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Obama Will Ration Health Care! Wake Up America: Part 3


Stanley Feld M.D., FACP, MACE


Dr. Tom Price, a Republican member of Congress from Georgia, the new chairman of the Republican Study Committee wrote an article in the Wall Street Journal that mimics my proposal for repairing the healthcare system. Someone should start listening to physicians.

During the last eight years the Republican Party has had a great opportunity to repair the healthcare system. I believe many Republicans in the House and Senate know what needs to be done. No one has taken a leadership position to do.

Now we have leadership that wants to do the right thing. Unfortunately the present leadership does not know the right way to do the right thing.

Consumer driven healthcare with the consumers owning their healthcare dollar is the way to repair the healthcare system. Personal responsibility for one’s health has been labeled conservative idea.

The concept is neither right wing nor left wing. It is simply logical. Self responsibility is the engine of American progress. Very bright liberal thinkers have advocated self responsibility. President Obama strikes me as one who can solve problems using logic and not right or left wing ideology.

I have pointed out the therapeutic magic of positive physician patient relationships. The government’s goal should be to nurture these relationships. It should provide a system that allows access to affordable, quality health care for all Americans. It should not nurture government dependency. It should also ensure that medical decisions are made in doctors’ offices, not in Washington or some by “independent “board (Federal Health Advisory Board) removed from the bedside. It should help educate both patients and physicians about best practices of medicine. Patients should make the decisions for their healthcare.

Dr. Price points out; “Atop the list of worrisome ideas proposed by Mr. Daschle is the creation of an innocently termed "Federal Health Advisory Board." (FHAB)

“This board would offer recommendations to private insurers and create a single standard of care for all public programs, including which procedures doctors may perform, which drugs patients may take, and how many diagnostic machines hospitals really need. As with Medicare, for any care provided outside the board’s guidelines, patients and physicians would not be reimbursed.”

All the stakeholders have been villains in the never ending escalation of costs to the healthcare system. I have blamed the healthcare insurance industry for being the worst villain. Its administrative service cost and waste as well as inflated overhead and excess executive compensation add 150 billion dollars to the healthcare system. It has lead to unaffordable premium costs, increased deductibles and co-pays, decreased patient access to care as well decreased reimbursement to physicians and hospitals. The reason everyone is “gaming” the system is the system reimburses waste and penalizes best practices. .

As Winston Churchill once said; “ Never has so much been paid to so many for so little” in the way of value added service to patient care.

I am presently reading John Bogles book “Enough”. In his book he describes the reason for rise and the fall of the financial sector. He could easily substitute the healthcare sector for the financial sector.

“That any endeavor that extract value from its clients may, in times more troubled than these, find that it has been hoist by its own petard”- proved not only eerily prophetic, but surprisingly timely. The industry has been blown up by its own dynamite.”

I said it less well when I said the healthcare insurance industry is killing the goose that laid its golden egg.

Tom Daschle has stated that the FHAB’s standards would serve only as a suggestion to the private market. Dr. Price points out the impeding results of Tom Daschle’s proposal.

“He has proposed making the employer tax deduction for providing health insurance dependent on compliance with the board’s standards.

In an overtly political ruse, Democrats will claim they are dictating nothing to private providers, while whipping noncompliant insurers in place through the tax code.”

“To be sure, this strategy seeks to eliminate private providers completely. Forced into accepting rigid Washington rules and unsustainable financing mechanisms under Mr. Daschle’s plan, most private insurers would be quickly eradicated.”

I believe the healthcare insurance industry has resigned itself to this faith. It is focusing on generating its income as an outsourced administrative service provider for the government’s massive new healthcare federal bureaucracy. The healthcare insurance industry has done very well with the Medicare Advantage programs and Medicare Part D. They have also done very well in the state of Massachusetts. It is making excess amounts of money under government sanction by controlling the healthcare dollar.

Who losses? The primary stakeholders lose (Patients and Physicians). The government also loses because it has formed another inefficient bureaucracy. America cannot afford Medicare in its present form much less expand it.

Dr. Price goes on to say; “This patient-centered approach must be built upon two pillars: access to coverage for all Americans and coverage that is truly owned by patients.”

“Through positive changes in the tax code we can make health-care cost effective and create incentives so there is no reason to be uninsured. This way, care is purchased without government interference between you and your doctor.”

