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Chicago, Chicago, It’s a Wonderful Town!

Stanley Feld M.D.,FACP,MACE

Springtime in Chicago can be totally unpredictable. One day it’s hot and sunny and the next day it’s cold and rainy.

Last weekend was a father and son bonding weekend for Daniel and me. Daniel is the younger of my two sons. Brad is 42 years old and Daniel is 39. I try to have a weekend alone with each boy every year with nothing scheduled except what Dad figures out.

Daniel and I had two full days in Chicago counting Friday afternoon and Sunday morning. I started to think about what we were going to do on Wednesday. Thanks to the weather O’Hare was closed down for three hours so we landed late right in the middle of Friday afternoon traffic. The late arrival slowed my plans down a little but we adjusted. The weekend is not about going to different cities; it is about being with each other.

We spoke non stop in the one hour taxi ride into downtown. I even got the taxi driver to contribute to my plans for the weekend. Daniel and I were energized and hit the streets right after we checked in.

Our first stop was Millennium Park.Frank Gehry created an extra ordinary space over an ordinary parking lot next to the Chicago Art Institute. This magnificent open space is enjoyed by many people from 6am to 11 pm daily. In our ever increasing commoditized society, it feels good to know someone out there is thinking about us as human beings with sensitivities, emotions and feelings that need nurturing.

The park is a huge quiet space in the middle of a noisy and potentially anxiety provoking city. The visual stimuli of the space are invigorating.

Next, we walked down Michigan Avenue (the magnificent mile). It has not lost it glitter for me. We stopped into the Atlas art gallery to participate in an art opening at 6pm showing of JalinePol’s work. Daniel and I had a great time at the opening.

At 7 pm it was time for dinner. Traditionally, Daniel and I eat once a weekend in a steak house reproducing his college days. I chose Sullivan’s. I talked Daniel into sharing a steak. The concept of sharing is important because it cuts the calories in half. Cecelia and I always do it.

After dinner it was on to on Rush Street. I had a fantasy from the past of a great jazz concert in a perfect venue. It turned out they were all clip joints today. We passed and took a taxi to the hotel to watch the end of the Dallas Mavericks game. We finally won a game.

It was warm and muggy after the rain. The next morning it was cold, dry and windy. We worked out at the hotel fitness center rather than jog along Lake Michigan. Then were off to the Historic District Architecture Tour conducted by the Chicago Architecture Foundation. This is a great tour. The Architecture tour of the Chicago River did not start until May 1. It is a great tour as well.

Next we went to “Art Chicago” and “Next” in the Chicago Merchandise Mart. We took the EL
for the experience of riding on an elevated train. The ticket machine was a little tricky. However we figured it out with the help of an attendant.

“Art Chicago” was an endless visual journey of contemporary art presented by art galleries from all over the world. This was another great but tiring experience. Daniel had to sit down and close his eyes as I had to finish Aisle 5 and 6.

Even though our feet were going to fall off we had to go to the Art Institute of Chicago. I wanted to see the Ed Ruscha show.

We arrived at the hotel at 4.30 pm. We passed out for about an hour nap, dusted ourselves off and hit the road again. Now we were off to the Italian Village Restaurant. I had never heard of it before and was afraid it was going to be tacky. It is an eighty year old Chicago institution with fair food, dynamite ambiance and more people I could imagine in this size restaurant space.

We left the restaurant at eight o’clock and had ten minutes before Jersey Boys was going to start. I figured if they had empty two seats we would get them if they were discounted since Daniel had not seen Jersey Boys. Chicago still has something to learn from New York. They would not budge on the price even after I told them having one empty seat after the show started was like trying to sell a rotten tomato. Your asset is worthless. The ticket salesman said rules are rules.

Next stop the Rock and Roll McDonalds on Ohio. I was disappointed when I found that McDonald’s Corporation had knocked down the old place and replaced it with an ultra contemporary store. Somehow the romance of McDonald’s creation was gone. The memorabilia of the 50’s, 60’s, 70’s, and 80’s remained enshrined behind glass wall cases. However, none of the customers seemed to connect to the exhibit.

Daniel and I walked about 15 miles on Saturday. Unfortunately, we did not have time for a Cubs game. We slept well. Sunday was another day.

We decided we would try a real old fashion Chicago breakfast. We tried the famous Eleven City Diner in the 1100 block of Washburn. This place is a very happening place for Sunday breakfast. After breakfast I decided I could not possibly eat anything for lunch and perhaps dinner. Every city has its institutions and this is one of Chicago’s.

We had more stimulating conversation during breakfast as we were winding down another special father/son weekend. It is great to be the father of such wonderful boys. They are loving, thoughtful, perceptive, sensitive, innovative and intelligent human beings. What else can a father want from his kids? It is a great pleasure to be involved in their lives. As I said after the weekend with Brad, every father should plan weekends alone with your children.

Whether or not you can plan a get-away weekend,, I have this advice. If you are a father or mother give your son or daughter a hug and a kiss. If you are a son or daughter give your mother and father a hug and a kiss. I believe love and the person to person connection is good preventive medicine.

