Stanley Feld M.D.,FACP,MACE

In response to my last blog,” Can You Believe This? UnitedHealthcare Is Committed To Improving the Healthcare System”. I receive this comment: “Believe it or not UnitedHealthcare is trying to repair the healthcare system and becoming user friendly?”

Just after I received that comment four articles appeared in press this week demonstrating that UnitedHealthcare is becoming less user friendly and continues to march forward to try to shut out the competitive environment necessary for constructive reform of the healthcare system.

This sort of information is immediately available through the broad reach of the internet and blogosphere. Ordinary citizens can now monitor events and actions occuriing throughout the country. We can instantly see the inconsistencies.

The major stakeholders in the healthcare system are the patients and the physicians. All actions taken by facilitator stakeholders should be for the improvement of the delivery of care by the physician to the patient. Judgments about patient care should not be directed by the facilitator stakeholder. It should be directed by the patient. Patient choice should not be limited by the facilitator stakeholder. The key to repair of the healthcare system is a competitive environment for the delivery of care and care driven by the patient.

Apparently this is not UnitedHealthcare’s goal.

The St. Petersburg Times published the difficulty physicians and patients are having with UnitedHealthcare about laboratory work. The most convenient place to have laboratory work done is in the physician’s office. One stop service is a great convenience to the patient in an over stressed medical encounter. This is not permitted by UnitedHealthcare even if the physician office is less expensive that one of their designated laboratories.

“The Connecticut State Medical Society has written to the state attorney general about United’s exclusive contract with LabCorp, saying the company has a limited number of facilities in its area.”
“If I give a patient a script for LabCorp, but they go to the Quest Lab in my building because it’s convenient, do I get fined?” Wasylik asked. “The insurer allows a patient to have out-of-network benefits. But if they use them, they punish the docs. That doesn’t make sense.”

It certainly does not make sense. Worse, it is a direct contradiction to developing a more user friendly healthcare system UnitedHealthcare professes in its advertisement in the Wall Street Journal March 19,2007. It simply forces the patients and physician to be more captive to its controlling tactics.

The AMA provided another contradiction to UnitedHealthcare’s advertisement.
“In a press release, the AMA said it sent a letter in strong opposition to the merger to U.S. Attorney General Alberto Gonzales. The AMA said that it has “deep reservations about United’s goal of dominating the Nevada health insurance market, and in particular the Las Vegas market, by purchasing the state’s largest insurer.”
AMA Board Member James Rohack, M.D. said in the letter, “Federal authorities must not allow United’s blatant grab for dominant market power. The proposed merger would have negative long-term consequences for patients, physicians, hospitals and employers.”

“If the proposed merger is allowed, the AMA estimates that United would control 78 percent of the HMO market in Nevada, and 95 percent of the HMO market in the Las Vegas-Paradise metropolitan area.
It looks like UnitedHealthcare’s plan is to limit the competitive environment.

Then another inconsistency appeared in San Francisco. “United Healthcare under fire over pay” was the headline of a San Francisco Biz Journal article
California Medical Association wants state investigationThe CMA, which represents 35,000 doctors statewide, wants the state Department of Managed Health Care and the Department of Insurance to see if reports of widespread delays, underpayments and other errors on doctors’ contracts by the giant Minnesota-based health plan are the result, as the doctors’ group says it suspects, “of a significant lack of administrative capacity.”

A lame excuse when UnitedHealthcare’s profits and executive salaries are so high.

These are just a few of the examples I picked up on the internet this week. They are a total contradiction of UnitedHealthcare’s advertisement of March 19,2007 in the Wall Street Journal.

Before we can believe UnitedHealthcare really means what it says, it must show us it is ready to repair the healthcare system rather than continue to destroy it.

Stanley Feld M.D.,FACP,MACE

UnitedHealthcare had a full page ad in the Wall Street Journal Monday, March 19.2007. There is a temperature thermometer in the top left hand corner on a red page implying something has a fever.

They have to be joking. Doesn’t UnitedHealthcare understand it is a major contributor to making the healthcare system sick?

UnitedHealthcare has a terrific tag line “UnitedHealthcare Healing Healthcare. Together.” It is a great grabber but has little meaning.

