college the hours spent in the library searching for a obscure event or fact. Google finds it for me in 10 to 20 seconds. We do not have to rely on manipulated media driven by commercial vested interest.

• It seems to me with freedom of speech and advancing communication systems (RSS), eventually Americans will understand what has to be done to the healthcare system before it is too late. Someone usually comes along with a BIG IDEA at the right time. The BIG IDEA catches on like a grass fire. The demand for change can occur overnight. Some of you may remember the growth of the fax machine use. Its adoption occurred overnight. At the beginning of December 1982 few offices and homes had a fax machine. At end of December, all the fax machines were sold out and the back orders were huge.

• The BIG IDEA in medicine is personal responsibility for ones’ health and ones’ health care dollar. Neither the government, the insurance industry nor hospital systems should be responsible for our healthcare, our access to healthcare, or of control our healthcare dollar. We should and need to be responsible for our own care. We need the insurance industry and government to set some rules in the major stakeholders’ favor and let the market take over. A system needs to be put into place where we and not the secondary stakeholders control our destiny.

My blog is about us as a people getting to that position. I do not think the concept is difficult to understand or execute. However, no one is going to do it for us. We have to create the demand for it to be done.

  • Cleve

    Great post and keep it up. After 44 years of perfect health, my 45th was spent with doctors, labs and hospitals …the system is beyond Kafka. I’m no expert but I have a feeling that doctors will have to be the spearhead of change(with patients the driving force maybe?). So keep at it…please!

  • Fred van Beuningen

    The healtcare system collapses because it treats -by and large- symptoms and people’s lifestyles leading to societal diseases fuelled by industry eager to sell us fat, sugar and additives. Another -big- idea, empower people to live a healthy life. Translate old esoteric knowledge of healthy lifestyle into practical advice and reward people for the improvement of their lifestyles: inspires and leads to less costs. Shareholders in pharma need not to worry, they can buy other stock and have children too…

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What Have I Said So Far?

Stanley Feld M.D.,FACP,MACE

  • The patient is the most important stakeholder in the healthcare system. The physician is next. They are the primary stakeholders.
  • There would be no need for a healthcare system without patients and physicians. 
  • The government, the insurance industry, the employer, and the hospital are facilitator stakeholders. They are the administrators of the patients’ healthcare dollars. They are the secondary or facilitator stakeholders
  • Patients should be the administrator of their healthcare dollars.

It is easy to notice that most of the discussion in the media is about the facilitator stakeholders:

    • HCA going private.
    • HCA fighting with United Healthcare.             
    • Government changing DRG system to reflect hospital cost rather than hospital charges.
    • Insurance industry raising fees on health insurance.
    • Insurance industry restricting health insurance on self employed sick patients.
    • Hospitals have multiple tier fee schedules with uninsured charged the most.
    • Hospitals and medical device companies fighting off the government price reductions.
    • The government lowering physician payments.
    • The government mandating electronic medical records.
    • The government developing a pay for performance plan.

Unfortunately, we have been programmed to be information junkies. The media feeds scandals to us. We hunger for media reports. This media circus keeps us in a constant state of fear and anxiety. States of fear and anxiety are bad for our health. We also miss the essential questions:

  • How do we reduce the cost of medical care?
  • How do we provide affordable insurance for the 45 million people uninsured?
  • How to we provide affordable medical care coverage so that all the patients can have access to medical care?
  • How do we align all stakeholder incentives?
  • How do we construct a system so that all the stakeholders make a reasonable return on investment?
  • How do we close the holes in the system to eliminate abuse by stakeholders?
  • How do we restore trust between stakeholders?
  • How do we restore trust between the patient and physician?
  • How do we stop secondary facilitator stakeholders from continuously destroying the patient physician relationship?

I have suggested some solutions in the past few months. I will cover these solutions in greater detail shortly. Developing methods to achieve the solutions are in themselves business opportunities that can help society. The appropriate use of information technology can help greatly. These solutions have to be coordinated and introduced simultaneously. Unfortunately, the government with its present administrative structure and political influences will find it difficult. The solutions have to be market driven by the customer (the patient) in order to be accomplished. The patients have the power to drive the solutions with the government’s help:

  • Price transparency is an essential beginning. No only must the retail price be published but all of the discounted prices. The net effect of this complete transparency will be lower the prices paid on some services. I can visualize debate going on for several years with no resolution under the present systems. The voters must say we want real Price Transparency
  • Elimination of a two tier payment system with hospitals receiving more for procedures than outpatient physician office payments for the same procedure.
  • Consumer driven healthcare using Medical Savings Accounts and not Health Savings Accounts.
  • Develop Centers of Excellenceand Focused Factories both Hospital based and Outpatient Clinic based. Payment for service for hospital and outpatient clinic should be the same for educational services.
  • Payment for early evaluation and recognition of chronic disease
  • A sophisticated information system connecting the cost of medical care with financial outcomes and not simple incorrect algorithms to measure procedures needed for quality of care to be accomplished. 
  • Disease management to lower the complication rate for chronic disease and reduce the cost to the healthcare system by more than 45%.

These solutions have to be instituted with authority and leadership.