Consumer driven healthcare using an ideal Medical Savings Account is a healthcare system that will be able to align all the stakeholders’ vested interests.

I expect a great debate to start shortly.

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

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You Can’t Change The Practice Of Medicine With Demand-Side Reforms. Let Us Put An End To Pay For Performance (P4P) Initiatives: Part 1

Stanley Feld M.D.,FACP,MACE

have pointed out the folly of P4P initiatives as a methodology for improving the
quality of medical care
medical care has not been adequately defined.
One definition could be to
maintain health at the lowest cost. Physicians have classically been trained to
fix things that are broken. The paradigm shift has been to prevent things from
becoming broken.

is a two way street
. It is the  patient who needs to prevent disease from
occurring. It is the physician who must teach the patient how to prevent disease
and its complications.

measures will not encourage behavior change
. The economist, John Goodman,
stated: “You
can't change the practice of medicine with demand-side reforms.”
  I have
said repeatedly it can only be changed with innovative and incentive driven
education for both patients and physicians. This will lead to behavior change
and a true increase in quality of care.

Quality medical care should not be judged on what tests are done for a
particular chronic disease in a given year. It should be judged on the basis of
maintenance of health of a patient with chronic disease. It should be evaluated
as a dual responsibility of both the patient and physician. If there is going to
be an increase reimbursement for performance, performance has to be judged
correctly and both physician and patient should be rewarded.

Quality medical care should be judged on the maintenance of health and
avoidance of the complications of chronic disease. The treatment of the
complications of chronic disease utilizes 80% of the healthcare dollar. If
complications of chronic disease are avoided the costs to the healthcare system
costs would be decreased to manageable levels and Americans would be healthier. 

Several readers have challenged me on the use of the term “socialized
medicine”. One reader said “our healthcare system is socialized already. The
government through Medicare and Medicaid controls 40% of the expenditures for
healthcare.” This is true.

The term “ socialized
medicine” has been demonized
. I believe most physicians’ and patients’
objection to “socialized medicine” is rooted in experiences they have had. It
has restricted access to care and freedom of choice, and it has dictated
permissible care of physicians. It has also produced an added layer of
inefficient bureaucracy.

premiums for patients are becoming expensive
. The premium is determined by
means testing. It can be as high as $14,000 per year. The government subsidizes
that amount with an additional $6,600.  Medicare advantage costs the government
over $9,000 extra.  Yet there is a decrease in access to care as the costs of
the system are spinning out of control. 

The government has its heart in the right place in wanting to provide
universal care. Americans should have access to healthcare coverage. A few
changes in the tax rules can solve many problems. The self-employed should be
able to purchase healthcare insurance with the same pre tax dollars as
businesses. They should have the same negotiated price structure large companies
have. The self-employed should have the same guaranteed  insurability as those
working in a large company without a premium penalty.

The healthcare system’s costs rise each year. The Medicare premiums rise each
year and patient’s out of pocket expenses rise each year. Medicare is going to
bankrupt the country. It will only be accelerated by putting everyone on

In order to reign in expenses someone came up with the idea of pay for
performance. It is a reasonable concept if a system could be devised that could
evaluate performance accurately and encourage improvement.

In order to test validity of any concept the government subsidizes
initiatives at a great expense. These initiatives are costly because of the
bureaucratic evaluation of the requests for proposals and the measurement

The list of government initiatives is long. The pilot studies are 3 to 5
years. There have been many cost overruns so that several outsourced study
vendors are dropping out of the management of the initiatives. Most initiatives
have been unsuccessful in proving cost savings.

The reason for lack of proof of cost saving to the healthcare system is
because of errors in design. The wrong questions are being asked and the imposed
bureaucracy is punitive to the healthcare entities. Below are initiatives that
are presently funded for pay for performance.