  • Daniel Feld

    Great weekend Dad! Let’s do it again after my feet get some rest.

  • ClizBiz

    Great post! A good friend of mine just moved to Chicago and I will share this with him.
    Also, for what it is worth, Chicago always has the best looking men – you and Dan undoubtedly enriched that image …

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The Primary Care Physician Shortage Emphasized By Universal Coverage In Massachusetts

Stanley Feld M.D.,FACP,MACE

Medical students are choosing procedure oriented subspecialties rather than family practice or internal medicine (Primary Care). There has been a 50% decrease between 1997 and 2008. This trend resulted from the fact that it is difficult to make a living in a non procedure oriented practice. Cognitive medical care and positive physician patient relationships have been devalued. The government and the healthcare insurance industry have not adequately compensated cognitive medical care in an attempt to save money.

“Once they discover that she is Dr. Kate, the supplicants line up to approach at dinner parties and ballet recitals. Surely, they suggest to Dr. Katherine J. Atkinson, a family physician here, she might find a way to move them up her lengthy waiting list for new patients.”

“Massachusetts primary care practices like this one in Shelburne Falls have been trying to manage an influx of new patients. Those fortunate enough to make it soon learn they face another long wait: Dr. Atkinson’s next opening for a physical is not until early May — of 2009”

Positive patient physician relationships have an important therapeutic effect. The patient physician relationship is disappearing as primary care physicians have less time to relate to their patients. They have to see more patients in a shorter time in order afford their practice overhead.

“Modest reimbursement, medical school debt, an aging population and the prevalence of chronic disease have each played a role in primary care physician “.

The primary care physician shortage widens with increases in population, decreases in the uninsured in Massachusetts, overuse of the healthcare system by first dollar insurance coverage, increases in obesity and subsequently increases in chronic disease and the decrease in reimbursement to the primary care physician.

“Since last year, when the landmark law took effect, about 340,000 of Massachusetts’ estimated 600,000 uninsured have gained coverage. Many are now searching for doctors and scheduling appointments for long-deferred care.”

The result has been an unintended consequence leading to the realization that Massachusetts has a severe primary care physician shortage. It also has resulted in the state’s widening budget deficit. The solution to the problem is to change the approach to care. The primary care physician has to be taught to extend his intellectual property.

“It’s a recipe for disaster,” Dr. Sereno said. “It’s great that people have access to health care, but now we’ve got to find a way to give them access to preventive services. The point of this legislation was not to get people episodic care.”

Dr. Serno is right on target. There are not enough Clinical Endocrinologists to take care of all the patients with Diabetes Mellitus. There are not enough Clinical Cardiologists to take care of all the heart disease patients. There are not enough Clinical Pulmonologists to take care of all the lung disease patients. Primary care physicians have to install systems of care of chronic disease in their practices. They initially see most of the chronic disease patients. The complications of chronic diseases absorbs ninety percent (90%) of the healthcare dollar. These costs can be decreased by at least 50% with effective chronic disease management.

“Whether there is a national shortage of primary care providers is a matter of considerable debate. Some researchers contend the United States has too many doctors, driving overutilization of the system.”

It seems obvious there is a growing shortage of primary care physicians. Politicians always want to do a study. All they have to do is go into a typical physician’s office and observe the demands on the physicians and the problems the physicians have.

“But there is little dispute that the general practice of medicine is under strain at a time when there is bipartisan consensus that better prevention and chronic disease management would not only improve health but also help control costs.”

“With its population aging, the country will need 40 percent more primary care doctors by 2020, according to the American College of Physicians, which represents 125,000 internists, and the 94,000-member American Academy of Family Physicians. Community health centers, bolstered by increases in federal financing during the Bush years, are having particular difficulty finding doctors.”

There are many who say we have more primary care physicians than previously. I believe all of their arguments blur the issue. The truth is every community there is a shortage of primary care physicians.

“I think it’s pretty serious,” said Dr. David C. Dale, president of the American College of Physicians and former dean of the University of Washington’s medical school. “Maybe we’re at the front of the wave, but there are several factors making it harder for the average American, particularly older Americans, to have a good personal physician.”

“Studies show that the number of medical school graduates in the United States entering family medicine training programs, or residencies, has dropped by 50 percent since 1997.”

Physicians are not becoming primary care physician because they can not afford to become primary care physicians. The Medicare reimbursement for a half-hour primary care visit in Boston is $103.42 while reimbursement to a gastroenterologist for a colonoscopy requiring roughly the same time would be $449.44.

“Dr. Atkinson, 45, said she paid herself a salary of $110,000 last year. Her insurance reimbursements often do not cover her costs, she said.”

“I calculated that every time I have a Medicare patient it’s like handing them a $20 bill when they leave,” she said. “I never went into medicine to get rich, but I never expected to feel as disrespected as I feel. Where is the incentive for a practice like ours?”