Responsibility for follow up care and compliance must be in the hands of the patient. The physicians are the teachers educating patients to be experts in their disease self- management. If patients do not comply there should to be a monetary as well as a quality of life penalty. The patient has to;

·         Be responsible for the purchase of care.

·         Have ready access to care.

·         Be responsible for the appropriate compliance for care and medication regime given by the physicians

If this is accomplished, and it can be, with the appropriate leadership and will of the public, we can turn this ship around.

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If You Know What To Do Why Do The Opposite?

Stanley Feld MD,FACP,MACE

Mark McClellan declared that 90% of Medicare costs are spent on the complications of chronic diseases. The Institute of Medicine has published that evidence based medicine for chronic disease is only practiced 10% of the time.

Osteoporosis and Diabetes Mellitus are two of the chronic diseases of the 5 big chronic diseases that clinical Endocrinologists’ have exceptional expertise in. These two diseases absorb a large part of the Medicare dollars. Osteoporosis and its complications absorb 20 billion dollars per year in direct costs. Diabetes Mellitus and its complications absorb 120 billion dollars per year in direct costs.

Evidence based medicine has demonstrated that with effective diagnosis, treatment and patient adherence to treatment of these diseases, we can reduce the complication rate by at least 50%. If 90% of the dollars for these two diseases are spent on the complications of these diseases, then 50% of 90% is 45% savings to the healthcare system. If we could translate evidence based medicine to clinical practice, we would save of 9 billion dollars for osteoporosis and 54 billion dollars for diabetes mellitus.
The total savings of 60 billion dollars would go a long way to repairing the Financial difficulties of the healthcare system. It would also go a long way to improving the quality of care for chronic disease in this country.

The distortions in the DRG system that evolved over the last 23 years must be fixed. Medicare was going to do something about it.

However, Medicare backed off by the weight of a well organized hospital association’s and medical device manufactures’ lobbying effort. Medicare backed off quickly as a result of this political effort. Medical care should not be politically driven nor its fate be decided by the vested interests of secondary stakeholders.

The solution to the medical cost problem is creating Centers of Excellence and Focused Factories. Systems of Care have been developed decrease or eliminate the complications of chronic disease.
Medicare has to reduce prices of the DRGs because it simply can not afford to pay the rising prices created by the old DRG system. Medicare has to reformulate a new DRG system. The excessive DRG charges are the main source of the uncontrolled healthcare costs to treat the complications of chronic diseases.

Who is the next candidate for a cut in fees? The physicians are of course. We are the most unorganized and least effective political force. We are losing members in the AMA and local organizations at a rapid rate. Unfortunately, the AMA has lost its effectiveness. Physicians have walked out with their feet and their dues.

I mentioned the 5.1% per year reduction until 2010. There is also a proposed cut in the payment for Bone Mineral Density testing. The BMD is the gold standard in the early diagnosis of osteoporosis. A note from the American Association of Clinical Endocrinologist states;

Dear AACE Member:
AACE is partnering with the International Society for Clinical Densitometry (ISCD) in conducting an online survey to respond to the Centers for Medicare & Medicaid Services (CMS) recently proposed dramatic cuts in reimbursements for DXA (from the current ~$140 to ~$40 by 2010) and Vertebral Fracture Assessment (VFA) (from the current ~$40 to ~$25 by 2010). These cuts will be in addition to the already-enacted imaging cuts outlined in the Deficit Reduction Act of 2005.

“AACE needs your assistance to assure that the work required for the performance of quality central DXA and VFA is accurately presented to the CMS by August 21, 2006. Therefore, your participation in this online survey is critical to our response to CMS.

This survey must be electronically completed no later than Thursday, August 10.
However, only online surveys will be considered. Estimated time of completion for the online survey is 45 minutes”

I am sure many physicians would want to complete the survey. However, few have the time to devote 45 minutes in a day to complete the survey. The American Hospital Association and the Medical Device Manufacturers did not have to complete a survey for Medicare to back off. Why can’t Physicians do the same for the good of patient care?

If Medicare wants to increase the quality of care for chronic disease and decrease the complication rate, cutting the BMD fee is absolutely the wrong way to go about it. The proposed payment for bone density is lower than cost of service. It is counter-productive to the goal of developing centers of excellence for the diagnosis and treatment of osteoporosis.

From my experience, the present level of reimbursement is low for Bone Density testing. Medicare reducing the fee to $40 is not an incentive for Clinics to even think of doing Bone Densitometry and increasing their quality of care for a silent disease that only generates a chief complaint when the complications of the disease occur. The specialty seeing the most patients at risk for osteoporosis are Family Practitioners. Medicare should help develop centers of excellence for osteoporosis so the Family Physician can have incentive to diagnose and treat these patients before the complications of osteoporosis occur. Family Practitioners are struggling to survive. They are not going to create a Center of Excellence that loses money.

Another important question is how much Medicare is going to pay the hospital for a Bone Mineral Density. Remember Dr. David Westbrock’s knee story. Medicare paid the hospital 3 times the amount it pays for the same x-ray in a physician’s office.

Something is wrong with the administrative system, and the patches it applies simply make the healthcare system worse.

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