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All items for September, 2007


Entrepreneurs Taking Advantage Of The Healthcare System. Part 1

Stanley Feld M.D.,FACP,MACE

There are oceans of information and data describing our options in the healthcare system. Neither the consumer nor agents for the consumer (typically Human Resource officers) have had an easy time distinguishing between good and bad information. Health insurance companies have large departments that “craft” its message to the media and for the sale of its healthcare insurance products. The goal is to increase the number of healthcare insurance policies it sells. They also have entire departments that negotiate them through the maze of rules and regulations. They also have multiple prices for multiple customers. All of the above increase the healthcare insurances companies’ inefficiency and overhead leading to an increase in premium pricing. All of these actions are entrepreneurial.

There are many rules and regulations imposed by government bureaucracy that distracts physicians from their duty of delivering medical care. The easiest thing for physicians to do is do their job the best they can. Physicians cannot fix our broken healthcare system. Our medical care system is not broken. It is inefficient in delivering care for chronic diseases. Physicians can and do deliver excellent medical care. We lack systems and motivation to deliver excellent preventative care. Preventative care goes beyond the annual physical examination. It is essential that the healthcare system create incentives to develop systems to deliver continuing care for chronic disease. This includes the patient being activity responsible for the self management of his chronic disease. This concept can be understood by reviewing the AACE’s “Management of Diabetes Mellitus A System of Intensive Self Management .”

Organized medicine has been dormant and ineffective in creating innovative ideas in order to teach physicians how to develop systems of care for chronic diseases. The government and insurance industry have been uninterested in supporting the development of these systems of care because I believe they do not have an understanding of its importance to the long term cost of healthcare. The attitude prevails despite the fact that we know that ninety percent of the healthcare system’s cost are spent on the complications of chronic diseases. If you are a company interested only in short term results, I can understand the attitude toward long term reduction of chronic disease complications. It would be an entrepreneurial activity to develop systems of care for chronic diseases that would teach physicians how to care for chronic disease. Additionally the incentives to execute that care would have to be provided.
The healthcare system as opposed to the medical care systemis extremely complex. The multiple small “political steps” taken over time to help repair the healthcare system have not generated effective change. As Nietzsche said, “sometimes small steps make the situation worse’.

It seems that everything that is done to improve the healthcare system ends up harming it even more. A recent example is the windfall profits provided by a defective DRG payment system for hospital systems. It took a couple of years for the hospital systems to figure at the loopholes in the DRG system. Once they did, hospitals’ profits soared. This was entrepreneurial on the part of the hospital systems.

CMS recognizes the defect and wants to implement a new DRG system based on hospital system costs rather than hospital system charges. This change implies true price transparency. Price transparency should be available to the consumer to choose the hospital. Price transparency should not be developed into a form of fovernment price controls. If a hospital experiences more overhead or delivery costs they should charge more. However, if they were forced by competition to become more efficient they would be able to reduce their prices. The result would be a decrease in cost. Hospital systems should make the cost of a band aid clear. It is simply wrong to charge $11 for a five cent item. However, hospital systems’ lobbyists successfully fought for a one year delay in the implementation of a new DRG payment formula based on cost and not charges.

I suspect Dr. Mark McCellan resigned as director of CMS out of political frustration. He was not interested in price controls. He was interested in accurate pricing. It is one thing for the government to know what to do. It is another thing to get it through the tangled way our government bureaucracy does business. To me, the only way to reduce the obscene hospital fees is by knowing the hospital costs for the service or item and not accepting the grossly inflated price and then negotiating a discounted price.

Hospitals should be paid on a cost plus basis in relationship to the average hospital cost per disease in the state or county. Allowances should be made for variation in overhead in different parts of the country. This methodology would force the hospital systems to become more efficient and be competitive. They would be forced to learn how to increase their profit margin as prices would decrease.

The present payment system encourages hospitals to be less efficient and incur higher fees and more costs. It would force hospitals to be entrepreneurial for the benefit of all the stakeholders and not simply themselves. I would guess implementing a new system will be delayed even longer than one year, especially with the change in administration in the next year. Hospital systems are not interested in real price transparency. They will fight it. I believe they are blindly encouraging government price controls. Price controls historically make things worse in every area of our economy.

If we as consumers do not force the secondary stakeholders to get smart we will end up with a single party payer system. Hillary Clinton’s new healthcare plan is heading us in that direction. Her 2007 words are crafted differently than her 1993 plan. Her 2007 healthcare plan will evolve to a single party payer plan. She has changed her direct approach. She has gotten her strategy from organizations like the Commonwealth Fund who are advocates of a single party payer being the only solution to our healthcare systems problems.
A full discussion of Mrs. Clinton’s plan will follow shortly.

I believe the government wants to help the people. What is the reason government initiatives misfire? They misfire because of the inefficiencies in hierarchical bureaucracies. The hierarchical bureaucracy is imbedded in all of our government agencies and in our body politic. Governmental decisions are influenced by vested interest’s lobbying and not by common sense.

There are a lot of very smart people in America. We have figured out the solutions to many problems in the past. Winston Churchill said “the American government always does the right thing after they have tried everything else. He might be right. “

The public can overcome the archaic bureaucratic structure of our government. We need an entrepreneur to step forward, recognize the patterns, be innovative, make the repair, and profit from his innovation. The repair will be driven by our knowledge based economy. The healthcare system can to be a healthcare system for the public good without price controls that do not work, single party payer systems that do not work and government restrictions on access to care that does not work.

We as consumers must become concerned enough and disturbed enough at the present healthcare system to generate the will to act in a constructive way to improve the system to the advantage of everyone. We have an excellent medical care system. We have a dysfunctional healthcare system. I believe the American consumer is getting there. We have at least forced a change in Hillary Clinton’s rhetoric but not in her policy. The solution in a free market system is to construct a system that will function for the consumers’ benefit and not the vested interests’ benefit.


What is an Entrepreneur?

Stanley Feld M.D.,FACP,MACE

“There are various definitions of an “entrepreneur.” An entrepreneur can be defined as a decision-maker whose entire role arises out of his alertness to hitherto unnoticed opportunities.”