The physicians’ goal is to help people get well. They also want to earn a reasonable livelihood for their efforts and intellectual property. Physicians have not done a good job arguing this point.

Organized medicine (AMA,AAFP,ACP) has not done a very good job of defending the physicians’ value.

As time passes the problems with the delivery of healthcare will escalate as the secondary stakeholders, the healthcare insurance industry, the pharmaceutical industry, and hospitals thrive making egregious profits while the primary care physician shortage intensifies.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

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Can You Believe This? Health Savings Account Threatened By The “Taxpayer Assistance and Simplification Act

Stanley Feld M.D.,FACP,MACE

The House of Representatives passed a bill called the “Taxpayer Assistance and Simplification Act” last week that will essential destroy Health Savings Accounts and the quest for consumer independence from the government’s control of the healthcare system. I have criticized HSAs in the past because they only give consumers partial control and not full control of their healthcare dollar. If you do not use the money you lose it. In my opinion this creates a perverse incentive that does not stimulate wellness. It stimulates potential abuse. Patients keep the money they do not spend with my Ideal Medical Savings Account. The MSA would increase incentives for wellness and decrease abuse, because if patients abused the system they losing their own money.

“Democrats have made affordable health care a mainstay of their election agenda, but apparently only if you’re willing to get insurance through the government. Witness their stealthy assault on Americans who prefer the private-sector option of Health Savings Accounts.”

No one in the Democratic Party dominated House of Representative nor the Democratic Party’s presidential candidates seem to understand the government can not afford to have a government dominated system. It is also clear they do not trust patients to pursue their vested interest.

“The House passed legislation on Tuesday, the mis-named “Taxpayer Assistance and Simplification Act,” that contained the awful provision that would throw a mountain of paperwork at Health Savings Accounts.”

<President Bush sent a note to congress stating that he would veto the bill if it contained the anti HSA provision. I do not think the Senate will accept the provision either. The frightening thing is the lack of understanding by the Democratic Party of what is necessary to Repair the Healthcare System.

“A key player here is Ways and Means Health Subcommittee Chairman Pete Stark, whose main purpose in politics is to give the U.S. a government-run health-care system. He is a known opponent of HSAs – once comparing them to “weapons of mass destruction” – because they introduce more individual choice into the health-care marketplace.”

“Mr. Stark and his friends want to impose the same bureaucratic overhead even on spending that consumers do with their own money. The Senate should stop this one dead in its tracks.”

I thought Pete Stark finally understood the folly of his thinking. He trusts neither physicians nor patients. I was misled by his comments in Forbes magazine when he admitted he made a mistake with his Stark Laws.

“This week, the House passed legislation that included a provision to require every HSA transaction be reviewed and verified as a legitimate medical expense. Democrats say this is to ensure that consumers are using their tax-free withdrawals for a knee replacement, rather than a new iPod. In reality it adds a layer of bureaucracy that could sharply reduce the appeal and cost savings of HSAs.”

Presently the healthcare insurance industry administers these health savings accounts and does not permit misuse to occur. Maybe the only way the Democratic Party can reach its goal of government controlled single party payer healthcare system is to destroy HSAs?

“Pushing for the provision was a company called Evolution Benefits, which has patented a system for the substantiation of health-care expenses. Evolution’s lobbyist, John McManus, was the former staff director of the Health Subcommittee under Republican Bill Thomas.”

Unfortunately, this is how the government works. It is influenced by vested interested other than the people it is suppose to represent. Republicans are furious at John McManus, a former Republican congressman’s staff director now a lobbyist.

“Liberals claim HSAs are insurance for the “healthy and wealthy,” but there’s little evidence this is true. “

There is no evidence that HSAs are only for the healthy and wealthy. It is a potential mechanism for the government to subsidize insurance for the poor and not so poor to promote patient responsibility and stimulate a substantial reduction in cost and increase incentive for citizens to improve healthcare habits. All congress has to do is pass a law saying everyone automatically will be insured using a community rating system and pre tax dollars.

“The high deductable insurance permits the insured to open an HSA and make an annual contribution up to $2,900 for an individual in 2008, which he can use to pay for ordinary health needs. Savings not spent in any given year can build up tax-free for medical expenses. HSAs also give consumers more reason to care about prices, bringing much-needed market discipline.”

A family contribution is over $5,000 in 2008.

“ In any case if people cheat on their HSAs, they are only cheating themselves.”

I wonder how many congresspersons really understand the problems in the healthcare system and what will motivate the people they represent?

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

  • Ryan Murphy

    Dr. Feld,
    You are absolutely wrong, with Health Savings Accounts the individual does keep the money if they don’t use it. HSA’s were designed with precisely this premise.
    See more information here:

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Costs Soar For Mass. Health Care Law

Stanley Feld M.D.,FACP,MACE

I hesitate to spend more time on the impending failure of the new Massachusetts healthcare law. However, the results of this experiment have consequences for the up coming presidential election. I have previous stated that Hillary Clinton healthcare plan is similar to the Massachusetts plan. The difference is Ms. Clinton would have the government plan competing with the insurance companies plan. It is destined to fail. The outcome will be the complete government take over of the healthcare system, an entitlement plan America can ill afford.