The advertisement defines the healthcare system’s illness.” They say the healthcare system isn’t healthy. There is no denying it. A system that was designed to make you feel better often just makes things worse. Costs are out of control, access is inconsistent, quality is too variable and the entire process has become unwieldy.”

UnitedHealthcare claims that costs are out of control. Why? Who paid their CEO 1.8 billion dollar over 8 years? The amount equals 300 million dollar a year in salary and benefits to one person. UnitedHealthcare. What are the other top executives at UnitedHealthcare receiving in salary and benefits? Do you think these salaries affect the cost of insurance?

UnitedHealthcare has made access to care inconsistent. Ask any physician caring for its members. Is its pre-certification system and the restriction of access to care dangerous to its members’ health. Ask its members. The key question is “am I covered?”.

I am convinced UnitedHealthcare can not define quality properly. In my experience insurance companies define quality to their economic benefit and not the patients or physicians. Remember Dr. Petak’s example with Blue Cross/ Blue Shield of Texas. UnitedHealthcare can not possibly define real quality medical care with the claims data it has available.

Is the process unwieldy? You bet it is. Who creates all the paperwork for physicians so they have less time to spend with their patients? United Healthcare! Who rejects or modifies claims payment resulting in physicians and hospitals appeals leading to more paper work and more cost? United Healthcare! Does this increase premium cost. Most certainly.

The advertisement goes on to say “Every day, more Americans are added to the rolls of the uninsured.”

Who wants only to insure non sick or at risk people? UnitedHealthcare! A fifty year old Type 2 diabetic with hypertension and elevated cholesterol lost his job. He is now self-employed. He can not quality for an individual health insurance policy for him and his family from UnitedHealthcare because he is a high risk patient. UnitedHealthcare is required by law to insure him in a group policy if he was employed by a company that qualified for UnitedHealthcare’s group insurance. UnitedHealthcare has simply raised the premium on the group health insurance to his employer because they have high risk employee’s until the employer could not afford to provide insurance for the group. This patient profile makes up the profiles of two thirds of the uninsured in America today.

“There is an epidemic and it’s time we found a cure.” No kidding.

They go on to say; “At UnitedHealthcare, we are committed to improving the health care system. We aim to take what’s wrong and make it right. “

A welcome change of heart, but what is their plan?

“Simplifying everything and eliminating red tape.
Ensuring access to the right care anywhere in the U.S.
Empowering you to make better decision about your health 24/7
Providing information to doctors to better support people
Rewarding first-rate physicians for first-rate medicine.

All while making your health care more affordable.”

UnitedHealthcare figures we are a “Sound Bite Society” and in my opinion they decided to feed us a couple of sound bites to make us happy. TXU tried to do the same thing in Texas while destroying our health by wanting to build 11 dirty coal plants.

To my surprise, Texans came through. We did not buy the sound bite. We are smarter than they think we are. It is painful to understand the details of most issues but somehow we Texans rallied round and did let them sneak their sound bite through. Enough is enough. We need leadership and action, not words. We are smarter than they think.

I hope the country is ready to reject empty promises from UnitedHealthcare. Let them show us that they are going to reform their ways with deeds and not throw disinformation our way.

In conclusion the UnitedHealthcare”s adververtisement states;

“ Will all this be simple? No Simple doesn’t mean simple-minded. Sometimes simple means ingenious. Sometimes it means revolutionary. And no one is better prepared to lead this revolution with you that the strongest, most committed health care company in the nation. Simpler process, smarter solution, better results for you.
UnitedHealthcare Healing Health care. Together.

The UnitedHealthcare advertisement compelled me to look of the definition of disinformation in Wikepedia.