“Medicare has various initiatives to encourage improved quality of care in
all health care settings where Medicare beneficiaries receive their health care
services, including physicians’ offices and ambulatory care facilities,
hospitals, nursing homes, home health care agencies and dialysis


1. Hospital Quality Initiative   (MMA section 501(b))

2. Premier Hospital Quality Incentive Demonstration


1. Physician Group Practice Demonstration (BIPA 2000)

2. Medicare Care Management Performance Demonstration (MMA section

3. Medicare Health Care Quality Demonstration (MMA section 646)


Chronic Care Improvement Program (MMA section 721)

ESRD Disease Management Demonstration (MMA section 623)

Disease Management Demonstration for Severely Chronically Ill Medicare
Beneficiaries (BIPA 2000)

Disease Management Demonstration for Chronically Ill Dual Eligible

Care Management For High Cost Beneficiaries

So far the chronic disease management initiative have not been proven to save

The pilot initiatives are not directed by physician in private practice.
Physicians are the stakeholders that will make these initiatives work.  Nine
sites selected are either healthcare insurance companies or disease management
groups. Disease management groups can be successful facilitators of physician
care only if they are extensions of physicians care rather than physician

Help desks of the healthcare insurance companies do not work because they are
not an extension of the physicians care. Free standing chronic disease
management clinics do not work because they are not extensions of physicians
care. Many hospitals have tried to set up Diabetes Education Centers only to
have them close because physicians do not refer patients to the centers. The
center is not reimbursed adequately by the government or private insurers to be
profitable. The fees charged in hospitals are at least twice as much as the fees
the physicians charges. Once the physician knows the charges he is even more
hesitant to send the patients to the centers.

The following are the groups selected for the pilot phase: Humana in South
and Central Florida, XLHealth in Tennessee, Aetna in Illinois, LifeMasters in
Oklahoma, McKesson in Mississippi, CIGNA in Georgia, Health Dialog in
Pennsylvania, American Healthways in Washington, DC and Maryland, and Visiting
Nurse Service of NY and United Healthcare in Queens and Brooklyn, New York.

I believe we should give up on trying to produce a pay for performance system
that will reduce medical costs. The health policy wonks should concentrate on
something that will work.

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

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    I have always gone to Call a Nurse for all of my health concerns. Whenever I have a question I call Call a Nurse and they are always very polite and knowledgeable.

  • Rhinoplasty Beverly Hills

    This is quite a comprehensive and interesting posting on the approach to put an end to the system of Pay for Performance Initiatives. This approach may turn out to be effective in the end.

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Texas Medical Association Hits A Home Run


Stanley Feld M.D.,FACP,MACE

I have called for real price transparency from all the stakeholders. The healthcare insurance industry has stated that it will become more transparent. So far its pricing has been opaque. There are many levels of opacity to its pricing.

The Texas Medical Association (TMA) has taken a historic leadership position in defining what it thinks the healthcare insurance industry code of conduct should be in 2009. It is very complete. I hope it is adopted by the state of Texas and every other state in the nation. It will serve to lower the cost of healthcare insurance and increase the insurance coverage of many of our citizens.

“Health Insurance Code of Conduct 2009

“These measures would ensure transparency and accountability in the way health insurance companies conduct business:”

  • “Health Coverage Cancellations: Require an independent review of all decisions to cancel an individual health insurance policy prior to the actual cancellation.”

Each point in the TMA’s code of conduct peels off a level of price opacity. The TMA should call to abolish the healthcare insurance industry’s ability to cancel healthcare insurance.

  • “Calculation of Premium Quotes: Subject health insurers to “file and use” requirements at the Texas Department of Insurance (TDI), like other kinds of insurers.”

The Texas Department of Insurance (TDI) controls permits for the sale of insurance in the state of Texas. The TDI has never had the same pricing information from the healthcare insurance industry as they have from other insurance vehicles.

  • “Calculation of Medical Loss Ratio: Require health insurers disclose how they spend the patient’s premium dollar.”

The healthcare insurance company will not only have to disclose how they spend the patient’s premium dollar, they will have to prove it. This is an area in which expenses are inflated by the healthcare insurance industry.

  • “Unregulated Secondary Networks (Silent PPOs): Regulate how a physician’s contract information is sold, leased, or shared among health insurance companies.”

Unregulated secondary networks must be regulated because the healthcare insurance industry has long practiced price fixing. Price fixing does not work and leads to further system abuse and mistrust.

  • “Physician Rankings: Require health insurance companies to use scientifically valid criteria to evaluate physicians’ performance and disclose those criteria in advance.”