America can not afford the future value of our present entitlements. The debt will be compounded by adding the entire population to the healthcare insurance rolls. Politicians at all levels have ignored the debt problem of 100 trillion dollars.

Hopefully, someone will wake up and realize the present healthcare insurance system must change. .

“Two years after the state’s landmark health law was signed, the cracks are starting to show.”
“Costs are soaring and Massachusetts lawmakers are weighing a dollar-a-pack hike in the state’s cigarette tax to help pay for a larger-than-expected enrollment in the law’s subsidized insurance plans”.

I believe the cracks were present before the law was passed. Governor Romney was going to run for President and needed an innovative and heroic accomplishment. A bipartisan healthcare law with mandated universal coverage was politically driven and foolishly passed.

“But that hasn’t dampened enthusiasm at the Statehouse. Leaders there boast that in the two years since former Gov. Mitt Romney signed the law with a choreographed flourish at historic Faneuil Hall, the number of insured residents has soared by nearly 350,000.”

The lawmakers in Massachusetts are living in a dream world denying the problem of the program’s cost and the increased state spending deficit. The state is raising the healthcare premium, decreasing the healthcare coverage and increasing taxes. Nonetheless, the state can not afford the entitlement.

“Along the way the law has been scrutinized by other states, sparked the ire of critics on the right and left, and drawn the attention of presidential candidates.”

The blind are leading the blind. One state develops a healthcare system that does not work and all the others try to jump in with slight modifications of the same plan with its mistakes.

“It’s the very first question I get when I’m with other governors,” said Massachusetts Gov. Deval Patrick. “I don’t think anybody is prepared to say that what we have done here in Massachusetts is necessarily the formula for the rest of the country or for a national reform, but at least we are trying.”

Massachusetts has tried to maintain the private healthcare insurance system without reforming the private healthcare insurance system. It has to fail because the basic problem is the incentives for the private healthcare insurance industry have not been changed.

“The Massachusetts reform law remains the focal point for other states and the nation in trying to figure out if state-based reform is possible,” said Alan Weil, head of the Maine-based National Academy for State Health Policy. “It’s the biggest game in town.”

“One of the most radical fixtures of the law is the so-called “individual mandate” — the requirement that virtually everyone have health insurance or face tax penalties.”

Policy makers are always thinking in punitive terms toward patients and physicians rather than creating incentives for people. I believe people should get a tax credit for losing weight, controlling their chronic disease and not over utilizing the healthcare system. They should be rewarded for good health and not a penalized for not wanting to pay an inflated healthcare insurance premium.

“Anyone deemed able to afford health insurance but who refused to buy it during 2007 already faces the loss of a $219 personal tax exemption. New monthly fines that kicked in this year could total as much as $912 for individuals and $1,824 for couples by December.”

How can a government determine the reward? It could be difficult. It is easier for the government to collect a penalty for a person not having insurance. The reward should be contributed to the person is tax free retirement fund. Patients should own their healthcare dollar. They would be motivated to shop for the best price. The more they saved the more they would have added to their retirement fund. If someone had a chronic disease and controlled the disease with proper treatment they should receive a reward. The payer could afford to give that person a bonus because of the money saved on the treatment of complications of that disease. My plan would in effect shift responsibility and motivation to control cost to the patients. It would motivate patients to fight the War on Obesity.

“Michael Tanner, a senior fellow at the libertarian-leaning Cato Institute, said the law has been an unqualified failure. He also noted the vast majority of the newly insured are receiving subsidized care.”

“They said it would get us universal coverage and reduce costs and it’s done neither,” Tanner said. “

The biggest problem is the rising costs of healthcare. Neither the Massachusetts plan nor any of the other state plans have done anything to change the motivation of the drivers of the old healthcare system.

“The law — and its individual mandate — has become a key talking point in the presidential race.”

None of the presidential candidates have even spoken of the importance of patient responsibility. If the government set the appropriate rules it could eliminate all the administrative waste in the system and decrease the complications of chronic disease. We would then have an affordable healthcare system. This can be accomplished by motivating and not punishing the patients and physicians.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

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Medicare Finds How Hard It Is to Save Money Part 2

Stanley Feld M.D.,FACP,MACE

Whatever happens with this particular program, Medicare says it wants to keep experimenting. “We’re not giving up on this stuff,” said Mr. Kuhn, the Medicare deputy. “We definitely want these programs to work.”

Mr. Kuhn is referring to Medicare’s $350 million dollar disease management program that has failed. I hope Mr. Kuhn is realizing that the chronic disease management programs must be systems of care directed by physicians in order to succeed. The systems have to be patient centered with the physician being the captain of the care team.