“Entrepreneur is sometimes mistakenly equated with “opportunist”. An entrepreneur may be considered one who creates an opportunity rather than merely exploits it. Sometimes the distinction is difficult to make. A role of the entrepreneur is to generate innovation or mobilize resources to address inefficiencies in the marketplace.”

Additionally, an entrepreneur in our knowledge based economy is a person who can see patterns that elude others. He acts on the patterns he visualizes to create opportunities no one thought existed.

Warren Buffet has a long history of success is discovering behavioral or cultural patterns and investing in them. My guess is the discovery of various evolving patterns in society is not made through a process of intensive study of endless data. It is made through a process of considering data and then visualizing the trends and patterns of the present time. Once visualized the entrepreneur has the courage to act and follow through.

There are many examples of entrepreneurs in our society. Some are beneficial to the common good and others take advantage of society.

Rick Scott and Steve Case have taken the lead with in-store clinics. I have predicted that they will sell out long before the in-store clinics fail. CEO’s of hospital systems have been entrepreneurs taking advantage of the holes in the DRG system. They are afraid that the government will finally close the holes in the DRG system.

KKR and HCA have been entrepreneurs taking advantage of the defects in hospital reimbursement. They have visualized that the sum of the parts of the gigantic proprietary hospital system are more valuable than the whole hospital system. They will benefit through divesting hospitals at society’s expense in a free country.

The healthcare insurance industry has been entrepreneurial in taking advantage of the leverage it has in negotiating physician fees and healthcare insurance premiums. They are trying to figure out how to appease the consumer without losing any of their power.

Some physicians have left the traditional healthcare system and opened concierge practices. Some physicians have been entrepreneurs in opening preventive health clinics and spas that have attracted wealthy patients to get fit. Most add no value to the care of patients in my view.

On close inspection none of these entrepreneurial ventures have been undertaken for the public good even though they have discovered patterns in society that lead to successful business undertakings.

How can the healthcare system promote innovation and entrepreneurship to reform the healthcare system for the consumer’s benefit while maintaining freedom of choice for patients and intellectual freedom for physicians. Both freedom of choice for patients and intellectual freedom for pysicians have been severely hampered in the last 35 years. The impingement on these freedoms by restrictions imposed by rules, regulations, and system advantage to secondary stakeholders have led to the mess we are currently encountering.

I believe the mess is a result of the influence various stakeholders’ vested interests have on the political system. I also believe the time has come for the consumer as the most important stakeholder in the healthcare system to demand that the politicians hear them. The politicians need to stop listening to and acting on the vested interests of secondary stakeholders who control the system presently.

This is going to take the will of the people to be informed and express their vested interest. I believe we are getting there and being heard. We still have a couple of problems. It is going to take a Google-like entrepreneur to help the consumer solve the existing problems in the healthcare system.

  • cheryl

    I volunteer for hospice. The director said in the last 2 years the people they are treating have become younger. She said it most likely is become healthcare is so unaffordable. Some people are actually choosing death over the high cost to their families. Myself I think it’s kind of convient when so many baby boomers are getting ready to retire and social security running out!

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This is What I Mean by Innovative Thinking: Part 1

Stanley Feld M.D., FACP, MACE

The public education system is just as broken as the healthcare system. The concept of “No Child Left Behind” is in reality empty rhetoric. In my opinion, it is a well intended but simplistic concept. It is a naïve view of the meaning of education.

In my view the purpose of education is to teach children how to think. The goal is not to memorize material to pass a standardized test. Once you understand the concepts effective reading, and arithmetic, reading comprehension and mathematical abstractions are easy. In our world we should be teaching people how to think in order to prepared them for our knowledge based economy.

Alvin and Heidi Toeffler nailed it in their recent booke “Revolutionary Wealth” which explains the nuances of education in the knowledge based economy.

“In the early 20th Century, business in short had a crucial stake in massifying armies of young to help build the mass-production economy of the industrial age.”

“Sir Ken Robinson, senior advisor on educational policy to the president of the famed Getty foundation in Los Angeles and author of Out of Our Minds: Learning to be Creative stated” The whole apparatus of public education has largely been shaped by the needs and ideologies of industrialism…predicted on old assumptions about the supply and demand for labor. The keywords of this system are linearity, conformity and standardization.”

“There are many forces that are for changing the dysfunctional public education system. They are the teachers, the parents, and the students who all recognize that our public education system is broken. They are the ones, the consumers of education, which are going to have to force the controller of public education to change the system.”

Does this sound familiar? It also relates to the healthcare system.

The Tofflers’ then quote Bill Gates who they say finally laid it on the line in 2005:

“America’s high schools are obsolete. By obsolete, I don’t just mean that our high schools are broken, flawed, or under funded. By obsolete I mean that our high schools-even when they’re working exactly as designed-cannot teach our kids what they need to know today… This isn’t an accident or a flaw in the system: it is the system”.

When I was at Columbia College the courses were very different than those at William Howard Taft High School in the Bronx. The high school curriculum in the mid twentieth century taught facts. It was up to the student to figure out how to integrate and abstract these facts into the real world if he had any chance of being successful and creative. The same was true when my children were in high school in Texas in the 1980s. All of us went to public high schools. These high schools were considered excellent public high schools at the time. The same obsolete teaching methods prevail in excellent public high schools today.

At Columbia College in New York, I was not taught any specific facts. I was taught concepts. Even in the pre medical courses we were taught concepts and few facts. I believe the facts are easily figured out if one understands the concepts behind the facts. When I was in medical school the same thing was true. The concepts were critical to learning the facts. It has little to do with memorization of facts. An excellent example is our final exam in pathology. The only question on the final pathology exam was a request to write ten important pathology questions and then answer them. I wrote ten questions that I thought were the most important questions about pathology. When is came time to answer them I was stumped. I wrote the best answers I could. I walked out of the test convinced that I failed my own test. Some of the people in the class were bragging about how easy the test was. I kept chiding myself for being so stupid as to ask such hard questions.

It turned out I got honors in the course and most of the others got a passing grade. Some failed their own test. Subsequently, I discovered it was a test of understanding the concepts and not regurgitating facts. I wrote the best questions in the class. The concepts had to be concepts that prepared you to be a competent critical thinking clinician.

