Stanley Feld M.D.,FACP,MACE

The nation must declared War on Obesity to save its people from themselves. If you think, about it the problem is we get in our own way. It is time that we recognize that obesity is a disease and we must do everything we can to eliminate it.

I like to think of obesity as a disease with a genetic predisposition precipitated by environmental stimuli leading us to become a nation of overeaters. We as a nation must say we are tired of being manipulated. This will take national leadership and compromise by vested interests that are profiting from the obesity epidemic. The epidemic is decreasing the health of our nation. It will have a devastating effect on the costs of healthcare if not corrected now.

The benefited vested interest is the food industry. They have conditioned us so that as a nation we eat more and more and get fatter and fatter. Presently, our children are also being affected. Childhood Type 2 Diabetes Mellitus is becoming more and more prevalent because of the abuse by the large agribusinesses, the restaurant industry, the snack food industry and the supermarket industry. The abuse is driven by profit margins.

People power along with strong leadership has the ability to turn this around. We have started to create the hype for healthy eating. However, the food industries have countered the positive direction we were going in by engaging the advertising industry to undermine the effort. They have also gone on the offensive with subliminal advertising that encourage us to feel good eating junk food.

There was a recent article in the New York Times magazine section “You Are What You Eat: 2006 and the Politics of Food”. It is important that we spend some time on this article. It is up the nation to say enough is enough.

“The headlines about food this year read like a remarkable replay of Woody Allen’s “Sleeper,” in which the things Americans think they should eat more of — lettuce and spinach — were suddenly the ones that could make them sick, or even kill them.”

I do not think anyone has gotten killed by a potato chip or soda pop in the short term. I know there is excellent evidence that it will kill you slowly.

Marion Nestle a professor in the department of nutrition at NYU said. “This is the year everyone discovered that food is about politics and people can do something about it,” she said. “In a world in which people feel more and more distant from global forces that control their lives, they can do something by, as the British put it, ‘voting with your trolley,’ their word for shopping cart.”

We can certainly avoid unhealthy food if we were educated to recognize unhealthy food. We would then be able to mount a national protest, but only with the governments help. Eric Schlosser, author of “Fast Food Nation,” is equally upbeat about the spinach disaster. “Those negative events brought attention to the problems,” he said of the past year. “Even the growers think the system is broken and has to be fixed.”

I have observed some positive movement. There is a growing bipartisan consensus that obesity is bad. Soft drinks and junk food vending machines are being removed from schools by individual school districts as the expense of losing an income producing profit center for the school district. Governors nation wide are making nutrition a priority in schools. Some states have even reinstituted physical education.
Whole Foods has become a major food marketer in the United States. They have forced main stream food marketers to advertise “healthy food”. The organic food movement even becomes main stream with Wal-Mart and Target food markets. However, as more and more “organic food” has been demanded the food has become less “organic”.

“As Mr. Pollan wrote in The New York Times in 2001, about the dairy farms operated by the organic milk producer Horizon, “thousands of cows that never encounter a blade of grass spend their days confined to a fenced dry lot, eating (certified organic) grain and tethered to milking machines three times a day.”

The Department of Agriculture is now considering allowing salmon farmers to call their fish organic even if the fish are fed nonorganic fishmeal. The increasingly loose meaning of the word has led some consumers, who once bought anything labeled organic, to rely on new signifiers, like grass-fed, sustainable or local.”

“It is not only individual shoppers who are choosing to vote with their food dollars. Tired of waiting for the federal government to act, local governments have stepped in. New York City banned trans fats in restaurants and told restaurants with standardized recipes that they must provide easy access to calorie information. Other municipal and state governments are requiring public institutions to buy more nutritious, locally produced food.”

My question is “where is the evidence that “organic” is better for your health than non organic food?” The key questions in my view are food quality and food safety. As food has become a huge business whose profits making potential can be leveraged, we need to worry about the safety of growing the foodstuff, its processing and delivery. Organic assumes that chemical fertilizers are bad and pesticides are toxic to humans in the doses used. Therefore organic fertilizers are imperative and pesticides should be forbidden. I do not think there is any evidence for this assertion. I can visual abuse of pesticides but have not seen evidence. It could be that organic fertilizer could threaten food safety more than chemical fertilizers. The organic food movement is making us aware that something is wrong with the food industry.