“Medicare is doing exactly what we should want Medicare to do — to test different life forms of disease management and see what works best,” said Dr. Arnold Milstein, the chief physician for Mercer Health and Benefits, a consulting firm. But, he said, “This particular form of disease management is not looking promising.”

Dr. Milstein works for a health benefits consulting firm. He makes no judgment on the defects in the study.

“Medicare is already exploring other ideas, like the development of so-called “medical homes,where a doctor with a team of other professionals oversees a patient’s care. A few doctors’ groups involved in a separate Medicare experiment have reported some success in saving the government money by more actively managing their patients’ care.”

The concept of “medical homes” is a variant of “Focused Factories”. Focused Factories have been championed by Regina Herzlinger at least 15 years ago as a plan to modernize medical care.

I believe the concept of “medical homes” will work. It is physician directed system focused on becoming expert in the care of one disease with a team of physician extenders. The patient is at the center of the management team. I can not find the design of the study Medicare is doing. “Medical Homes” was developed by the American Association of Medical Colleges. (AAMC).

The problem with the American Association of Medical Colleges performing the study is most patients are taken care of by physicians that are not in an academic setting. The system must be tested utilizing practicing physicians in a real world setting.

Twelve years ago I present the concept of AACECare as a system of intensive diabetes self management. It is a system of care with the patient being at the center of the diabetes management team and the Clinical Endocrinologist being the captain of the team that includes nurses, dieticians, and psychologists.

Family Practitioners have to be taught how to develop this system of care in their practices. There are not enough Clinical Endocrinologists to care for all the diabetics in the country. The Family Practitioners see most of the diabetics. In order to have any impact on cost of care they have to be engaged in the system of care.

“Many of the companies involved in the failed program say the experiment was flawed in the way it was designed and that Medicare has failed to work with them to make the program a success.”

Now the eight companies are blaming Medicare for its own faulty design of the $350 million study. I could have told Medicare it would not have worked before it spent a dime.

“We haven’t proven anything,” said Dr. Jeffrey L. Kang, a former Medicare official who is now the chief medical officer for the insurer Cigna.”

“The companies say Medicare signed up patients who were much sicker than they had expected.”

All patients with Type 2 Diabetes Mellitus are very sick. They usually have the disease for eight years before it is discovered and are on the way to develpoing chronic complications.

“The companies also say Medicare failed to make good on its promise to give them timely information about the use of prescription drugs, for example, or lab results that would have allowed them to help direct the patients’ care.”

Medicare is not the medical doctor. Nurse help desks are not a direct extension of a physicians medical care team. They are not going to get patients attention as a physician office team can. The participating companies are now in a defensive mode.

We overestimated the real desire expressed by the organization,” said Ben R. Leedle Jr., the chief executive of Healthways, who has been an outspoken critic of Medicare.
“Mr. Leedle says that Healthways will probably be able to demonstrate savings from at least some of its Medicare efforts, although the company also says it is projecting a loss on the experiment because it may have to pay back federal fees.”

On the other hand Medicare claims that it worked with the companies.

For its part, Medicare said that it had worked extensively with the companies to address their concerns and that its final analysis would take into account how sick the patients initially were.”

The blame game has started. This exercise will last the better part of a year and become politicized. An experiment with chronic disease management designed and executed correctly will prove that it works and saves money. If it is done incorrectly it will not save money.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

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Medicare Finds How Hard It Is to Save Money: Part 1

Stanley Feld M.D.,FACP,MACE

“An ambitious three-year experiment to see whether the Medicare system could prevent expensive hospital visits for people with chronic conditions like congestive heart failure and diabetes has suggested that such an approach may cost more than it saves.”

In our sound bite society this first paragraph can nullify the potential benefits and cost savings of focused factories and chronic disease management. Nothing could be further from the truth.

Social science experiments invariably suffer from design flaws. They are not double blind controlled studies with comparable treatment and placebo groups. This study compounds a potential error when the study centers are not applying comparable treatment protocols. The faulty methodology invariably leads to faulty and erroneous statistical conclusions. The study was intended to show positive results for the hypothesis. The hypothesis to be proven was that disease management decreases the cost of care.

I have stated in the past that the patient must be the driver of the care and the professor of his disease. Nurse driven call centers detached from patients physicians are not going to accomplish the goal of making the patient the “professor of his disease”. The study groups’ nurses call centers do not use similar protocols. The results of all the centers are usually lumped together. Is one center better than the other in reducing the cost of care? Are the patients well educated? Do the educated patients avoid the costly complications of the disease? Is a three year study long enough to determine if diabetes management works? Were the patients who incurred complications of disease the sickest at the onset of the study? Were patients risk weighed so that comparable groups under intensive glucose control were studied and compared to the same patients that had uncontrolled glucose levels? What was the duration of the disease in patients who were the most expensive to treat?

Additional characteristics of the patients need to be compared and separated. All the people in the study were over 65 years old. However, was there a difference in interest to learn among patients? Did this make a difference in complications? What was the compliance rate with intensive treatment? How long did each patient have his Diabetes Mellitus? How effective were patients at in losing weight? How effective were they in exercising? How many became disease management experts?
None of these questions were answered within the study. The data might be present. The conclusion is not correct until the study is done properly.