Disinformation is the deliberate dissemination of false information. It may include the distribution of forged documents, manuscripts, and photographs, or propagation of malicious rumors and fabricated intelligence. In the context of espionage or military intelligence, it is the spreading of deliberately false information to mislead an enemy as to one’s position or course of action. It also includes the distortion of true information in such a way as to render it useless.
Disinformation techniques may also be found in commerce and government, used by one group to try to undermine the position of a competitor.
Disinformation differs from propaganda in that its true source is concealed, and it usually involves some clandestine action. Unlike propaganda and Big Lie techniques designed to engage emotional support, disinformation is designed to manipulate the audience at the rational level by either discrediting conflicting information or supporting false conclusions. Another technique of concealing facts, or censorship is also used if the group can affect such control. When channels of information cannot be completely closed, they can be rendered useless by filling them with disinformation, effectively lowering their signal-to-noise ratio.

Is this advertisement disinformation or propaganda or both? Does UnitedHealthcare think we are stupid?

UnitedHealthcare has to show us what they are going to do and do it. Not throw sound bites at us.

Stanley Feld M.D.,FACP,MACE

Readers of my blog Repairing the Healthcare System have realized that I am developing a story of why the healthcare system is dysfunctional and the steps necessary to repair it. I have described some of reasons for the increasing costs; the 46.7 million uninsured and the restriction to the access to care.

I am also developing a story on how to repair the healthcare system. All of the entries are interconnected. They all should be linked. I have linked some of the posts. The links can be reached by clicking on the words that are in maroon and underlined.

When my son Brad Feld and I spent our weekend in Las Vegas, he said, “ Dad, you need Ligit. I will send you the link and put it on your blog.” Ligit is one of Brad’s portfolio companies. It is wonderful.

According to Ligit, “Lijit allows you to create your own search engine (in a very slick and pretty automated way), which searches your blog, blogroll, bookmarks, photos, etc. By placing the Lijit search Wijit on your blog, readers can search your collective goodness and receive amazing results. In turn, Lijit gives you information about the searches performed, such that you can get a better understanding of your reader community”.

I used to go crazy, wasting a lot of time finding related links in my blog to refer readers to. I now simply search through Lijit.

You can find Ligit at the bottom of my blog on the right hand side of the page. All you do in put in a topic you want to search for. Ligit will bring up all the blogs that mention that topic or keyword.

Readers could start using Ligit to dig deeper into the connections on my blog. Ligit is powered by Google. It presents the search information that same way Google presents information.

For all those out there with their own Blogs I suggest you install Ligit.

Stanley Feld M.D.,FACP,MACE

I have mentioned mistrust by physicians of the insurance industry, the government and hospitals. I have also pointed out the invaluable potential of the Ideal EHR in helping physicians increase the quality of care delivered without being penalized by the insurance companies and government. This mistrust is part of the reason for delayed adoption of information technology by physicians.

Steven Petak M.D., J.D.,FACE, FCLM, current AACE(American Association of Clinical Endocrinologists) President wrote an important editorial in First Messenger (the Newsletter for the AACE) illustrating the danger Information Technology presents as a tool against doctors by Blue Cross/Blue Shield of Texas.

BC/BS of Texas data collection resulted in a defective value judgment of Dr. Petak’s quality of care. BC/BS information technology system made that judgment measuring the wrong thing. BC/BS clearly did not understand the use of a specific drug. Dr. Petak is an excellent doctor as are others in his group. Blue Cross/Blue Shield of Texas did not bother to ask Dr. Petak why he did not practice evidence-based medicine while using the drug metformin.

BC/BS of Texas simply awarded Dr. Petak with a gray ribbon (which is bad) for the whole world, his patients, and potential patients who have insurance with BC/BS of Texas, to see. A dark blue ribbon in the Texas Blue Compare program of Texas Blue Cross/Blue Shield stands for excellent. A light blue ribbon is defined as good or average. How would you, as a patient, like to be going to a bad or average doctor? You wouldn’t!

The ribbon classification is available for all the BC/BS of Texas insured patients. It is an attempt at quality transparency for the benefit of their insured members. The coveted dark blue ribbon would indicate to the world that physicians have mastered applying evidence-based medicine and cost efficiency to their patients. Dr. Peak states “ The dreaded gray ribbon would only communicate my shame and wanting to the world. Although a gray ribbon is defined as not being able to provide a measure because of insufficient data for the physician or specialty or their threshold was not met, I knew my hard won reputation for excellence would now be lost”.