I think the real issues are the safety, quality and quantity of the food we eat. The quality and quantity of the food we eat has a direct impact on the obesity epidemic.

I will discuss the quality and quantity of food we are exposed to next time.

Stanley Feld M.D.,FACP,MACE

I hit a nerve with my criticism of P4P. The reaction came from healthcare professionals who have worked hard to help organizations generate guidelines to improve the quality of care. They recognize that the healthcare system is in trouble. They all are sincere in wanting to help fix the dysfunctional system. You may recall I said everyone is to blame for the dysfunctional healthcare system. Government, insurance companies, hospitals, patients, and pharmaceutical companies as well as physicians are at fault. The healthcare system has to be repaired before it implodes.

In 1984, the government was certain that the DRG system for hospital reimbursement would control the escalating hospital costs. The defects in the DRG system made DRGs ineffective in controlling hospital costs. The result was escalating hospital costs rather than decreasing costs.

Intuitively, P4P is system that sounds like it should work. However, P4P does not include the entire meaning of the evaluation of quality of care. It is a good idea to develop criteria to judge effective treatment. However, who is the judge of effective treatment? Does anyone have the power to judge the judge? Both the physicians and the patients are responsible for the effective treatment outcomes. Patients must understand their responsibility in the outcomes of treatment. If they do not comply, the treatment will be ineffective. If the physicians are not reimbursed for developing education centers and a team approach to the treatment of chronic disease in order to help the patients become the professor of their disease, they are unlikely to develop that resource necessary for the treatment of chronic disease. The approach to treatment for chronic diseases must be a team approach with the patient at the center of the team. Physicians can not afford to set up the educational facility if they are not reimbursed for the service. Hospitals have opened and subsequently closed chronic disease education centers. They can not afford to keep them open. Who is at fault? Is it the physician, the patient, the government, the hospital or the insurance company? Who should bear the burden of proof of performance be on?

It is generally accepted that most of the money spent in the healthcare system is on treating the complications of chronic disease. Physicians are great at fixing things that are broken. We have not done very well at preventing disease or treating chronic diseases according to the Institute of Medicine. Why is there no compensation for this important skill set?

We know obesity is a risk factor for many chronic diseases such as heart disease and diabetes. Yet we continue to gain weight and increase the chances for the complications of these diseases. Who is responsible for this obesity epidemic? Is it the patients, the physicians, the government or our farm subsidies?

Patients are frustrated by the difficulty in negotiating with the healthcare system stakeholders. It is claimed that it is nearing impossible to speak to a physician on the telephone. There are stories of long waits for appointments to see physicians. Once the appointment is made there are long waiting room waits. It is difficult to coordinate tests in a timely manner. The work up is often attenuated when diagnosis should be made promptly and treatment should start quickly. The problem coordinating schedules with the various medical services is becoming more difficult. The segmentation of diagnostic workup and delays in getting workups completed have created increased distrust for physicians and eroded their therapeutic effectiveness. The physician patient relationship, an important aspect of therapeutic effectiveness is undermined. Whose fault is that and how does it get fixed? The answer is all the stakeholders are at fault as costs continue to escalate.

Physicians have to see more patients in a shorter time without complete workup in order to meet productivity quotas imposed by hospital systems that employ the physicians. If the physicians are in private practice, they have to see more patients in a short time in order to meet their overhead as reimbursement diminishes. They cannot afford not technologies that might improve their efficiency and lower the cost. Also, they might not have the skill set to make their practice more efficient. Electronic medical records have been an expensive false hope to many physician practices.

All the key stakeholders are frustrated. Hospital administrators claim they work hard for their million dollar plus salaries, and insurance executive claim things are tough as they go home with their two million plus salaries.

There are many things wrong with the healthcare system. P4P is not going to fix it. It is time to be honest and get serious about fixing all the defects in the healthcare system. I have outlined many of the steps necessary in my recent summaries.