“The test borrowed a practice long available through private health plans. Nurses periodically place phone calls to patients to check whether they are taking their drugs and seeing the right doctors. The idea is that keeping people healthier can help patients avoid costly complications.”

Private health plans have tried nurse directed help desks in the past. The healthcare insurance companies never made nurses call centers an extension of the physicians care. Nurse’s help desks were imposed on the physicians care. This is not my definition of disease management. The patients have to be engaged in self management. They have to be motivated to prevent the complications of their disease. Patients at different stages of their disease are going to have different outcomes. Patients in the later stages of a chronic disease are going to have worse outcomes than patients at the early stage of a chronic disease. Patients with long term diabetes are at greater risk for complication of the disease.

“After paying eight outside companies about $360 million since mid-2005 to try to improve such patients’ health, Medicare is still trying to figure out whether the companies were able to keep people healthier. But the preliminary data indicate that the government is unlikely to save money.”

There is not a single physicians practice in the group report nor a single physician involved in the study design. The healthcare industry somehow convinced Medicare that it does not need physicians to take care of patients with diabetes mellitus. It simply needs industry designated healthcare providers to run nurse call centers.

“The eight selected Medicare Health Support Organizations (MHSOs) are well known in the industry and vary in size, complexity, and organizational focus. Some focus primarily on the provision of care management services, while others provide a broader range of services (including commercial insurance products, information systems, etc.”

Patients with Diabetes Mellitus need medical care and not commoditized healthcare. The patient physician relationship is critical. The physician has to be the manager of a chronic disease team with the patient being the player and the physician extenders being an extension of the physicians care. This model of nurse directed health desk has not worked in the past and can not work now.

“Each MHS program has a nurse-based health coaching and health support program; however, the MHSOs vary in how they implement the various components of their model. While all MHS interventions involve a telephonic nurse component, only five of the MHSOs are actively engaged in serving an institutionally based population.”

If the experiment is set up incorrectly the results are meaningless and a waste of money. The fighting over where it worked, whether the government gave the study enough time and whether the results are valid have begun.

No matter how much time the government gives the study it will fail. The study was doomed to failure before it started. It does not mean the concept of disease management is a failure.

Did the study prove that disease management is ineffective? I do not think so. It simply proved that the design of the study was defective? If 90% of the healthcare dollar is spent on the complications of chronic disease, the healthcare system must figure out an effective way to decrease the complications. This is where the money is!

The concept of disease management is in jeopardy because the media is the message and the message of the study is wrong.

Physicians were not involved in this disease management project. One of these days the government is going to realize that medical care is different than healthcare. Physicians provide medical care not healthcare. Medical care should be driven by physicians, not corporations and its executives.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

  • Healthcare and Treaments

    You are right. The basic need of healthcare plans are underfunded. Its shocking know this is happenening in this era of intellectual.
    God help us.

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Insurers, Doctors At Odds Over “Concierge” Care Insurer to drop 4 physicians charging retainers for more personalized care

Stanley Feld M.D.,FACP, MACE

Physicians are smart people. If a physician’s integrity, livelihood and joy of practicing medicine are threatened he will eventually figure out what to do to make life more pleasant. Over the last 15 years physicians’ enjoyment of medical practice has been decreasing.

Some of the reasons are the increasing volume of paper work, decreasing reimbursement, increased delay in payment by healthcare insurance companies, increasing overhead and the pressure of escalating malpractice suits.

Medical practices have attempted to increase efficiency by installing Electronic Medical Records. Many attempts to install Electronic Medical Records have failed at great expense to the medical practice.

Recently Primary Care Internists have attempted to decrease their stress by limiting their practice. They are converting their medical practice to Concierge Care Medical practices. MDVIP has created a national network of 210 physicians so far who practice concierge medicine.

Several models of concierge care decrease the need for a physician to have a large panel of patients, decrease stress and paperwork while creating the ability for physicians to enjoy their medical practice once again.

Healthcare insurance companies are unhappy and are starting to become punitive to patients and physicians who use this innovative approach to medical practice.

“Doctors who charge an annual fee to patients in exchange for customized care including house calls are drawing the ire of some health insurance companies.”

United Healthcare confirmed it is dropping four local doctors from its network in April because the company disapproves of their so-called “concierge medicine” model.”

“Cigna is also condemning the practice, in which physicians charge an annual retainer of $1,500 to $1,800 for patients who then receive more personal care. The claim is it is in violation of the physician’s contract with the insurer.”

UnitedHealthcare and Cigna think it is improper. The other insurance companies think it is fine as long as the patients know they will no be reimbursed for the physician retainer.

“Humana would not exclude doctors practicing this model of care from our networks,” said Dr. Mark Netoskie, medical director of Humana, Houston. “It is the consumer’s choice whether or not to pay for these additional services.”