I do not believe physicians are afraid of being evaluated. I believe they are afraid of being judged by defective criteria leading to reimbursement penalties.

  • “Claims Processing: Prevent health insurance companies from reverting to their old, unethical ways of processing claims.”

I have pointed out abuses that have occurred in several states. Minimal monetary fines do not deter this abuse. It must be stopped. The healthcare insurance companies should lose their privileges to sell healthcare insurance in the state.

  • “Timely Health Insurance Information: TMA’s “Health Insurance Product Labeling Plan” would require health insurers and their brokers to use standardized reporting measures to help employers and individuals make direct, side-by-side product comparisons.
  • Once a plan has been selected, patients should have convenient access to benefit information when they are making their health care   decisions. Health insurers should make this information easily available. Almost every card in your wallet has some ability to provide data — except your health insurance card. There is absolutely no reason why health insurers cannot provide accurate, real-time information regarding the different benefits and exclusions.”

Buyers of healthcare insurance should have the ability to know the provisions of their insurance clearly and not be surprised by their lack of coverage when they get sick.

  • Routine Medical Care for Clinical Trials
    Texans participating in a clinical trial should be able to use their health insurance to pay for routine medical costs — especially when they are suffering from a life-threatening disease or condition.”

Many states have this provision. Texas does not. Patients have had to spend out of pocket expenses unexpectedly.

  • “ TDI needs authority to require health plans to disclose the methods and data they used to set “maximum allowable” amounts for out of network services.”

There is a tremendous burden place in our mobile society on citizens if they get sick while traveling for business or pleasure.

  • “TMA opposes health plans’ attempts to prohibit balance billing or to establish wholly inadequate payment rates for non-network physicians and hospitals.”

I disagree with the TMA balance billing position. We have to have total transparency from all stakeholders. I have maintained often that all stakeholders have to be subject to real price transparency including physicians

  • Regulation of Preferred Provider Organizations (PPOs)
    Currently the discounted rates physicians negotiate with health plans are being hijacked by unregulated PPOs. These entities, called “silent” and “rental” PPOs, shop around to find the lowest rate a physician has agreed to with any health plan. Then the PPO sells, resells, or leases that discounted rate to insurance companies, discount brokers, and other unregulated health care businesses without the physician’s knowledge or permission. Fourteen states outlaw these arrangements. Texas should, too.”

Few healthcare policy wonks know about this practice. It is a very effective practice by the healthcare insurance industry to create price controls. The results in further distortions in the healthcare system.

If the Texas legislature passes all these proposals it will make the state of Texas a more attractive state for large multinational corporations to set up corporate headquarters. Presently a powerful stimulus is our low tax rate.

I believe these proposals should be national for the benefit of all Americans. It will go a long way toward Repairing the Healthcare System.

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

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Obama Will Ration Health Care!: Wake Up America: Part 2

Stanley Feld M.D.,FACP, MACE

Mr. Obama has promised a quick, hard push to overhaul the healthcare system. Americans can expect a quick push to build a larger federal bureaucracy, impose price controls, restrict the use of new medications and technologies, boost taxes, mandate the purchase of health insurance, and expand government control of health care. This is the promise Mr. Daschle made in his book "Critical: What We Can Do About the Health-Care Crisis,"

If Mr. Obama continues on the present path the prognosis is horrible for patients, physicians and taxpayers. Tom Daschle’s excuse is the present system is an intolerable status quo. An intolerable status quo is not an excuse to destroy the healthcare system in America.

“In his book, Mr. Daschle proposes a National Health Board to regulate the way health care is provided. This board would have vast powers in regulating the massive federal health-care system — a system that includes Medicare, Medicaid, and other programs.”

Healthcare coverage will likely expand to greater government healthcare control. Businesses and corporations are anxious to get out of the business of providing healthcare coverage for their employees. They would rather pay the penalty proposed than provide unaffordable healthcare insurance for their employees. The result will be defacto socialized medicine before we know what hit us. Socialized medicine is Mr. Daschle’s plan for all Americans even though America can’t afford it. He is going to claim this is the plan the people want. I would add until the people realize the consequences of his plan.

“Given the opportunity, Mr. Daschle would likely charge the board with determining which treatments and drugs are cost effective and therefore permissible to use for patients covered by the government.”