Stanley Feld M.D.,FACP,MACE

Various non-physician organizations (NCQA and NDRP) have developed quality measurements that should be used as educational tools for the primary stakeholders. Instead, these quality measurements are code for secondary stakeholders to penalize physicians in the form of P4P. This is the problem in a healthcare system that has generated so much stakeholder mistrust. As long as the insurance industry, the government and the hospitals control the healthcare dollar, I do not believe these initiatives will work. The system must be driven by the patients. The patients must reward the physicians who utilize some of the resources that are being developed. The resources should not be forced on the physicians by the third parties.

The measurements used in evaluating quality lack an understanding of the complexity of the various disease processes or the responsibility of both the physicians and the patients in the patient-physician relationship. Physicians and patients have previously experienced negative information technology with pre-certification requirements for referral and procedures. Unfortunately, information technology does not work all the time. It can not substitute for physician judgment. The pre-certification system was modified so that the physician had to justify his thinking to a computer or review of a newly hired medical director that might not have expertise in that area of medicine. The result was is time comsuming process. The process threatens the physicians’ intellectual and moral integrity while increasing the intensity of mistrust and mutual disrespect.

The organizations developing these quality measures are very sincere and want to fix the healthcare system. It is my belief that it can not be done measuring only one criterion in the definition of medical quality care improvement. I also believe that if you are going to judge physicians it must be done by a peer group in a very discrete manner. Imagine in our litigious society the opportunity the P4P system offers to lawyers in the absence or real tort reform. A new profit center for lawyers will be developed.

The clinical endocrinologist knows it is possible to achieve an excellent HbA1c of 6%. However, it is very difficult. Very compliant diabetic patients can achieve a perfect HbA1c but they fully appreciate the difficulty. Neither the patient nor the physician should be punished for not achieving the goal they are seeking.

The physician-patient teaching relationship has been the tradition in medical care without 3rd party interference. This relationship needs to be promoted. If the punitive measures of reducing reimbursement inherent in P4P drive the Family Practitioners and Internists out of business, who will take care of the 20 million diabetics in the country? I know the 2000 practicing full time clinical endocrinologists can not take care of 20 million diabetics. If the process of quality care measurements were started after the onset of complications, achieving a HbA1c 8.1% would not halt the progression of the impending costly complications.

Each diabetic patient is at a different stage of his disease. Therefore each patient is at different stage of risk for complications. Patients have to be “risk weighted” to guess at the prognosis. Risk weighting is not a science at present. Patients further along the disease complication curve might not be able to have the progression of complications their complications stopped. They may be able to have the progression of complications slowed. However, the cost of treatment at each stage of diabetes mellitus and treatments will be different. The quality care measurement of how many times a HbA1c is done each year and the average level of HbA1c will not measure the skill of the physician or patient in decreasing the cost of the complications of the disease. This is a matter of physician judgment and patient adherence. Information technology can not make those judgments.

A faulty payment system (P4P) that cannot judge physician performance should not be instituted. It will only create a more dysfunctional healthcare system. Patients alone need to determine the quality of their care as previously described. Consumer driven healthcare will drive physicians to increased quality medical care. It can only happen if the healthcare dollar is in the hands of the patient, not the insurance industry or the government. The insurance industry’s and government’s job should be to help physicians develop systems of care and to educate the patient on the principles of good quality care and compliance. Patients must be taught their responsibility to their healthcare and how to use their healthcare dollar wisely. We have the information technology available to teach and reward both patients and physicians (the primary stakeholder). The result would be a competitive improvement is the quality of medical care. Remember the Lasik example.

We as physicians should create the systems of care for our fellow physicians. Many physicians do create systems of care and provide excellent care. However, preventive medicine services and educational services are not compensated or poorly compensated. Only when an environment is created for the success of focused factories for chronic diseases and patients control their health care dollar will we have true quality care. P4P is not the answer!

Stanley Feld M.D.,FACP,MACE

Unfortunately, the devil is in the details. P4P has devils in its details because of potential misuse of information technology. I will present of the many examples in endocrinology alone. The example of an application of P4P will make the concept of P4P seem ridiculous.