United Healthcare says the concierge model “directly conflicts” with the insurer’s contract with the doctors.”

I think United Healthcare feels threatened by physicians and patients taking control of their medical care needs. UnitedHealthcare will lose control over the healthcare system.

“Concierge medicine is a relatively small movement in the U.S.”

I believe the retainer charged is too high. However, if patients want to pay the fee it is their decision.

“Typically, physicians who charge an upfront annual fee reduce their caseloads, which allows them to make house calls and focus on wellness matters from weight management to depression. Some give patients their cell phone numbers.”

With a smaller panel of patients, physicians will have time to have a therapeutic physician patient relationship once more.

“Proponents say concierge care is a revolt against the modern health care system where diminishing Medicare and insurance payments have forced doctors to herd dozens of sick patients through their offices in five-minute increments every day.”

The concierge system permits the physician give personalized care without the reimbursement controls imposed by the insurance companies or Medicare. Patients enjoy the service because they have a personal physician who cares for them. The physicians enjoy the setup because it decreases the stress they experience in the present reimbursement system.

“Our national network of physicians remain in-network with most of the insurance companies in which they participate, and MDVIP maintains excellent relationships with a number of national and local insurers,” the CEO said.

I can foresee that if the movement catches on it will intensify the primary care physician shortage in America. I do not believe this movement is the answer to Repairing the Healthcare System.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

  • Kelly

    Thanks for the information on concierge medicine. It was very interesting to see what the insurance companies had to say.
    We recently wrote an article ( on concierge medicine at Brain Blogger ( Concierge medicine is a rising trend in medical practice. But is it worth the cost for the patient or the effort fo the doctors?
    We would like to read your comments on our article. Thank you.

  • Elite Health

    I am a corporate lawyer and usually do not have time to spend time waiting in doctors’ offices. I generally look for expedited care, VIP treatment and 24-hour access to my personal physician via cell phone and email. I was looking for a concierge medical facility or plan since a year almost and lately found providing more than my wish list. I have registered along with my wife and have made a couple of visits to our primary care physician already. We are quite pleased with the experience and would post further feedback in a few weeks time again.

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Focused Factories: A Way To Improve The Quality Of Medical Care

Stanley Feld M.D.,FACP,MACE

The best way to beat competition is to not permit their entry into the marketplace. Businesses would do this if they could.

Medical specialists learn the nuances of disease processes and have the ability to discover early clues of disease. Surgical specialists understand their facility needs to increase their efficiency and effectiveness. They know what they need for effective post operative care. There is no reason that family practice groups can not have a couple of physicians become expert in a particular chronic disease.

“Focused factories’ are needed for medical and surgical care to avoid the complications of both acute and chronic disease. General Hospitals do not have the ability or desire to create focused factories. Focused factories could convert the care of profitable diseases with complications to unprofitable diseases without complications. The economics do not work for General Hospitals. General Hospitals try to prevent Specialty Clinics and Specialty Hospitals from being developed in their area.

“Hospitals are still the heart of the health care industry, consuming a third of the $2 trillion U.S. health care bill. Some are very good. But many are not, brimming with infectious bugs, systemic error and negative hospitality. And because the hospital industry does all it can to thwart competition, many communities are stuck with the hospitals they have.”

Hospitals hide behind the provisions of the Stark law to prevent the development of doctor owned efficient facilities for treating specific diseases (Focused Factories). There are many examples proving Focused Factories’ expertise used in treating particular diseases are more effective than a General Hospital. The most quoted examples are a hernia hospital in Canada and the Heart Hospital in Houston.

“Congressman Fortney “Pete” Stark (D-Calif.) passed legislation in two parts between 1989 and 1995, banning physicians from “self-referral,” meaning that a doctor can’t refer a patient to an physical therapy practice, lab or other facility that she owns part of because then she’ll benefit from the revenue associated with the services provided. Without Stark, the theory goes, unnecessary and expensive procedures would proliferate”

Congressman Stark thinks all physicians are crooks and will take advantage of patients. However, I think he is realizing the unintended consequences of his thoughts about physicians and his legislation. If patients own their healthcare dollar(ideal medicalsavingsaccount) they would be wary of anyone taking advantage of them.

“Recently Congressman Stark told a Forbes reporter that he regretted the bill because of the perverse effects and the army of lawyers creating an industry to take advantages of loopholes in the bill” .“The Stark laws have had a huge impact on how medical business models are structured.”

The laws have had an impact on discouraging physicians from creating Focused Factories. Focused factories are one stop clinics. They avoid fragmentation of and duplication of care. They take advantage of the concept of continuing quality improvement of care. They provide care in the most cost efficient way to remain competitive in the marketplace. They also permit the physicians to retain the value of his intellectual property rather than giving their intellectual property to a third party businessperson. .

“Yet in an interview today the Congressman lamented that he had ever made his legislative intrusion into medical practices. The unintended consequences of trying to legislate good behavior, as Sen. John McCain would tell you about campaign finance reform, is too many lawyers looking for loopholes.”