“It is nearly certain that the process of determining which drugs and which treatments would be approved for use would be quickly politicized.”

The Federal Health Board will be made up of “expert clinicians” from academic centers who will determine what physicians can and cannot do. The enforcement of these rules will be impossible. The punitive weapon will be withdrawal of physician reimbursement. I have said over and over again that punitive measures do not work to force a workforce to comply.

“In his book, Mr. Daschle complains about overuse of new technology and praises the United Kingdom’s National Institute for Health and Clinical Excellence (NICE), a rationing system that controls government costs.”

Mr. Daschle believes that America needs to ration new technology and drugs because the cost of care is skyrocketing. Another reason is the government cannot afford to provide access to care. The result will be rationing of care rather than giving patients the freedom of choice. The British system is well known for restricting access to drugs and medical care.

He is ignoring the waste in administrative services outsourced to the healthcare insurance vendors. He is ignoring the inefficient billing practices of hospital systems. He is ignoring the responsibility patients have to adhere to treatment medications prescribed and the maintenance of their health. He is ignoring the fact that patients should be responsible for their health and their healthcare.

“Health care is personal and voters will pressure lawmakers on access to care. Americans will not put up with such limits, nor will our elected representatives.”

Mr. Daschle is claiming that through his community home meetings in December people are demanding the changes he is proposing. I believe once the voters realize what he is proposing the will voice the opposite opinion.

Managed care of the 1990’s was nothing more that managed cost. It provided the healthcare insurance industry with the opportunity to place restrictions on access to care and decrease reimbursement to vendors. It temporarily reduced the increase in the costs of care. However, managed care failed work because the public objected to the restrictions and it did not hold down costs. The HMO experiment failed for the same reason.

Tom Daschle has learned something from these lessons. He learned that he has to strike quickly and deflect the decisions about rationing of care to a “neutral board” and not the market. It is clear he does not respect the intelligence of the consumer. He does not understand the responsibility of the consumer. If he was doing this right he would be going after the abuses in the system and not the decision making engine in the system.

Tom Daschle is in the process of creating a giant HMO. It will fail as the Massachusetts experiment has failed.

“Mr. Daschle’s model is Massachusetts. But Massachusetts’s plan is an unfolding disaster and demonstrates how Mr. Daschle’s private/public model is merely a stalking horse for government-dominated health care.”

Massachusetts helped 442,000 people obtain healthcare insurance. However an additional 80,000 people were put on Medicaid. 176,000 people were put on government subsided healthcare insurance. The cost to taxpayers has exploded because the basic cause of increased cost of care has not been addressed. The healthcare insurance industry control over the healthcare dollar has to be reduced. The onset of chronic disease and the reduction of the complications of chronic disease must be attacked effectively.

“Costs have exploded, requiring additional tax hikes and the entire system is only possible due to sizable transfers from the federal government. The plans are so unaffordable that in 2007, 62,000 people were exempted from the individual mandate.

So much for universal coverage. It could work if the consumer controlled their healthcare dollars with the government protecting the consumer.

The only way the Massachusetts plan will survive is with continued and increasing federal subsidies -that is, tax revenue from the residents of other states.

Tom Daschle’s plan is going to follow the same misguided path. The problem is worse the healthcare system becomes the harder it will be to dig our way out.

Wake up America

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

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President Obama Will Ration Healthcare. Wake Up America! : Part 1

Stanley Feld M.D.,FACP,MACE

I spent a glorious weekend with Brad and Daniel in Las Vegas at the Consumer Electronic Show (CES). I thought there were some phenomenal electronics exhibited which will be coming to Main Street soon.

Brad introduced me to many young entrepreneurs who are very concerned about providing healthcare insurance for their employees. They are having trouble finding affordable healthcare insurance. My suggestion is for them to consider my ideal medical savings account.

Most of these young entrepreneurs realize they do not understand the issues that have resulted in the exorbitant healthcare insurance premiums.

I told them to not listen to the sound bytes of Tom Daschle and his team. They do not understand the issues either. If they did, they would be pursuing a different course. Tom Daschle is going to try to force the Democratic Party’s healthcare agenda of the last forty five years down the country’s throat. .

I have described most of the issues. I like President-elect Obama very much. Many voted for him because of the promise of renewal, new thinking and hope for the future.