The insurance industry and the government have been trying for many years to define quality in order to measure quality care. They have asked healthcare organizations and healthcare administration organizations to develop the standards.

The American Diabetes Association volunteered for the Diabetes Mellitus Quality Improvement Project (DQIP) initiated in 1997. There were no physician organizations represented in this project initially. Unfortunately, this is not uncommon when one wants to develop standards or set reimbursement principles for the practicing physician.

If physician organizations wanted to have a seat at the table they could join. Physician organizations that joined were practicing clinical endocrinologists as well as others. Clinical Endocrinologists are most effective in treating diabetes because of their training and their clinical experience. Academic endocrinologists have much research experience. These academic endocrinologists know little about the challenges of clinical practice.

The steering committee, composed of representatives from four organizations (American Diabetes Association (ADA), the Foundation for Accountability (FACCT), the Health Care Financing Administration (HCFA), and the National Committee for Quality Assurance (NCQA) met, with the overall goal of establishing a set of diabetes-specific performance and outcome measures. The goal was to allow for fair comparisons of health care plans, stimulate quality improvement, be based on scientific evidence, and yet be user-friendly to payers and consumers. DIQP is funded by the HCFA portion of the Balanced Budget Act of 1997. The design of the Project was well intended but the outcome of the measures used by the insurance industry is punitive to physicians and patients rather than educational.

Few of the participants understood that compliance with these outcome measures was predicated on the patients making lifestyle changes as well as the patients adhering to medication prescribed and faithfully doing home blood glucose monitoring so they could effectively self-manage their disease. There is a 40-60% non adherence rate. In additional, even if the physicians give the recommended medications there might be subtle barriers in the clinical disease that renders the recommended medication ineffective in controlling the blood sugar. These patient barriers to diabetes care might include occupational stress or situational depression.

DQIP was formed to develop minimal guidelines for measurable outcomes of diabetes mellitus. I believe DQIP was very sincere in the quest to improve the outcomes of diabetes, namely decrease the chronic complications rates of diabetes. The complications of diabetes mellitus are heart disease, eye disease, kidney disease and neurological disease. It is true that controlling ones blood sugar will prevent or slow down the onset of complications of the disease.

The HbA1c test measures the integrated three month average blood sugar. It could be the average blood sugar was a combination of blood sugars that were high and low with very few normal blood sugars. A normal HbA1c level is 5.5% or lower. With the development of national laboratories and their national data basis we can now determine the national average of HbA1c, by zip code, or by physician. The national average is 9.2%. This is a terrible HbA1c and is a good predictor of complications of diabetes mellitus. DQIP stated the standard average HbA1c should be 8.1%. The total burden quality of care (achieving HbA1c) is on the physician. The American Association of Clinical Endocrinologist (AACE) goal is 6.5% The DQIP goal was to be a wake up call to the physician to try harder. A HbA1c of 8.1% is high value. The onset of complications of diabetes mellitus will be significant at 8.1%. Therefore the standards published are for educational purposes in my view. These standards are inadequate and will not decrease the complication rate or the cost of care.

Physicians’ agenda was to decrease the complications of diabetes by increasing awareness of the need for intensive self-management. Others in DQIP had other agendas. Some wanted to increase their funding from whoever would fund a project. Some just wanted to get the benefit of the consensus of intellectual property after compromises were made. Others wanted to sell more drugs or medical devices.

The agenda of all the stakeholders should have been to create a system that could create a competitive environment for excellent care among physicians without punitive consequences. The punitive consequences should come from the consumer driven market place. The only punitive consequence should come from the demand by their patients to help them get their HbA1c down to normal. If their physician could not help them they should be empowered to know the physician that could.

This did not happen. Instead a system of minimal quality care measurements was created. If they were not met by the physician then his P4P would be decreased by the government and the insurance industry. The quality measurements that DQIP created to help improve the quality of care delivered turned out to be a stick to beat physicians. The responsibility of the patient to improved quality of care is not taken into account. Only the physician and his healthcare team with the patient being the most important member of the team will increase the quality of medical care delivered and not the faulty incentive of P4P.