The loopholes have given an advantage to already large clinics and hospitals and do not provide incentives to smaller clinics to devise efficient models of medical care.

Patients have a choice, but it’s not widespread yet. It’s called the specialty hospital, a center that focuses on the care of a particular body part such as the heart, spine or joints, or on a specific disease such as cancer. There are 200 specialty hospitals in the U.S. (out of 6,000 hospitals overall).”

The protection for large healthcare institutions is cracking with the realization that hospitals absorb two thirds of 2 trillion dollars spent on healthcare. Hospitals earn much of this money treating hospital acquired illnesses and complications of surgery. The government and the insurance industry is now making noise to stop paying for hospital acquired complications. In order to protect themselves, hospitals are starting to enter into joint ventures with their physicians.

” The specialty hospital often deliver services better, more safely and at lower cost. A recent University of Iowa study of tens of thousands of Medicare patients found that complication rates (bleeding, infections or death) are 40% lower for hip and knee surgeries at specialty hospitals than at big community hospitals. A 2006 study funded by Medicare found that patients of all types are four times as likely to die in a full-service hospital after orthopedic surgery as they would after the same procedure in a specialty hospital.”

If the correct rules are made by the government Mr. Stark’s fear of physician being crooks can be assuaged. The government must collect appropriate data to determine the need for car the quality of care, and the real cost of that care. So far no one has figured out how to collect correct data.

Three of the nation’s top ten cardiac programs are at specialty hospitals in South Dakota, Indiana and Texas. Three of the top ten hospitals for total joint replacement surgery are specialty centers in Oklahoma, Ohio and Georgia.”

There is good reason for this. The physicians develop the facility they need and use it efficiently. Their motivation is quality care and a good cash return in a competitive marketplace.

“Specialization is a law of nature,” says Robert Tibbs, a neurosurgeon and part-owner of the Oklahoma Spine Hospital. “Spine surgery is an elective procedure. One of the biggest risks to any surgery is infections. Last year, out of 1,773 patients who slept over at the hospital, only 7 got an infection. That’s one-third to one-ninth the rate seen for similar patients at a big hospital.”

“At Oklahoma Spine anesthesiologists are practiced in putting patients under in the prone position for back surgery. At a big hospital few anesthesiologists would be skilled in that particular task. “You don’t take your Ford to the VW mechanic,” says Tibbs’ partner Stephen Cagle.”

If physicians are permitted to be innovative under appropriate rules without fear of penalty or disgrace they can accomplish amazing things. Our government should be looking at making rules that encourage innovation not abuse.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

  • Dr. Incognito

    This post was given recognition on’s Honorable Mention list.
    Dr. Incognito

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Now We Are Talking Real Money! $100 Trillion Dollars in Debt!

Stanley Feld M.D.,FACP,MACE

John Goodman published a summary of Present Value of Unfunded liabilities the government has for Social Security, Medicare Part A, B and D. The $34 trillion dollars I previously mentioned was not far off. This figure does not include the increased liability if the government takes over the healthcare system and is the single party payer.

John Goodman pointed out the Social Security and Medicare Trustees report was announced during Spring Break and would be released when congress was in recess.

“ On Good Friday (when most people were off, including most reporters) the Administration announced that the following Tuesday during Spring Break (when Congress was in recess and everyone’s attention was focused elsewhere) the Social Security/Medicare Trustees annual report would be released.”

“ Apparently someone isn’t anxious for you to pay close attention to this year’s report. The table below may explain why. The federal government has promised more than $100 trillion in benefits over and above expected taxes and premium payments!”

Program 75-Year Infinite Horizon
Social Security $ 6.6 trillion $15.8 trillion
Medicare Part A $12.7 trillion $34.7 trillion
Medicare Part B $15.7 trillion $34.0 trillion
Medicare Part D $7.9 trillion $17.2 trillion
Total Medicare $36.3 trillion $85.9 trillion
Total Medicare and Social Security $42.9 trillion $101.7 trillion

*These calculations ignore the existence of the trust fund, estimated at a little more than $2 trillion.
Source: Social Security/Medicare Trustees Reports 2008

How could a presidential candidate believe he or she could possibly afford to provide Medicare like insurance to all citizens when they cannot afford to provide it for the seniors they have an obligation to?

Why don’t they start listening to physicians? They should study blogs physicians write. They would get a pretty good idea of what is going on at ground level. A good place to start is KevinPo’s blog.
Dr. Po picks up a lot.

Rather than the presidential candidates creating false hope about improving the healthcare system, they should study human nature, human goals and what motivates people to be responsible for themselves. They should study what would give patient incentive to save their healthcare dollars. A clue would be to study my Ideal Medical Saving Account.

If we continue heading down the present path and add yet another unmanageable entitlement program we will be in bigger trouble. There will be a shortage of physicians, limited access to care and no money to pay anyone. I do not think the Federal Reserve Bank can print enough money to cover the dysfunctional entitlement program.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

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