Thursday August 16th was launch day for TechStars at the Atlas Institute on the campus of Colorado University. I have been talking about the need for innovative thinking in healthcare in this blog. David Cohen, Brad Feld, Jared Polis and David Brown developed the concept of TechStars. They published a call for applications from technology start up companies on their blogs. They received applications from 300 start-up companies from around the country. TechStars selected 10 teams from the 300 applicants. They provided funding of $15,000 per team, free office space, operational support, and a three month mentorship curriculum with Boulder Colorado venture capital firms, entrepreneurs and business leaders. The course content taught the start up entrepreneurs how to think about, execute and get funding for their new start up company.

TechStars Inc. received 5% equity position in each company for the educational process and ability to relate to these successful Boulder mentors. If the companies failed the venture capitalist lost $15,000. The goal was to stimulated smart young entrepreneurs to think critically about the development of their company. They were also taught to develop street smarts by entrepreneurs that have been through the start up process. If one or two of the companies succeeded TechStars Inc would more than make its money back. David Cohen did a magnificent job leading the troops and developing the course curriculum.

This morning’s presentations included Eventvue, Intense Debate, SocialThing, J-Squared Media, MadKast and Searchtophone, StickyNotes, Villij, FiltrBox , KBLabs, and BrightKite. I bet you will hear about these companies in the future. If a couple of these companies do not succeed you will hear from its entrepreneurs as they develop other companies.

The lecture hall was packed with venture capitalist from as faraway as California and entrepreneurs, mentors and friends from all over Colorado. Each presenter did a great job in pitching his company. The presentations were crisp and clear. They all knew what they wanted and made very compelling cases to get the funding they needed. Brad told me when they started putting their presentations together almost all of them did terribly. They were all fast learners.

I spoke to most of the founders of the companies after the meeting. They all felt this was the best educational experience they have ever had. Most were in their 20’s, and many had completed business school. The overriding theme that excited them was they learned the concepts necessary to develop a successful business. These concepts plus the mentors’ practical experience was not available in business school.

Every one of the companies has a great idea. However, that is not the point. These young entrepreneurs have learned an incredible amount about how to start and run a business in the trenches from mentors who are and were in the trenches. Every person has been energized. They have also energized the mentors.

This is how our public education system, which is just as dysfunctional as our healthcare system, needs to function in order to be effective in our knowledge based economy.

The people who control the healthcare system have to start thinking of concepts that will benefit all the stakeholders and not simply the stakeholders in power. I am certain the stakeholders in power are threatened by the potential for change just as the controllers of the educational system are. We now live in a knowledge based economy. The legacy thinking in healthcare has to change. It is presently proprietary and opaque. It is dominated and controlled by the insurance industry. It has to be transparent and beneficial to all.

Only the consumer will change the healthcare system. It will start with the demand to change the insurance paradigm to the ideal medical saving account.

We have seen the failures of the government as a single party payer in the VA Healthcare System. I suspect we are only seeing the tip of the ice berg. I cannot understand why politicians think it will be any better when a single party payer system is applied to the entire population.

I know the consumer does not want that system.

I believe it will not be the baby boomers that change the system. It will be young people who were brought up on computer technology such as the Tech Stars and their mentors who will make the innovative changes necessary to establish a new paradigm for medicine in a knowledge based economy.

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Look What Happens When You Are Not Looking. Part 3

Stanley Feld M.D., FACP,MACE

Convienent Clinic Association’sCCA’s press release challenges the AMA to join them in providing convenient care that is affordable and high quality and not fight them.

The AMA is put in the position of being reactionary. More precisely the AMA has been portrayed as being protective of turf. In reality the AMA is not protective. They are challenging the claim for quality care. A claim for which CCA and the in-store clinics have no evidence for.

On CCA’s web site they claim:
“At most Convenient Care Clinics (CCCs), standardized protocols and guidelines assist nurse practitioners (NP), physician assistants (PA) and physicians (MD or DO) in clinical decision making. (These protocols are not intended to replace the critical thinking or the clinical judgment of the providers, but to enhance the decision making process.) The leading CCAs’ protocols are grounded in evidence-based medicine and guidelines published by major medical bodies such as the American Academy of Pediatrics and American Academy of Family Physicians.”
“Most Convenient Care Clinics are incorporating rigorous quality assessments into their practice, such as:
• Formal chart review by collaborating physicians
• Peer-review by NPs and PAs
• Medical diagnosis and treatment code auditing
• Processes to ensure that all providers possess an adequate experience level to work in this new independent setting

In addition, most NPs are Master’s prepared and nationally certified in their specialty. Furthermore, all Convenient Care Clinics comply with all state regulations regarding the practice of physicians, NPs and PAs.”
The reader should notice the frequent use of the word most. What does most mean in this press release. Is this disinformation? If it is it is disinformation that is readily acceptable to the healthcare insurance industry. The real question is how many clinics adhere to the standards they say they set.
“One of the primary goals of the CCA is to establish common clinical guidelines and standards of operation to ensure the highest quality of care throughout all Convenient Care Clinics. To achieve this goal, the CCA has assembled a Clinical Advisory Board. The purpose of this advisory board is to provide input and guidance in the development of industry-wide quality standards and clinical guidelines.”

It sounds as if standards have not yet been developed. We are lead to believe that they have been developed because they provide high quality care with a 98% approval rating. There is no evidence for a 98% approval rating except CCA saying so.

Who is not looking? The consumer, patients, doctors and hospitals are not looking. Some day they will all wake up. It is important to see right now what is happening in front of everyone’s eyes. The devaluation of medical care as a way of lowering the price of medical care is happening right now.

The real problem to solve with medical care costs is the cost of the treatment if complications of chronic disease. The complications of chronic disease cost the healthcare system 90% of the healthcare dollar. Effective treatment can lower the cost by at least 50%.