Stanley Feld M.D.FACP,MACE

The intuitive meaning of Pay for Performance (P4P) is the better you perform the more you get paid. This is true in many industries. The concept is well advertised in the well publicized salaries of professional athletes. Recently we have heard of grotesques salaries of fired CEO that get hundreds of millions of dollars in termination salaries for doing a bad job. They are getting paid well for poor job performance.

The underlying assumption is that with P4P, physicians should be responsible and accountable for medical outcomes. The physicians will be reimbursed for medical outcomes. The reimbursements made to the physicians are under the control of the government or insurance industry. These entities are interpreting the criteria for the quality of medical outcomes.

We have seen what happened to Dr. Petak even though his treatment is correct and saves money for the health care system. Many physicians feel P4P is simply code for reducing physician reimbursement. In an environment of existing mistrust between all the stakeholders, the potential is great for generating more mistrust. The growth of the mistrust will result in more dysfunction in the healthcare system and increased cost.

The definition of quality medical care has not been made clear by the secondary facilitators while proposing the P4P rollout. Organized medicine has not been outraged by the proposal. No one has analyzed it with all the potential for unforeseen consequence. Can P4P prevent the onset of disease or decrease complication rate for chronic disease? Who are the responsible stakeholders for increasing quality? The stakeholders responsible for medical quality care are the physician and the patient. If the patients do not adhere to the medical regime prescribed, the quality of care will not improve. Many studies have shown that compliance rates are as low as 30% for certain treatments. Patients will not have improved medical outcomes if they do not follow a treatment plan. Why should the physician be penalized? Why doesn’t the government and the insurance industry declare that patients are equally responsible for both good and bad medical outcomes? The structures of bureaucratic systems would not permit it because not only would it be judged to be insensitive it would be socially incorrect and result in a public outrage.

Patients have to be educated and become professor of their disease, be responsible for their health behaviors such as filling their prescriptions, exercising , decreasing obesity, not smoking or drinking. All preventive measures must be promoted. Patient need to be responsible their behavior and adherence to therapy. The physicians should not experience all of the brunt of poor outcomes or the credit for good outcomes. The P4P movement is misguided.

They are misguided when they think this is the fix. P4P represents another false hope and complicated mistake that in my opinion will lead to great cost to the healthcare system without improvement in medical outcomes.

I have defined quality medical care in a measurable way. None of these criteria are individual indicators of quality medical care. The system of quality of care should be the quality measure of prevention of medical complications and not the measurement of the parts on the path toward quality medical care. The patients’ activity is at least half of the quality equation to reduce the complications of chronic disease.

However, the secondary stakeholders are making a mistake with P4P. They have developed artificial quality indicators that do not measure quality medical care accurately. They want to force physicians to follow their indicators rather than use their medical skill and medical judgment. The way to improve quality is not to be punitive to the physicians. They are only one half of the quality equation to reduce medical care cost. The way to do it is to set up a competitive environment.

Lasik surgery is a perfect example. It stated with all ophthalmologic doing Lasik for $3000 an eye. Insurance did not pay for Lasik surgery. Some ophthalmologists’ developed focus factories that did just Lasik surgery. They developed economies of scale and expertise that enabled them to reduce the price. Patients chose these focused factories on the bases of price, and outcomes rather than the local opthalmologists. The price in some cities is now $250 an eye. Remember patients are not stupid. However, they are the 50% of the quality care equation. They will spend their money wisely and drive quality, if they own their healthcare dollar. It is our job to teach patients how to make the correct decisions. It is not the insurance industry or the government to restrict access to care and judge what is best. I believe the market place can do it.

In diabetes the healthcare system sends 15% of the healthcare dollar on 5% of the population and rising. Ninety percent of those dollars is spent on the complications of diabetes. If patients with diabetes were given control of their healthcare dollar and were rewarded for avoiding complications of diabetes we would be on our way to a competitive environment for the treatment of diabetes. The patients would search for physicians that had economies of scale and expertise to help them improve their quality of medical care. They would drive the creation of focus factories in diabetes as well as any other chronic disease. The system would then be stimulating competition and improving quality medical care not punishing physicians and patients. A negative and faulty penalty system (P4P) will not solve any of our problems. I predict it will only make it worse for the patient and the physician and more profitable for the insurance industry and hospitals. The physician and patient community ought to be outraged. They are not because we are a sound byte society and do not pay attention to the details of issues.