What did Dr. Petak do wrong? He failed to meet the evidence-based requirements concerning diabetes care. He did not do enough eye exams, HbA1c, and urine microalbumin assessments. Metformin is used to treat diabetes. Dr. Petak does not treat Diabetes Mellitus and had so informed BC/BS. He did not submit the claim form with a diagnosis of Diabetes Mellitus. He sees many patients with Insulin Resistance Syndrome (Metabolic Syndrome). Metformin is used in the treatment of Metabolic Syndrome by many specialists. Many female patients with Metabolic Syndrome do not ovulate. When the insulin resistance is treated they can ovulate and become pregnant.

Patients can buy metformin for $4 per month at Wal-Mart. If they had a successful ovulatory cycle and became pregnant, the patient has avoided the multiple tests and procedures of in-vitro fertilization. The saving to the patient in stress, anxiety and money is enormous. The savings to the entire cost to the healthcare system is great.

What was BC/BS of Texas’ problem? The problem was a lack of understanding of medical care. They did not evaluate Dr. Petak with accurate or useful information. Their computer system did not search for the diagnosis of Diabetes Mellitus. They assumed he was treating Diabetes Mellitus. They did not ask Dr. Petak why he used metformin. They simply penalized him. They only evaluated him with one of the elements of quality care. They simply used the tests that should be performed at a given interval in treating a diabetic. BC/BS was only interested in showing the world they are a great company protecting their patients from bad doctors. They had no concern for the physicians’ reputation or the physician-patient relationship.

There are other of examples of insurance companies evaluating quality care with the wrong criteria and presenting physicians with report cards that seem meaningless to me. This is part of the reason there seems to be such resistance to the Pay for Performance. It is simply mistrust by the patients of the insurance companies and the government. Both have declared they want to gain our trust. However, they continually act in a way that creates an environment of mistrust.

Bravo, Dr. Petak for publishing this example. The ideal EHR must be set up so it is physician friendly and a physician extender. It should not be a weapon to be used against the physician.

Stanley Feld M.D.,FACP,MACE

If you ask a number of physicians to define quality medical care, most will come up with a definition close to the Institute of Medicine’s definition.

IOM Definition of Quality:

“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

Systems of medical care are necessary to reproduce the results of clinical trials for chronic disease. How does one develop a system of care to decrease the complications of chronic diseases? One must divided the elements of quality medical care into separate modules. The result should be the improvement of medical care outcomes.

Quality of Medical Care should be defined specifically to include all the elements of quality care. Continuous quality improvement means improving the processes used in fulfilling each element of quality care.

The elements of quality care are as follows:

1.Recognize patients at risk for diseases
2.Do appropriate evaluation
3.Make the appropriate diagnosis
4.Start the appropriate treatment
5.Schedule the appropriate follow-up
6.Stimulate the appropriate compliance/adherence to treatment

Goal is to decrease complication rate, morbidity, mortality and cost of care

Three of the six element of quality medical care can be automated by the ideal EHR. Three of the elements require physician judgment and patient participation.

1. Recognizing The Patient At Risk

The following are screening procedures to detect disease early so preventative measures can be taken:

a. Cholesterol and HBA1C measurements every 5 years if normal
b. Fecal occult blood yearly after age 50
c. Flexible sigmoidoscopy/Colonoscopy every 3-5 years after age 50
d. Clinical breast exam yearly
e. Mammogram yearly after age 50
f. Pap smear every 1-3 years
g. Clinical testiscular examination once a year
h. Digital rectal exam yearly after age 50
i. PSA yearly after age 50
Vaccines
j. Influenza yearly
k. Pneumococcal once after 65
l. Tetanus/Diphtheria every 10 years
m. Hepatitis A once
n. Hepatitis B once
o. Osteoporosis indications for bone density
WOMEN
All using steroids > 65 > 40 with low trauma fracture > age 45 with risk factors

One can easily see that the EHR can cue the physician to screening tests and timing vaccinations automatically. Automating this process of quality would increase the detection of disease early. Appropriate timing of vaccines can prevent disease. The patient could also receive advanced notice of screening procedures due through the PHR (Personal Health Record) module of the Ideal EHR.