Unholy alliances are formed by the smell of money. The healthcare insurance companies would love the in store clinics because they serve to devalue the physician driven medical care services even further. Innovative cutting edge ideas for medical care should be developed by physicians. After all, who are the experts in the delivery of medical care? However, many physician groups are dysfunctional because of the pressures of overhead, reduction in reimbursement and malpractice concerns. They are fighting for their lives as reimbursement continually decreases. Physician practices must become more innovative, more efficient and more effective. If not I believe the delivery of quality medical care in a dysfunctional healthcare system with decrease even further.

Business executives are developing in store clinics because they perceive a business opportunity. If the in store clinics succeed it will be the fault of organized medicine’s inability to help physician practices achieve a new efficiency. It will be because state licensing boards buckled to pressures and permitted various healthcare practitioners to practice medicine and bill without supervision.

The frustration of patients to get appropriate, timely medical attention, and the inability of physicians to adjust to the changing medical environment could drive the in-store clinics to succeed. However, I believe Americans are smart. When they own their own healthcare dollar and see the clinical outcomes of these clinics they will not support them. In the present insurance environment there is little evidence that the public is supporting these clinics.

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Look What Happens When You Are Not Looking. Part 2

Stanley Feld M.D.,FACP,MACE

The AMA House of Delegates met and developed policy recommendations concerning the In Store Clinics. They stated they were not opposed to the in store clinics. However they wanted certain quality criteria met. I do not believe that the healthcare insurance industry relies on the AMA policy making meetings to help them determine who and what they will pay for what services these in store clinics provide. Its only concern is that the patient gets treated at the lowest price and permits the healthcare insurance industry to retain its control of the healthcare system
The AMA press release contained the following statements;

“Patients want quick and easy access to health care services, but they shouldn’t have to worry about the safety and quality of care provided in these clinics, said Rebecca J. Patchin, MD, AMA Board Member.”

Implicit in the AMA’s statement is that the in-store clinics have the ability to provide quick and easy access to healthcare services, while the practicing physician’s office can not. The only objection the AMA has is that the treatment might not be safe and the quality might be poor.

“Physicians deliberating the new principles at the AMA’s policy-making meeting agreed with the public’s concerns, noting that intensive diagnosis and care should not be carried out at clinics staffed by less-qualified health professionals and equipped for basic services. Physicians added that health care safety could be negatively affected if in-store clinics lead to fragmentation of patient care, inadequate follow-up and missed opportunities for preventive care of patients.”

“To enhance public confidence in the quality of care provided by store-based clinics, the AMA adopted the following principles to help promote their safe and effective operation.”

• Store-based health clinics must have a well-defined and limited scope of clinical services, consistent with state scope of practice laws.
• Store-based health clinics must use standardized medical protocols derived from evidence-based practice guidelines to insure patient safety and quality of care.
• Store-based health clinics must establish arrangements by which their health care practitioners have direct access to and supervision by those with medical degrees (MD and DO) as consistent with state laws.
• Store-based health clinics must establish protocols for ensuring continuity of care with practicing physicians within the local community.
• Store-based health clinics must establish a referral system with physician practices or other facilities for appropriate treatment if the patient’s conditions or symptoms are beyond the scope of services provided by the clinic.
• Store-based health clinics must clearly inform patients in advance of the qualifications of the health care practitioners who are providing care, as well as any limitation in the types of illnesses that can be diagnosed and treated.
• Store-based health clinics must establish appropriate sanitation and hygienic guidelines and facilities to insure the safety of patients.
• Store-based health clinics should be encouraged to use electronic health records as a means of communicating patient information and facilitating continuity of care.
• Store-based health clinics should encourage patients to establish care with a primary care physician to ensure continuity of care.
Who is going to administer and enforce these rules? No one. Who cares about these rules? No one. The patients using these in store clinics should care about the rules and demand that the local governments administer and enforces these rules.

“There are clear incentives for employers, health insurers, and retailers to participate in the implementation and operation of store-based health clinics. Employers and insurers report being able to contain health care costs by using in-store clinics, while retailers state that the clinics help increase store traffic and drive sales.”
“The new AMA principles will help ensure these incentives do not override the basic obligation of store-based clinics to provide patients with quality care, said Dr. Patchin an AMA board member .”

The CCA responded to the AMA’s principles to promote in store clinic safe and effective operation with the following press releases.

“Responding to an American Medical Association resolution regarding retail pharmacy-based clinics, Tine Hansen-Turton, executive director of the Convenient Care Association, released a simple statement: “If it’s broken, fix it.”

Everyone agrees the healthcare system is broken. The CCA and the in store clinics are marching to the front of the line to fix it. Did the AMA march to the front of the line to fix the healthcare system? No. The Convenient Care Association has captured the healthcare repair initiative. The AMA has been idle and then reactive.

Hansen-Burton continued, “Convenient care clinics have proliferated in retail settings throughout the country due to a widespread lack of access to high-quality, affordable health care in America.
There has been a perception among consumers that there is a widespread lack of access to high quality, affordable health care in America.”

Americans love people and companies that are innovative and visionary. Americans certainly agree that we need an innovative and visionary model of healthcare to repair the broken system. Has medical practices or organized medicine provided them? It is the perception of most Americans that American medicine has not provided an innovative and visionary model.

“ Convenient care clinics collectively boast a 98 percent patient satisfaction rate, which indicates that Americans have embraced this innovative and visionary model of health care.”

I would like to see CCA’s evidence for a 98% approval rating for their care. I would also like to see how Americans have embraced the services of CCA members. It sounds like hype to me and a well crafted public relations campaign.

The AMA quotes a Harris Interactive poll that had a different conclusion.
“According to a Harris Interactive poll, while 78 percent of the public believes that store-based health clinics could provide a fast and easy way to receive basic medical services, 75 percent raised concerns about the quality of care these clinics provide. The vast majority of respondents were also apprehensive about staff qualifications in a clinic not run by medical doctors.”

CCA’s press release goes on to say;

“While the AMA convened its annual meeting this week to discuss ways to prevent patient access to convenient health care, the CCA held an annual retreat to promote accessible, affordable, price-transparent health care to all Americans.”

The above causes one to think the CCA is proactive and innovative while the AMA is defensive and reactive. In our sound bite society the CCA would win even though the organization is only eight months old and represents only sixteen corporate companys’ interests. In reality these corporate interests true concern is to profit from the 2 trillion dollars spent in the healthcare system.