David Remnick of the New Yorker summarized Barack Obama’s appeal.

“Barack Obama was not elected the forty-fourth President based on the depth of his legislative achievements or on the length of his public service. John McCain and Hillary Clinton were the “experience” candidates. Rather, Obama projected an inspiring message, a “narrative,” of change at a moment when so much in American life––the economy, the environment, national security, health care––is in such parlous condition that, for many voters, political familiarity seemed less a source of solace than a form of despair.

Barack Obama has hired “experienced people” to run his healthcare team( Daschle, et al). His “team” has the same old tired ineffective story that Hillary Clinton and others have had for healthcare reform. It is a story the American public does not want to hear.

During the campaign, Obama embodied novelty and a broader American coalition, and everything we heard about his temperament—as a community organizer in Chicago, as a president of the Harvard Law Review, as a legislator, as a campaigner—spoke of someone who, in contrast to the outgoing, faith-based President, possessed a gift for rational judgment and principled compromise. “

His healthcare advisors are old school. They do not understand the importance of the physician patient relationship. They refuse to understand the problems in the healthcare system. They ignore the importance of patient responsibility for their own health and healthcare. They do not seem to believe in the importance of the role of incentives and self reliance as an engine of America’s greatness. They believe government can fix everything.

President Barack Obama’s healthcare team is going to be successful in passing healthcare legislation. Healthcare system reform they will propose and pass will fail. It will bankrupt America as it is bankrupting Massachusetts.

The Congressional budget office estimated a 100 trillion dollar a year healthcare deficit in forty years without an improvement in the health of seniors alone. Adding the entire population to the Medicare roles will make this deficit unimaginable.

Tom Daschle’s plan is similar to the Massachusetts universal healthcare plan. We must understand the cause for the failure of the Massachusetts plan in order to comprehend the impending failure of Tom Daschle’s plan. There is nothing innovative about his plan. It is the same plan Hillary Clinton advocated in 1993 and others in the Democratic Party advocated for many years.

The plan will probably pass in a congressional vote because Americans are frightened by a huge economic recession. They have little idea what is being advocated by the Daschle healthcare team.

When a population is frightened all politicians have to promise is hope. People will give unprecedented power to politicians even if they do not understand the results of those promises.

Many are claiming Ayn Rand was right 52 years ago when “Atlas Shrugged” was published. The names of the new controlling bureaucracy are different but the methodology is the same.

Where are you John Galt?

Mr. Obama is taking a dangerous chance by advocating these old, and proven to be ineffective ideas. The Congressional Budget Office (CBO) noted in its report the failure to reduce the cost of healthcare significantly or increase the quality of care. The CBO’s report was published just before Christmas when everyone’s thoughts were on the holiday.

Wake up America!! Please !!

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

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Congressional Budget Office Reveals Budget Hurdles In Financing Healthcare Reform


Stanley Feld M.D.,FACP,MACE


The Congressional Budget Office report states that President-elect Obama’s healthcare plan would carry a high price tag. The healthcare plan would generate only modest savings.

Mr. Obama and other Democrats have not been precise about the cost of their proposals, nor have they said in detail how they would pay for them.” Some of the options, including proposals to increase taxes on cigarettes and nondiet soft drinks, are sure to meet stiff political opposition.

President-elect Obama has not been precise about any of his proposals on purpose. Both political parties say they will make a serious effort to overhaul the health care system in 2009. In our current economic crisis it is essential to that. As unemployment rises the uninsured population will rise. The fear in the population will create pressure on congress to pass any bill that promises hope and relief.

However, President-elect Obama’s transition team is going about the overhaul of the healthcare system the wrong way. I am positive they think they are doing it the right way.

“One bright spot in a generally bleak picture was the estimate of potential savings from a requirement for doctors and hospitals to use health information technology (EMR), including electronic medical records, as a condition of participating in Medicare.”

Such a requirement could save the federal government $7 billion in the first five years and a total of $34 billion over 10 years, by reducing medical errors and avoiding unnecessary tests and procedures, the budget office said.

President-elect Obama does not plan to create a universal electronic medical record. Electronic medical records are essential to repair the healthcare system. The administrations healthcare transition team believes it can force physicians to purchase, install and service electronic medical records most physicians cannot afford. The government plans to make EMR a condition to participate in Medicare. Many physicians would not mind being forced out of Medicare.