The P4P fad is simply another reason why patients need to be in control of their healthcare dollar. They should be rewarded if they avoid complications and improve their health. Physicians should compete to develop focus factories in order to generate economies of scale and improved medical outcomes. All of this has to be done in a price transparent environment.

Stanley Feld M.D.,FACP,MACE

Many people have made the following comments about the healthcare system
“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.”

Only 20% of the people are sick at any one time. Therefore only 20% of the people think about the healthcare system and their healthcare insurance policy at any one time. The uninsured think about the potential cost of getting sick and fear not having health insurance.

When insured people get sick and navigate through the healthcare system is a nightmare for only about 40% of them. At any one point in time only 8 out of 100 people who have health insurance are having difficulty with the healthcare system. When all the people with healthcare insurance are forced to think about the healthcare system only 40% have experienced a horror of the situation. The other 60% that did not have a problem think the problems with the healthcare system are over exaggerated.

In August 2006 I received this comment from 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!!
Cleve”

Last week I spoke to a friend who had neck surgery two years ago. He was hospitalized for 2 days. He had the opposite comment. He has health insurance with UnitedHealthcare. He thought my comments about UnitedHealthcare were exaggerated. His hospital bill was $17,500. The surgeon charged him $17,000. I remember his complaining about how atrocious these two bills were. I assured him the adjudication of the bill would look nothing like the retail charges. UnitedHealthcare paid both the hospital and the surgeon $3,500 each. He was responsible for nothing. He was relieved and pleased with the system. He said the hospital and surgeon seemed satisfied.

What about Denise? Remember her. She did not have health insurance. She was self employed with a preexisting condition. She did not qualify for health insurance. If she needed emergency neck surgery she would have been responsible for the entire $34,500. Both the hospital and doctor would have been unrelenting in the pursuit of payment. If the hospital and doctor would settle for $3,500 with the insurance company they should settle for the same with Denise. However, she would probably go to the collection agency and if she did not pay, her credit would be destroyed.
Denise could not get information for the price of a simple x-ray from the hospital. This precipitated her frustration and letter to then gubernatorial candidate Kinky Friedman the comedian cowboy running for governor.

My goal is to help people who are not sick understand the problem with the healthcare system. I believe the only thing that will repair the healthcare system is people and their purchasing power.

Matthew Huebert wrote:

“There is something meaningful about blogs and RSS that I’ve only begun to understand recently, and this post describes and exemplifies it well: you are a thinking person, putting yourself ‘out there’, introducing outsiders into your own world and adding depth to a discussion that matters to you and matters to society. For me, it is writing like this that is an antidote to the superficial sound bytes that obscure possibilities for change by avoiding the “Why?” questions. I think what’s finally hitting me is the fact that these conversations simply wouldn’t be happening if RSS did not exist! What you’re doing is inspiring. Thanks for the great post.
Matthew Huebert”

A huge barrier to real repair is the lack of awareness of 60% of the insured population. The 46.7 million uninsured are a mere abstraction to these people. The horror of the 40% insured is also an abstraction. If the trend continues the system will cave in all at once and everyone will be affected. People have to be stimulated to action now and demand the solutions I outlined in the last three blogs.
We are approaching a Presidential election year. We will hear all sorts of noise from “leaders” who in my opinion have little serious knowledge of the problem or the solution as seen in recent initiatives in California and Massachusetts. Our leaders are not stupid. The problem is the input of information is coming from the facilitator vested interest groups and not the people in the street.

Perhaps I can capture the imagination of all of the stakeholders. If we could all focus on the higher goal of excellent medical care at an affordable price rather than improving the financial results of facilitator vested interests, all of the stakeholders could all flourish with the minimum of pain and maximum creativity.