2. Appropriate Evaluation

The appropriate evaluation is at the physician’s decision using his medical judgment. The physician’s clinical judgment is the most important element in the diagnostic decision. Options could be provided by the EHR. However, it remains the physician’s judgment. He could elect a less invasive test for some illnesses depending on the patient and the patient’s circumstances.

3. Make The Appropriate Diagnosis

The physician has to interpret the test with the patients history in mind. He has to read the studies with an expert if he has an incomplete report. There are many subtle changes in laboratory studies that indicate disease and can not be picked up by a computer. Guidelines should be provided. An example of what I am talking about is the early detection of a low bone density secondary to both osteoporosis and a vitamin D deficiency. The calcium will be normal to low or high, the phosphate low normal, the alkaline phosphatase high normal. This is a clue to osteomalacia secondary to vitamin D deficiency. Further testing is necessary to make a diagnosis that would otherwise be missed and blunt the effect of the appropriate therapy.

4. Starting The Appropriate Treatment

Starting the appropriate treatment is the physician’s decision. The evidence based medicine could be connected to the EHR. The clinical outcome of his decision could be available for his own education by the EHR.

5. Scheduling The Appropriate Follow-up

Scheduling the appropriate follow-up can be done at the point of physician service through the EHR. The physician can be guided by evidence based medicine guidelines instantly. If it is important to see the patient sooner the physician can override the guidelines and justify the visit.

6. Compliance/Adherence To Appropriate Therapy

Compliance/adherence to appropriate therapy is essential for improved outcomes. The compliance/adherence rates reported in the literature are awful. The range is 10% to 50%. There is too little emphasis on the patient’s responsibility to adhere to medical therapy. However, patients live with their disease 24 hours a day and should have the burden of being responsible to adhering to therapeutic regimes. The defect is that the patients often do not understand the significance of the therapy. Patient education is essential. Patients have to become the Professor of their disease. The physician has to be the educator himself, or with the use of physician extenders. Education by built in information to the PHR (Personal Health Record) can help. Interactive patient interactive sessions can also help. If the patient does not take the medication we can not hope for improved outcomes. The physician can track the patient adherence through electronic communication with the pharmacy to determine compliance through refill frequency. The EHR can automate this conduit of adherence.

Quality medical care is not only about evaluating patients at risk. It is only the first step in quality medical care. The other five steps are just as important. I tell physicians it is not about how many bone densities you do, or how often you measure the HBA1C for diabetes mellitus, it is about preventing osteoporotic fractures, and decreasing the complication of diabetes mellitus.
Practicing the process of quality medical care should decrease the complication of chronic disease. The translation of evidence based medicine to clinical practice is a continual process of quality improvement. The ideal EHR could help greatly in achieving this goal.

Stanley Feld M.D.,FACP,MACE

After the last post I received the following comment.

“But here’s the problem. How can you keep government agencies, malpractice lawyers, and so on from accessing an EHR? They can subpoena written records or EHR’s, but the ability of sophisticated computer users to hack into an EHR system is what gives a lot of us ordinary folks the willies.”

This is a comment that always comes up. I believe the software companies with electronic medical records can answer the question better than I can. I have asked the question of security to many software companies who create EHRs and EMRs. Their answer has always seemed satisfactory to me.

Other industries seem satisfied with the security they have. The banking industry is elated with the savings and efficiency of online banking. I should think security in banking is as much of a privacy concern of people as medical records. Paper records all over the place in laboratories, physicians’ offices and hospitals never seemed very secure to me. One of my son’s (Brad Feld) portfolio companies “Still Secure” has created a software package that creates a fence around the computer server which makes the server is totally invisible to incoming and outgoing data. The thirty four year old CEO of Still Secure, Rajat Bhargava, is one of the brightest people I have ever met.

I spoke about the EHR cueing the Primary Care Physician to evidence based medicine tests, procedures and treatments. It is practically impossible to remember all the screening procedures that need to be done while treat care of an illness that brought the patient into the office. If done automatically, this would increase the quality of medicine practiced.