The big question remains. Is the care provided good medical care by people capable and qualified to provide good medical care?
Who should be the judge of good safe medical care?

Walgreen Co. spokesman Michael Polzin stated in response that AMA members were more likely to find out “that that legislators and constituents have been demanding accessible, affordable and high-quality health care for years and that’s what retail clinics are delivering.”
The in-store clinics claim they are simply responding to what legislators and constituents were demanding for years. The assumption that they would be providing high quality health care is simply an assumption. No one has adequately defined high quality health care and CCA has not proven that the in store clinics deliver quality care. CCA simply declares that they deliver quality care.

“The CCA partners with all health care providers, including physicians,” Hansen-Turton said. “We are surprised that the AMA would take the position that it has because so many physicians and other health care professionals have accepted this new model and see it as part of the solution to our broken health care system.

Where is the evidence that physicians and other healthcare professionals have accepted this new model and see it as part of the solution to our broken health care system? I have not been able to find the evidence for this statement. Physicians who participate in the in-store clinics by signing off on the nurse practitioners and physician assistants work as figureheads. They do not know the patient or the patient’s illness. The physician’s actions cannot be interpreted as confirmation of quality medical care.

Carl Sandburg said in the Prairie Years “If you tell a lie enough times it becomes the truth.
The problem is a liar has to have a good memory.”

The executive director of CCA then goes on to scold the AMA for its position on the in store clinics.
“The AMA and CCA should be working together on solutions to improve our health care system’s efficiency and effectiveness. America has embraced the services that CCA members are providing as part of the solution, and we invite the AMA to recognize the role clinics provide in offering access to affordable, high-quality, basic health care services to all individuals.”

Carl Sandburg is right. The goal is to keep repeating the same unsubstantiated statement over and over again until it becomes the truth. In 2007 this tactic is called spin.

I believe these clinics will fail because they will not be able to generate a positive cash flow from these clinics. Perhaps the pharmacies and big box store want them as loss leaders. Rite Aid closed their in store clinics in Portland after one year.

I believe it is organized medicine’s responsibility to develop programs to teach physicians to service patients in need of basic health care services more efficiently. Physician practices must provide affordable, high quality, medical care services to patients. The medical profession must change the publics perception of physicians’ practices.
The only thing I can say to patients at the moment about in store clinics is
Let the buyer beware!!

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Look What Happens When You Are Not Looking. Part 1

Stanley Feld M.D.,FACP,MACE

I believe in-store clinics are a bad idea and they will fail. If successful these clinics can potentially put family practitioners out of business. If they are marginal, they will put a reasonable dent in the primary care physician’s ability to make a living. It is presently difficult for family practitioners to make a decent living. The development of in-store clinics is the result of the difficulties patients are having with affordable access to medical care. If patients have to go to the emergency room of a hospital, wait three hours to be seen, and incur a large bill for a simple illness the healthcare system is not being responsive to the patients’ needs. Convenient Care Clinics’ attraction to patients is they help them avoid these barriers to care.

The growth of these in-store clinics is the result of the primary care physicians’ (PCPs’) inability to set up their medical practices to match the needs and schedules of the hectic life of patients in America today. The blame should not only fall on the PCP. The blame should also fall on organized medicine’s inability to recognize and respond to the needs of the PCPs’ and the practicing physicians’ patients. Organized medicine should be developing programs to teach PCPs how to respond to the changing needs of patients’. If medical practices do not respond to the needs of their patients, someone will.

A problem with the in-store clinics is they are run by nurse practitioners or physician assistants. They are not under the direct supervision of physicians. For years, physicians have fought to prevent physician extenders from practicing medicine on their own for the protection of patients. Some in-store clinics will have a physician sign off on the medical care provided. However, the physicians will not have had contact with the patient or examined the patient. Most of the time the in-store clinics can get away with this level of care. This type of care cannot be defined as quality medical care. Hopefully the nurse practitioner or physician assistant will recognize a really sick patient. Hopefully, when they do they will send the patient to the nearest emergency room.

I believe the in-store clinics will have a difficult time achieving positive cash flow unless they raise their prices or do more in-store procedures. The financial experience of hospitals that opened DOC in the Boxes to feed their hospitals was disastrous. I predicted a decade ago that it will only be a matter of time before the hospital DOC in the Boxes would go out of business. Many physicians who started these clinics did well monetarily when they sold their DOC in the Boxes to hospital systems. It might be that the pharmacies (CVS, Target, Walgreens, and Wal-Mart) are hoping to make money when the patients are in the stores. Rite-Aid has already closed their in-store clinics in Portland Oregon.

In October 2006 a trade association for these in-store clinics was founded to lobby for insurance payments and other interests. The Convenient Care Association is a nonprofit organization representing health care facilities that provide routine, non-emergency services to walk-in patients at pharmacies.

The goal of the association is to help the in-store clinic learn to profit from acute convenient medical care. The CCA is an association of convenient care clinics that provide accessible, affordable, quality health care throughout the United States. Convenient Care Clinics (CCCs) are being launched across the country to help provide care to meet the basic health needs of the public. These health care clinics, located in convenient locations accessible to the public, are primarily staffed by advanced practice nurses, including nurse practitioners (NPs) and clinical nurse specialists (CNS). They may also be staffed by physician assistants (PAs), and/or physicians (MD or DO). CCA states; “Health care driven by the needs of the patient is at the heart and soul of the Convenient Care movement. “

It looks like the CCA has captured the high road for sound bites. The statement that healthcare is driven by the needs of the patient is at the heart and soul of the convenient care movement is a very powerful statement. It assumes that medical practices have failed. Their statement is in contrast to the public’s perception of non user friendly medical professional clinics.

I have recently received several comments from patients who were examined and blood tested in their physician’s office. The results of the examinations were called to the patients by the physician nurses. The nurses told the patients the results and physicians’ recommendations for specific treatments. One person asked to speak to the physician. She was told she had to make another appointment with the physician. The recommendation was to start a statin. The patient was afraid of the side effects of the statin. The nurse was going to call in the prescription. The writer stated “ so much for your emphasis in your blog has been on the importance of the patient physician relationship.”
“This encounter does not speak well for the patient physician relationship.” I must say the patient was correct. My hope is this is an infrequent occurrence.