Stanley Feld M.D.,FACP, MACE

The following are additional solutions necessary for the Repair of the Healthcare System

• Develop Centers of Excellence and Focused Factories in both hospital based clinics and physician outpatient clinics to treat chronic diseases by a team of multi disciplinary experts using systems of care based on evidenced based medicine. Disease management systems can be developed in primary care physicians’ offices because there are not enough specialists to take care of all the patients with chronic disease. Treating chronic diseases this way should lower the complication rate for chronic diseases. The result should be a reduction in the cost of healthcare by at least 45%.

• Emphasis should be place on teaching the patient how to be the “professor of his disease”. Payment should be available to the Center of Excellence for this education.

• Promotion of and payment for early evaluation and recognition of chronic disease. It is essential to detect and prevent these chronic diseases early to prevent costly complications of these diseases.

• A sophisticated information system connecting medical care with financial outcomes. An ideal EHR should be made available to physicians on a per use basis so that the investment cost is not a burden to the physician. The information technology should be used as a learning tool for the physician to continually improve the quality of care and not as a weapon to penalize the physician. .

• Quality of care should be defined as whom to evaluate, how to evaluate, whom to treat, how to treat, how long to treat, how often the patient should be seen, how often the patient should be retested, and the measurement of adherence to medication. Measurement of quality should be all of the above. However, the key measurement of quality is the medical outcome as it relates to the financial outcome. If you prevent a $50,000 complication utilizing $1,000 of treatment you have a leveraged financial outcome as well as an excellent medical outcome. The main question is, “was the complication of the chronic disease avoided?” We are misguided when we start believing that measuring the percentage of our patients we measure cholesterol on, or the percentage of patients on whom we do colonoscopies or bone densities is a measure of quality of care. It is simply one element of quality medical care and it should not be rewarded as the Pay 4 Performance advocates are suggesting. This thinking makes us vulnerable to another false hope of reducing complications of chronic diseases.

• Increasing obesity in our population is a huge health risk. The government should declare war on obesity. It should strive to eliminate the many stimuli we are exposed to. It should institute a gigantic public media campaign to explain the health risks and the stimuli to overeat.

The most important need is to put the patient in charge of his disease management. The patient must be responsible for his care and in control of his health care dollar. We do not need more schemes destined to fail such as the California and Massachusetts mandates. We do not need the Pay 4 Performance scheme that will distort the healthcare system even further. We need some common sense infused into the development of a system that is driven by the patients and not the facilitator stakeholder for the purpose of the facilitator stakeholders’ bottom line.

If patients do not want to take care of themselves they will suffer medically and financially.
These are some of the solutions I have proposed. We need the political will and leadership to institute and execute these solutions. Responsibility for follow up care and compliance must be the patient. The physicians are the teachers educating patients to be experts in their disease self- management. In the present system the penalty to the patient is bad health. The new system should have a clear message of good health and financial reward. It is much cheaper for all the stakeholders in the long run.

The patient has to;
• Be responsible for the purchase of care.
• Have ready access to care.
• Be responsible for the appropriate adherence to care and medication regime given by the physicians.
• Be rewarded for excellent lifestyle changes and avoidance of complications of disease.

If this is accomplished, and it can be with appropriate leadership and the demand by the consumer, we can repair the healthcare system.

Stanley Feld M.D.,FACP,MACE

The solutions I have proposed are all directed to a patient centered, patient driven, and patient advantaged system. I will review the proposed solutions in the next two blogs.

• Price transparency is an essential beginning. No only must the retail price be published but all of the discounted prices must be transparent as well. Somehow, the government has to enact legislation so that the providers and the insurance companies post their range of prices. The government has to empower the patient with negotiating power to get the best price. There are many different prices paid for a service depending on the negotiating power of the purchaser. The net effect of this total price transparency will be lower the prices and decrease cost of health insurance. The consumer must demand real price transparency. Aetna’s declaration of price transparency last year was a rouse. The hospital associations of Wisconsin and now Texas have developed web sites to provide hospital retail prices. We have little idea how much the government or insurance companies pay for these services. I assure you the discount is very deep and the hospitals are satisfied with the payments. The automobile industry has figured out how to deal with total price transparency and the internet publication of the MSRP, the invoice prices and the average prices paid for an individual automobile. We should demand that the healthcare system does the same. The system should be set up where the patient can negotiate price pre or post treatment. Sometimes the patients need a care emergently and are not in a position to negotiate in an emergency room.