The malpractice attorneys’ opportunities would disappear if the governments, both state and federal, had the courage to pass realistic malpractice reform. Unfortunately the reform is occurring too slowly and sometimes incorrectly. The practice of defensive medicine has wastefully increased the cost of medical care.

If a patient has not seen a physician in a year, then visits with a common cold, there might be several screening tests due for the patient. If the patients chart is thick, it might be difficult to find the PSA (Prostatic Specific Antigen), rectal for blood, or chest x-ray in the paper chart as there is pressure to see the next patient. In an electronic chart all of this data can be presented at point of service to the physician. The physician can then recommend the evidence based screening test to the patient. There is simply too much information to keep in one’s head. The patients can decide, with the doctors help,which screening test they want done.

If the patient went to several physicians and had a Personal Health Record, the doctor would know instantly if the patient had the test at another physician’s office. The test and treatment could be available to the present examining physician. Having this information available could serve to discover disease early, avoid costly complications and save lives.

Physicians are always checking the literature to see the latest treatments, complications or drug interactions. Most physicians have computers in their office. In recent years rather than going to their textbooks which are outdated as soon as they are published they go to Pub Med, various journals or organized medicine sites to get the latest information. To get the latest information on a drug they do not turn pages in the PDR anymore. They go to the online PDR or pharmaceutical web site. Internet access in a typical practice day can be invaluable.

In an Ideal EHR all of this information would be at the physician’s fingertips at the point of service. The physician would have to learn to use the computer as a physician extender. He must learn to treat the patient and not the computer. He must remember that a positive patient physician relationship has great therapeutic value. Personal contact and communication is vital to the therapeutic effect. My good friend, Dr. Richard Reece, a noted healthcare policy expert pointed out graphically this potential hazard in his excellent and funny blog post The Chart Before The Horse.

I believe with the ideal EHR both the patient’s and physician’s privacy can be protected. Actually, there should be a reward. The companies manufacturing the EHR should be able to provide the data to prove the increase in quality care automatically. I spoke about eliminating the barriers to improving medical care. The EHR can provide information to both the physician and the patient to increase the quality of care patients receive. Instruction to the patient can be printed in detail or sent to the patient online to their PHR.

There should be nothing about this transaction that gives patients the “willies”. It can only improve the delivery of care.

Stanley Feld M.D.,FACP,MACE

Some very good Electronic Health Records have been created. Last week, I received an excellent comment from Dan Schmidt, whose practice bought one of these very good EHRs. The views and pain he relates is exactly why quality Electronic Health Records have not gained traction with physicians. Dan has one of the best EHRs in Centricity by GE Healthcare. Actually Centricity is potentially an excellent product. GE Healthcare has invested heavily to solve the EHR problem. They manufacture and sell many products for the healthcare system. One problem they have is that the various products are not interconnected with their EHR.

Centricity is a relational data base that converts data points of information into word paragraphs. It provides a good looking electronic medical record, gets paper off the desktop and charts off the shelves. GE Healthcare is on the right track with Centricity. Centricity is capable of being what I believe is the Ideal Electronic Health Record. However, it misses on several counts. Why? Because they never asked the physician what his problems are. Again if they did ask some physicians, the physicians probably did not know what they needed.

Dan Schmidt M.D. expresses the problem beautifully.

“I believe the resistance in Primary Care to EHR is a reflection of the cynicism that has become pervasive.

So the problem, as you stated, really comes down to what does the physician expect from an EHR? There are lots of good products…We installed and ran Logician (Centricity) for 7 years in a primary care office. Paid for it ourselves, with no government support,,,,And now we have a huge data base that we don’t have the time or capital(manpower) or enthusiasm to institute quality improvement…”

My reaction to Dan’s comment is the following;

1. Dan knows what he needs. He has to have the important questions about the effectiveness and efficiency of his practice answered with his electronic health record. These questions are not answered because he does not have the time or capital to get them answered. The answers to his question have to be built into the EHR as he is creating the patient data at the point of service. The data analysis should be for his education. The data should not be for the insurance company, the government, or some malpractice lawyer to use against him.