Most installed EMRs in large hospital systems are not fully functional. Many do not have total functional cross hospital system compatible interfaces that would allow efficient flow of information. Most EMRs do not allow for real price transparency that can stimulate efficient use of healthcare system resources.

If the government requires physicians to buy an EMR by penalizing them, physicians will drop out of the Medicare program. The result will be the creation of a shortage of physicians. The government should make available a fully functional EMR free of charge. It should not require a capital outlay. Physicians would pay by the click monthly.

Without action by Congress, the report said, health costs will continue to soar, the number of people without insurance will rise by nearly one million a year, to a total of 54 million in 2019, and spending on health care will increase to 25 percent of the gross domestic product in 2025, up from 16 percent in 2007.

All agree that something must be done to repair the healthcare system. The Congressional Budget Office (CBO) must work with the data they have even if the data is incomplete. CBO’s estimates are modest. During our present economic recession I think the number of uninsured will rise to 54 million by the end of 2009, not in ten years.

“Lawmakers from both parties said they would pay close attention to the cost of new federal subsidies for health coverage because these subsidies — unlike the one-time bailouts for banks and other financial institutions — would be recurring federal obligations for years to come.”

A large problem is that all the proposals would force a stakeholder to do something. In order to accomplish real change the government needs to provide incentives for stakeholders, not mandates. Historically, mandates never work.

1. Requiring employers to provide health insurance to their employees.

1a. or pay a fee to the federal government would bring in $47 billion of new federal revenue in the next 10 years, the report said.

The savings of 4.7 billion dollars a year is insignificant in a healthcare system that has 150 billion dollars of administrative waste a year. The government should go after the administrative waste.

A proposal to establish a national insurance pool for people who cannot obtain coverage on their own in the individual market would cost $16 billion in the next decade in subsidies.

The real issue is the need to put the individual market on a level playing field with the group market. Secondly, it is essential consumers be in charge of their healthcare dollar. Presently the healthcare dollar is owned by the healthcare insurance industry. Ownership of the healthcare dollar will remain with the healthcare insurance industry in a President-elect Obama’s administration.

Mr. Obama and many other Democrats want the government to negotiate with drug manufacturers to get lower prices for Medicare beneficiaries.

This is an important action. Medicare Part D is a structural disaster. Medicare Part D has to be restructured to be in favor of the consumer, not the healthcare insurance industry. Part D was a good idea turned into an overpriced plan. The plan does not improve patient compliance because patients cannot afford the medication. The result is that it will not decrease the complication rate of chronic disease.

But the budget office said Medicare could save $110 billion in the next 10 years if Congress simply imposed a form of price controls, requiring drug makers to provide the government with a 15 percent rebate, or discount, on brand-name drugs covered by the new Part D of Medicare.

Historically price controls do not work. Incentives and competition work, if Medicare Part D was structured correctly there would be no overcharging for medication.

Under the current proposals the saving would be insignificant compared to the rising cost because President-elect Obama’s team is trying to fix the wrong things.

Doing what they are proposing is going to result in a more expensive healthcare system. The result will be cost overruns and a decrease in access to care and quality of care.

We have all experienced inefficient government rules and regulations. We must brace ourselves for the worse and start understanding the deficiencies now so we can speak out with one voice.


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

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We Want Real Change!


Stanley Feld M.D., FACP, MACE

A major defect in our healthcare system is that the healthcare insurance industry controls the entire healthcare dollar. In California, Nevada and Hawaii the healthcare Medicare vendor has held back physician reimbursement and restricted access to care.

Private healthcare insurance companies have done the same.

Government funded healthcare programs such as Medicare and Medicaid outsource their administrative services to the healthcare insurance industry. The federal government provides Medicaid funds to state governments. State governments outsource their administration services to the healthcare insurance industry. The healthcare insurance industry controls these dollars.

A recent headline in the Dallas Morning News read, “Is Texas looking out for you? Health-care Outsourcing is rolling on, but many patients suffer from silent treatment.”

Evercare of Texas, a unit of the giant UnitedHealth Group, is the Medicaid administrative services vendor for more than 80,000 elderly, blind or disabled North Texans.