You will notice the in store clinics are run by business people and corporations. They are not run by physicians. The primary goal is to make money. The vehicle is providing care that the primary care physician should be delivering.

The AMA in its June meeting passed a policy resolution concerning in store clinics:
“With quick clinics opening in chain stores across America staffed by nurse practitioners and physician assistants, the AMA House of Delegates made clear during the Association’s Annual Meeting that, while it’s not against the facilities in principle, it believes they are no substitute for a long-term relationship with a doctor.”

If the consumer’s clinical experience with the medical profession is negative one and CCA publicizes that its health care is driven by the needs of the patient and those needs is at the heart and soul at the in-store clinics, and you are a patient in need of convenient care, which would you choose?

If CCA’s claims were true, the answer to the question is obvious. CCA sponsored by the corporations listed is in the midst of a huge public relations campaign and media blitz to capture the hearts and minds of the public. CCA’s campaign is clever and might be extremely effective. Everyone loves the underdog, the David who is going to slay the Goliath (the AMA). CCA’s sound bites are perfect for our sound bite society. It looks as if CCA has caught the AMA flatfooted. The AMA’s response has seemed anemic so far.

  • Stephanie

    I appreciate that your blog covers all angles of this cuurent trend in healthcare in the US. I personally have to say that the “Doc in a Box” clinics have been a godsend in my experiences. I am an educated business woman, mother of a 3 year old child and a wife. All of us have insurance coverage and a primary care doctor that I have been going to since I was 18 years old (I am now 32). Within the last couple of years it has been extremely hard to get appointments within 2 weeks of a call…and if it’s an emergency (when your child is screaming due to an earache, believe me it’s an emergency) I get the old “then you should go to the emergency room” statement from the attendants at thier offices. When I DO get in to see her, I wait over an hour even if I have an appointment, and spend 90% of the time there with a NP anyway…I see my doctor for a whole 5 minutes. When you work 8 hours a day and run a household, time is very valuable. I have been able to visit The Little Clinic on a Friday night for my childs fever, sat with the NP who was extremely thorough with us, and had a prescription in my hands within a half hour and didn’t even need to make an appointment. She also made it a point to advise me to go to my doctor when I could get in to assure that the problem was resolved with my child. I understand your perspective as a MD, but the medical community has not addressed these issues which are rampant in every state and with most doctors, therefore leaving the door open for these types of facilities to take care of us when our doctors fail to do so.
    I think these clinics are a very valuable asset for communities where they are located and are a wonderful compliment to family healthcare when a doctor can not (which is most likely) provide services due to hours, or unavailable appointments.

  • RJS

    …and Stephanie’s comments completely nullify anything the ivory tower types have to say about the matter. You included.
    It doesn’t matter what the AMA says. Even doctors don’t really care what the AMA says because they’re so out of touch with current issues in medicine. No one cares what the motivations behind a company are so long as the end user experience is good. It’s a non-sequitur. A cheap shot that doesn’t have any place in this discussion.
    Until you can compete on the same playing field as the Retail Health Clinics, you’re going to lose.
    “It assumes that medical practices have failed.”
    Well obviously the system has failed, otherwise these retail health clinics wouldn’t exist in the first place. The niche wouldn’t exist if the current way of doing business — yes, BUSINESS — was good enough.
    It ain’t rocket science.
    The problems is yours — as in the average PCP — not the RHC. Until you can meet the average mother’s needs — same-day appointments in a reasonable amount of time — you lose. And no amount of hot air is going to change that.
    Protect your turf if you want. I would if I were in your shoes. But I’d do it more intelligently than standing on a soapbox. Compete or die. The choice is yours.

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“Keep Your Head In There !”

Stanley Feld M.D.,FACP,MACE

This is another in my series of stories about my childhood. You could guess that I am baseball nut. I was also a pretty good baseball player. I guess it was the result of watching all those New York Yankees and New York Giants games. I made the William Howard Taft baseball team. This is one of my baseball stories.

We were playing Cardinal Hayes High School at McCombs Field in the shadow of Yankee Stadium. This was the first or second game of the season. Cardinal Hayes is a well known catholic school in the Bronx. It always seemed to me that the guys on the Cardinal Hayes team looked bigger and stronger than we did. Someone told me they were a year older than us.

I am a lefty and therefore played first base. The only other position they put lefties in those days was right field. I always had the impression that the worst guy on the team was put in right field. I chose first base and turned out to be a pretty good first baseman.

It was a beautiful spring day and we were all excited to get the game started. Cardinal Hayes was designated the home team so Taft High School batted first. Being lefty, I batted second. SM our 5’4” 130 lb. centerfielder batted first.

The Cardinal Hayes pitcher was a very tall guy (about 6’4”). He looked like a giant on the mound. SM and I were in the batters circle warming up for our at bat. I noticed the big tall guy was fast but he couldn’t get a pitch over the plate.

I told SM to be careful because this guy was wild as hell. He assured me not to worry. Anyway the first pitch went right at SM and hit him in the head. We did not have helmets in those days. SM was unconscious and the ambulance was called.

It frightened the heck out of me. I had already made my mind up on how I was going to handle myself with this pitcher. Our coach HL knew me well. He had an idea how I was going to handle myself.

I was a pretty smart kid, actually within the top 1% of my class. My father had already decided my career path. He told me I could do anything I wanted to do as long as I became a doctor. It was settled. I had to strike out quickly and not give this pitcher a chance to hit me in the head.

If I got hit in the head there goes medical school. He could knock my brains out. I knew I could not disappoint my father. He would kill me. My strategy was set. I would swing at the first three pitches no matter where they were. HL, our, coach read my mind. He came running out of the dugout as I was approaching the batters box. There was a three quarter hour delay of the game in order to get SM to the hospital. I had plenty of time to think. HL came running up to me and shouted, “Stanley I want you to keep you head in there.” The last thing I was going to do was keep my head in there and HL knew it.