The Institute of Medicine has said only 10% of physicians practice evidence based medicine. A relational data based information system can cue the physician to the practice of evidence based medicine. This system must be built into the EHR. The physician is then free to use his judgment. Centricity’s EHR has this capability. It is not available to Dan Schmidt because of the added cost of capital or time. If our goal is continuing quality improvement, physicians need the tools for continuing quality improvement. These tools have to be immune from liability in order for the physician to be interested in using an EHR.

2. The care to the patient has to be connected to the financial cost of the care as well as reimbursement for care. The cost of care includes pharmacy charges and hospital charges. The prices must be completely transparent to the physician. Most physicians have no idea of the cost of various drugs. If they knew they might order less costly drugs. Presently, Pharmacy Benefit Managers tell us what we can prescribe even if it is against our clinical judgment. This is not the way to generate trust between the physician and pharmacy. The physician should make the judgment with an understanding of the difference in cost to the patient. The EHR could provide that information with one click if programmed correctly.

These are two of many needs the physician has from an effective EHR. I will cover most of the other needs in future articles on EHR. These two additions would add value to the physicians practice and promote his understanding of his practice patterns. These additions should be used as a learning exercise by the physician. The data should not be used to criticize the physician and reduce his reimbursement. In other word he should not be penalized for his practice patterns. Most measurements of practice patterns have the wrong viewpoint. The point of view is to grade the physician’s practice pattern and not teach him how to change constructively. The measurements used to grade the physician presently are mostly the wrong measurements. It becomes easy to see the physician resistant to collecting data at a very steep price that is useless to his continuing . The physician does not have the time or the money to invest in an EHR that adds value to practice.

Once again, I thank Dan Schmidt for his truthful comment.

“The enthusiastic primary care docs are the ones doing lots of procedures(indicated?) and satisfying demand. You mentioned the 80% costs on chronic care. Most docs can name these 20% of their practice off the top of their heads(without an EHR) and their definition of improved care is to SEE THEM LESS.. Since the marginal improvement one obtains( 1-2 less hospital admissions, 1-2 less ER visits/ year) is such an incremental improvement, most primary care docs dismiss this success.
And it is hard to quantify.”

The above comment is also very important. It highlights the difficulty in Repairing of the Healthcare System. The only asset primary care physicians have to sell is time. Educating patients properly about their chronic disease is time intensive. The education time is either uncompensated or under compensated. Taking care of a patients with a chronic disease is also time intensive. The primary care physician’s time has been devalued. The only way for the primary care physician to improve time effectively is to not take care of the time intensive patients. The primary care physician passes these patients off to a specialist. The problem is the primary care physician is the contact physician for most of the patients with chronic diseases. There are not enough specialists to take care of all patients with chronic diseases. Therefore, they are not taken care of using evidence based medicine. If all physicians practiced evidence based medicine we could reduce the cost of care by at least 40% because 80% of the cost of care is spent on treating the complications of chronic disease. If we all practice evidence based medicine we could reduce the complications rate by at least 50%. Fifty percent of 80% is 40%. The total healthcare bill presently is $15 trillion per year. In an ideal world that would be $600 billion per year.

I hope some of the EHR companies are listening.

Next time I will define quality medical care, evidence based medicine and the role the EHR can play.

Stanley Feld M.D.,FACP,MACE

Paul Krugman (PK) wrote an article entitled “Is The Health Insurance Business A Racket?” Yes, literally — or so say two New York hospitals, which have filed a racketeering lawsuit against UnitedHealth Group and several of its affiliates.
I don’t know how the case will turn out. The two hospitals accuse UnitedHealth of operating a “rogue business plan” designed to avoid paying clients’ medical bills. For example, the suit alleges that patients were falsely told that Flushing Hospital was “not a network provider” so UnitedHealth did not pay the full network rate.

UnitedHealth has already settled charges of misleading clients about providers’ status brought by New York’s attorney general: the company paid restitution to plan members, while attributing the problem to computer errors.

But whatever happens in court, the lawsuit illustrates perfectly the dysfunctional nature of our health insurance system, a system in which resources that could have been used to pay for medical care is instead wasted in a zero-sum struggle over who ends up with the bill.”(PK)
Mr Krugman has said exactly what I have been saying in “Repairing the Healthcare System”. I believe this behavior occurs regularly with UnitedHealth.