• Elimination of a two tier payment system with hospital clinics receiving more money for procedures than outpatient physician clinics for the same procedures. Eliminate the restricting of payment to the physicians’ office clinics as long as there is proof of equal quality and qualifications to do the procedures in the physicians’ office. This can serve to increase price competition for services. Price competition is a vital element on the repair of the healthcare system.

•Expand consumer driven healthcare using the ideal Medical Savings Accounts and not the present Health Savings Accounts. I have made clear the difference between the two. The ideal Medical Savings Account would be to the patients’ advantage and not the insurance industries advantage. The ideal MSA would serve to motivate the patient to shop price and quality because they are spending their own money. It would also encourage adherence to treatment for the same reason.

• Create a level tax exempt playing field for the self employed and uninsured
so they can buy insurance with pretax dollars. Provide those who qualify for subsidy with a subsidy to pay for their Medical Saving Account. If they use the healthcare system appropriately or they do not have to use the system they should be rewarded with a lifetime tax exempt saving account. Incentives on all levels drive our system of free enterprise.

• Administrative waste in hospitals should be penalized and not rewarded. The system of payment presently is very opaque. For example payment for some chemotherapy is 10 time the cost of the drug. Yet the oncologist is not permitted to administer the drug in his office for one and one half times the cost. It is estimated that $150 billion dollar are wasted on administrative costs in the hospital and in the insurance industry. These costs add not value to the treatment of patients. The administrative waste is absorbed by increased executive salaries and increasing construction of enlarging hospital facilities. The brick and motor expansion of hospitals should be over since much can be done on an outpatient basis.

These are some of the solutions necessary to repair the healthcare system. The solutions have to be instituted as a total plan and not introduced piecemeal. Each of the pieces of the solution is dependent on each other in order to have a positive effect on repairing the healthcare system. Next time I will review the other elements of a plan I have proposed that will solve the dilemma expressed by the questions that need to be addressed to Repair the Healthcare System.

Stanley Feld M.D.,FACP,MACE

In August 2006 I summarized my blog to that point. I outlined some important solutions necessary for the repair of the healthcare system. Since then I have covered many of the solutions to the key questions I raised. Not one of these questions has been addressed effectively by our leadership or people in control of making policy. One must ask: Do they really want to solve the problems in healthcare delivery in this country or are they focused on preserving their own vested interest to the exclusion of a breakthrough that might benefit not only their vested interests but the vested interest of all the stakeholders.

The questions were:

• 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?

In reality, developing solutions to these questions are in themselves business opportunities for facilitator stakeholders that can help Repair the Healthcare System. However, neither the insurance industry, hospital systems, nor the government see the long term advantage and economic opportunity. In a comment to my blog Shel Isreal said “

The insurance industry has the money and the power.”

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2007/01/the_ideal_elect.html. However, we have demonstrated the abuse and misuse of the power of information technology by the insurance industry. The misuse and abuse has lead to further dysfunction in the healthcare system and mistrust by the hospitals and physicians. The insurance industry and the government have used information technology to penalize both physicians and patients using the wrong data to draw their conclusions. Insurance companies do not have the information technology resources to measure the correct parameters to measure quality care. I do not see an attempt on their part to correct this deficiency. I only see a movement to make the healthcare system worse with a Pay for Performance (P4P) reimbursement system that is not well thought out. .

It is essential that the solutions I have proposed be coordinated and introduced simultaneously as a single plan rather than introducing elements of the solution separately.

Unfortunately, the government with the pressures of its present political vested interest influences finds it difficult to present the components of repair as a single plan. The solutions will have to be driven by the consumer (the patient) and not the government. The patients have the power to drive the solutions because they are the users of the healthcare system. If they were the purchases of healthcare, some clever entrepreneur could provide the option for a compelling insurance product that could reward the patient for being responsible for their own care and well being. The insurance produce could be built to fix the healthcare system.