I had already concluded that I was going to blow this at bat. This guy would be out of there by the time I was at bat again. Needless to say, I had trouble getting out of the way of four wild pitches. They were so wild I did not have a chance to swing and miss. To my luck and my baseball career he walked me on four straight pitches. It disrupted my strategy. All I wanted to do was get safely into the dugout.

It turned out the 6’4” Cardinal High School pitcher walked the next two batters and was taken out of the game by his coach. We went on to score three runs and win the game despite their size and strength. It was not because we were so great. We just stuck in there even though we did not want to.

The lesson to be learned is never put you head in front of a fast ball. The healthcare system lesson to be learned from this story is even though they (the healthcare insurance industry) are bigger, more powerful and stronger you need to stick in there and do the right thing.

Remember there would be no healthcare system without the primary stakeholders, the patient and the physician.

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Can Employers and Patients Trust the Healthcare Insurance Industry? Part 3

Stanley Feld M.D.,FACP,MACE

Medicare Part D is the drug benefit insurance for Medicare recipients.
The government constructed a program where the healthcare insurance industry sells insurance to provide prescription drug coverage.

There are various plans available from various healthcare insurance companies charging various prices. The healthcare insurance industry would call it competitive pricing. However, without real price transparency, multiple pricing is meaningless. The real important price is the price the patient is charged against his doughnut verses the price the healthcare insurance company pays the pharmacist. The various plans are confusing, to say the least. The plan outlines have been standardized by the government. The prices for the various healthcare companies’ plans have not been standardized.

If we drill down deeper, the price the healthcare insurance company pays the pharmacy has not been standardized. The industry negotiates that price with the various pharmacy chains. The price the healthcare insurance company charges the patient is applied against the patient’s doughnut. The patients’ doughnut (coverage gap) kicks in after the patient purchases $2200.00 of drugs. Therefore, the higher the price the healthcare insurance company charges the patient’s account for a medication the faster the patient hits the doughnut and the faster the patient pays full price for the medication. The price the healthcare insurance company applies to the patient’s doughnut has nothing to do with the price the healthcare insurance company paid the pharmacy for the drug. This is the place the fairness to the patient breaks down. Many seniors who have purchased these plans, in order to feel financially secure, are now discovering the deception in these various Medicare Part D plans.

Richard Jellicoe writes; I have Medicare Part D from AARP. UnitedHealthcare
is the carrier.
UnitedHealthcare offer drugs with co-pay almost twice what I can get the same drug via cash. I guess that is how UnitedHealthcare can pay its fired CEO $5 million a year in retirement.”

He goes on to say:“What amazes me is that AARP endorsed this company when it was time for 2007 Medicare sign up and it was not till many months later that AARP acknowledged that it’s endorsement of UnitedHealth care was a paid endorsement. And AARP is supposed to help the seniors.”

Consumers can not assume the government will protect them. It has not in the past. You can not assume that organizations like AARP who advertise that they will protect you will protect you. Consumers must become sophisticated buyers of healthcare products. Consumers have trained themselves to become sophisticated buyers of other products such as automobiles, electronics, food, clothing, and housing. They have learned to receive good value and have created competition among vendors for their dollars.
The healthcare insurance industry continually says that consumers are not capable of dealing with healthcare pricing. If you think about it our most precious possession is our health. We should be most responsible for our health and the price we pay to maintain it. I know consumers can be very smart about healthcare consumption if they owned their healthcare dollar.

Mr. Jellicoe goes on to say “I have been reading everything I can find on UnitedHealth Care. I have been amazed on how those in the know understand the lack of ethics at this company. The thought of 90% of Nevada being under the control of this corrupt company frankly scares me to death.”

Mr Jellicoe, you have defined a monopoly. Our government is supposed to be working for us and not for the healthcare insurance industry. Consumers have to demand that our government does something about your complaint. The problem is most consumers are not aware of these abuses. Our sources of information (mass media) do not provide detailed information. Detailed information does not hold our attention and attract advertisement revenue. We are an inpatient, sound bite society seeking sensational stories. However we become very concerned when an issue affects us directly. The broken healthcare system is directly affecting us all now. I believe as a people we are very smart. We are starting to demand a solution. However, the government has put the fox in the hen house to protect the hens. The hens will not be protected.
One of the reasons I am writing this blog is to try to get the people who are not sick to pay attention to what is going on. The healthcare system needs to be fixed before we get sick and need medical care and medical drug benefits.

Many years ago a well connected patient of mine was an advisor to several U.S. Presidents. He was working on stopping drug trafficking to the United States from Mexico and South America. Hundreds of millions of dollars was laundered through Miami banks. His assignment was to convince the banks to stop laundering drug money. One day I asked him why congress doesn’t just pass a law revoking the banking permits.
In his frustration, he said “most people do not know what they vote for. They do not express their opinions to how their congresspersons should vote in congress.” He said the law could not be passed because of the banking lobbys’ influence in congress. He also said” we as a people get what we deserve. We have the right to demand the appropriate action. We do not exercise that right. Until we start paying attention to what is going on and get rid of the politicians who do not do what is right out of power nothing will change”.

“All of the news in the press is about unimportant issues. Th “news” is a distractions from the real needs of the people. None of the important issues are covered in detail so that we rarely know the real issues. “

It is important to notice that the only easy way Mr. Richard Jellicoe can express his frustration is through the new media, the blogosphere. Will the new media be effective? I hope it will. Americans’ are not a stupid people. Our freedom of speech is precious. Social networking of a concerned population will change the paradigm of healthcare insurance to a consumer driven healthcare paradigm.

  • Dwight Brisco

    Controll your health costs by asking questions
    We all complain about the cost of healthcare, but you could be adding to the costs by not asking questions:
    1) If your doctor is prescribing you drugs, ask if there is a generic version available.
    2) If you’ve been requested to go to a different location for lab tests, inquire if the services can be performed by your plan’s network provider.
    3) If you’re a Medicare supplement recipient, inquire if the doctor or hospital either accepts Medicare’s assignment or if they bill more than what Medicare will pay; This one inquiry could save you possible thousands of dollars.