I do not believe the people who run the insurance companies are bad people. It is simply that they will do many things to maximize their profit while destroying their cash cow, the healthcare system. Obviously, it is very short sighted on their part and very bad for the delivery of medical care. It seems they have no interest in improving the delivery of medical care.

“It is a fact that insurers spend a lot of money looking for ways to reject insurance claims. And health care providers, in turn, spend billions on “denial management,” employing specialist firms — including Ingenix, a subsidiary of, yes, UnitedHealth — to fight the insurers.”(PK)

You have heard all this before. However, I think it is important to repeat the obvious so people remain aware of what is going being done by facilitator stakeholders in the healthcare system.
One could say this is happening in every industry in America. They would be correct.

We can name many other industries where the same things are occurring. I have pointed out similar behavior of TXU and the Dirty Coal Burning Plants in Texas. Both industries seem to have a total disregard for the health and welfare of the common good as they price their way out of the market in order to maximize profits to the detriment of their customer, the American people. At the same time they are weakening the valuable American Healthcare System’s infrastructure. If the insurance industry and hospital were far sighted, we would not be in a healthcare delivery. Wouldn’t it be better for everyone to have all 46.7 million uninsured Americans’ have healthcare insurance in an environment that is competitive and provides constructive incentives to make the healthcare system better? Presently we have destructive incentives that make healthcare more costly and unaffordable.

“So it’s an arms race between insurers, who deploy software and manpower trying to find claims they can reject, and doctors and hospitals, who deploy their own forces in an effort to outsmart or challenge the insurers. And the cost of this arms race ends up being borne by the public, in the form of higher health care prices and higher insurance premiums.” (PK)

This arms race did not start yesterday. It started in the 1980’s when a distorted Medicare system caused industry to adjust to the price controls of the government. Everyone tried to figure out how to maximize profits at the expense of the patients, the healthcare system and the entire population. One compensating adjustment led to another distortion. The system became more and more dysfunctional.

“Of course, rejecting claims is a clumsy way to deny coverage. The best way for an insurer to avoid paying medical bills is to avoid selling insurance to people who really need it. An insurance company can accomplish this in two ways, through marketing that targets the healthy, and through underwriting: rejecting the sick or charging them higher premiums.”(PK)

Thus, the distortions that has lead to 46.7 million uninsured and an insurance industry that is paying its CEOs 2-10 million dollars a year, while the successful hospital CEO’s are busy justifying their $1 million plus salaries. The tragedy widens as Family Practitioners are barely making a living and the specialty of Internal Medicine is on the brink of extinction. The drivers of the healthcare system, the patients and the physicians, are in pain, while the life blood is being sucked out of the healthcare system by the insurance industry and hospitals.

“Which brings us back to the racketeering lawsuit brought against UnitedHealth by the hospitals. UnitedHealth is America’s second-largest health insurer, has a reputation for playing even rougher than its competitors.”(PK)

Even Mr. Krugman knows about UnitedHealth and the $1.8 billion payout to its former CEO. Ask any physician not working for UnitedHealth. They will tell you how rough UnitedHealth plays.

“ But the larger problem isn’t the behavior of any individual company. It’s the ugly incentives provided by a system in which giving care is punished, while denying it is rewarded.”(PK)
The same way People Power got the attention of the entire Texas population in the TXU case and TXU stock started to crash, People Power is the only thing that is going to turn this perverse Healthcare System mess around. You out there are the people!

Shel Isreal co author of Naked Conversations: How Blogs are Changing the Way Businesses Talk with Customers They say “we live in a time when most people don’t trust big companies. wrote a comment on January 20,2007 “Thanks for being so gracious. I enjoyed the conversation that it spawned between by email. repairing the medical system (Healthcare System) in America is a lofty goal and about 98 percent of the American people see the need. The rest work for insurance companies.”

I believe our democratic system works. The internet and blogosphere are democratizing organs. As soon as a critical mass of people are aware of the etiology of the problems in the healthcare system the Healthcare System will be Repaired with the consumer driving the change, not the government, or the insurance industry.