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Can Employers and Patients Trust Healthcare Insurance Companies? Part 2

Stanley Feld M.D., FACP, MACE

Michael O’Grady of Grosse Pointe Farms, MI expresses the mistrust between the employers and the healthcare insurance industry much better than I can. He also confirmed for me that people on the internet are not only thinking about the problem of healthcare and what I am saying but are upset about the terrible things that are going on in the healthcare industry.

“I must comment on two key components of the healthcare system I felt were blatantly missing from your blog. ”

“The first was in your list of stake holders. No where to be found are the employer groups who actually fund most of the health care in this country.”

At the time I received Michael’s comment he was correct. I was concentrating on how the 46.7 million uninsured can be insured. The key answer is for employers to be able to provide tax deductible funds to their employees in order for the employees to purchase their own healthcare insurance policy with their own money. If an employee chooses not to buy healthcare insurance he does not get the money.

This maneuver accomplishes three things. First, it gets the employer out of the healthcare insurance loop. Employers may stay in the loop if they think they can protect their employees. Second, the employee relieves the employer of the burden of negotiating a premium at a tremendous disadvantage. Employers have noticed that they have be less than effective in keeping premium cost down in recent years as expressed by EC previously. Third, it puts the patient in charge of his healthcare dollar. This creates a huge buyer pool and forces the healthcare insurance companies to develop innovative and cost effective products. If they do not become efficient, someone will come along and take away the business.

Unemployed or self employed consumers can buy healthcare insurance with pre-tax dollars. This level playing field does not exist today. A self employed or unemployed person must be able buy insurance with after tax dollars. Notice that this simple change in the tax law would weaken the healthcare insurance industries hold on healthcare and force them to compete for the healthcare insurance dollar.

President Bush has called for this tax reform. However, there has been no follow-up. It seems he has backed off. Congress has no interest in passing this logical law that could help cure the uninsured problem. It would be putting power in the hands of the consumer. It has been opposed by the healthcare insurance companies lobbying effort. The evaluation of the Congressional Budget Office seems to point to a positive outcome when read in detail.

“Although you appear to have many good ideas, and are a proponent of changing many of the necessary evils of the broken health care system, you are in fact a stake holder.”

Michael, I am presently a consumer stakeholder. I retired from an excellent practice of Clinical Endocrinology in order to devote adequate time to help repair the healthcare system for the benefit of the consumer and the survival of the patient physician relationship. I believe the patient physician relationship is a critical therapeutic element in the care of sick patients. Making medical care a commodity will destroy medical care in this country.

“The employers are the one in the end who actually foot the bill for most of the health spend in the U.S. The unfortunate circumstance is they are being led blindly down the path of excessive baggage by consultants and their partners, who we refer to as BUCA (Blues, United, CIGNA, and Aetna).”

Michael, you are correct. The large employers have human resource officers whose responsibility is to choose the correct healthcare insurance plan for its employees. The BUCA have learned to manipulate and confuse the human resource officers. It gets back to the old question: would you let your human resource officer, or insurance company purchase your food, your clothing or your car? You might let the HR person negotiate for you. However you are the owner of the purchase and would be responsible for the choice. Your unwillingness to let the HR person negotiate for you would increase if the purchases became more confusing and unsatisfactory. You would want control.

The seller (healthcare insurance company) is motivated in the present system to confuse the HR officers. The seller also has the advantage because the number of people in a single company is small compared to the total number of people in society as a whole. The key to repair is to motivate the seller to compete. In a real price transparent environment the healthcare insurance industry would be competing for customers. All the necessary changes would have to occur at the same time for it to be effective.

“The second piece I felt that was missing was the reimbursement methodology in place today prevents any fix of the health care system. The PPO discount system is a disaster and adds between four to six billion unnecessary dollars to the health care system each year. These are dollars employer groups are paying to the BUCA’s and PPO networks in access fees each year, to provide provider discounts. Twenty years ago there may have been a value to an employer group to receive discounts in exchange for steering patients. There may have been a value to a provider to provide discounts in exchange for steerage. These days are over, and retail is for suckers.”

Michael, you are right on target. No one pays retail unless they want to. The reason Sam Walton went from a bloomer salesman to the largest department store on the globe is because he learned how to provide the best price with a good quality product to the consumer . Consumers figured out which price and product was best for them.

“So why should employers pay four to six billion a year for what really amounts to retail pricing? Transparency? Does it matter if a provider makes transparent their charge master? Each network or carrier has their own deal with each provider that is considered proprietary. What is being charged by the provider is irrelevant, thus making any HSA plan doomed to failure.”

Price transparency is bogus in healthcare lingo presently. The automobile industry is getting close to real price transparency. They are not there yet. The electronic industry is close with organizations like c/ and The consumer is not stupid. When they are in control or their healthcare dollar they will force real price transparency. Actually, they are getting smarter each day.

“A new reimbursement methodology needs to be adopted. This new methodology needs to be developed in partnership with employer groups and providers. There is a necessity for administrative functions within the health care system. Third party payers and insurance carriers do provide a valuable service. Unfortunately, BUCA now is the majority stake holder in health care. Until this changes, and employers and providers begin to work together, BUCA and the consultants will continue to take advantage of this lack of connectivity and continue the path of absolute disaster.”

Bravo, Michael O’Grady. The easy way to accomplish your goal is to get the employer out of the picture. As EC pointed out the employer really wants to provide healthcare insurance to his employees. However, it is becoming an impossible and over costly task. Let it be between the patient and the physician. Reducing the physicians overhead by 20-30% will give the physician the ability to reduce his price. If he doesn’t he will suffer the consequence of the consumer walking with his feet and pocket book.

It does not have to be complicated. The primary stakeholders are the patients and the physicians. They should be the interface for the medical care transaction. If a hospital is too expensive, he would send his patients to another hospital. If patients had no choice of hospital the government should impose regulations on the hospitals to reduce the price. It can be done. It can also be profitable for everyone except the stakeholders that profit from the 150 billion dollars of administrative waste.

The healthcare insurance companies would once again be converted to a 6% broker and not the unconscionable owner of the healthcare system.

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