“We help make it easier to get the care you deserve,” the company promises on its Web site.”

The state has received hundreds of complains about its administrative services vendor. Evercare’s excuse is the same as Palmetto’s excuse in California

“Evercare said it experienced the normal start-up problems associated with a program that serves tens of thousands of people.” “It was a massive undertaking,” said Beth Mandell, regional executive director of Evercare of Texas.

Evercare has been servicing Texas for a while now. It was fined 1 million dollars in 2007 and $400,000 in 2008.

A few horror stories can be expanded to many. The healthcare insurance industry controls the healthcare dollar. They are in the business of making money. It would be much easier and less costly if patients controlled their healthcare dollar.

“Willis Stewart, a 61-year-old carpet layer who had his teeth pulled during treatment for mouth cancer, said he has waited three months for Evercare to approve the dentures that will allow him to eat solid food again.”

“ Steven McGee, a 55-year-old truck driver disabled by multiple sclerosis, said he phoned the company for seven months without reaching a medical coordinator.”

“Mary Hunt, a 72-year-old widow, said she has waited months for dental care. “They ought to call them ‘Nevercare,’ “ said Hunt, among the hundreds of people who have complained about denied or delayed medical care.”

Physicians have experienced the same difficulties with reimbursement that patients have experienced with receiving care.

“North Dallas doctor William Walton says caregivers must be vigilant in working with UnitedHealth, parent company of Evercare of Texas.”They’re dishonest, and they’re sneaky,’ Walton said.”

The state’s recourse is to fine Evercare. However the fines are insignificant compared to the money made by Evercare while exercising this behavior.

“UnitedHealth caught the front end of the Texas outsourcing wave launched by Gov. Bush. Since 2003, the state has paid the company’s Evercare and United Healthcare units more than $1.2 billion to provide managed care to more than 255,000 Texans under four programs.”

Fines are not high enough to be a deterrent to the abuse of patients, physicians and other vendors.

“The state has fined Evercare, more than $1 million in the last year, ordering it to increase staff and fix other problems. The most recent fines, totaling nearly $400,000, were in reaction to the mounting complaints about the North Texas program.”

The healthcare insurance industry does this all over the country. No one seems to connect the dots. The only recourse governments have exercised is to fine these companies. The fine is usually minimal compared to the healthcare insurance company’s financial gain.

President-elect Obama and HHS secretary Tom Daschle plan to provide universal healthcare coverage. Federal universal healthcare coverage in the present healthcare system will result in an expansion of outsourced administrative services. The state of Massachusetts has expanded outsourcing of administrative services. It has experienced massive cost overruns with little evidence of improvement in the delivery of care.

I fear that if and when the present Obama/Daschle plan provides universal healthcare to our entire population, Americans will suffer the same abuse with massive cost overrun and without appropriate recourse.

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

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Consensus: A Clever Way To Build One, Whether It Is Right Or Not: Part 2

Stanley Feld M.D.,FACP,MACE


Consensus is usually defined as a general agreement by groups of people. Consensus decision-making is the process of developing a consensus. A consensus is theoretically inclusive, participatory, cooperative, and egalitarian. Egalitarian means all stakeholders in a consensus decision making process should be afforded equal input into the process. All stakeholders should have the opportunity to table, amend or block proposals.

The consensus decision making process should be solution oriented. It should strive to be all inclusive, promote compromise and resolve positions of difference.

President-elect Obama issued an important challenge to forming a consensus.

"In order for us to reform our health care system, we must first begin reforming how government communicates with the American people," Obama said in a statement yesterday. "These Health Care Community Discussions are a great way for the American people to have a direct say in our health reform efforts."

The consensus decision making process has been contaminated by President-elect Obama’s healthcare transition team in order to arrive at Tom Daschle’s predetermined solution. The results of the consensus building will be molded to fit the ideas the Secretary designate of HHS has to repair the healthcare system.

Dr. Val Jones had a Healthcare Community Discussion in her home. It seems the healthcare transitions teams goal is accumulate as many horrible healthcare interface stories as they can to use as evidence of the need for the new bureaucracy to be imposed on the healthcare system.

“President-elect Obama and Secretary of HHS designate, Tom Daschle, invited concerned Americans to discuss healthcare reform in community groups across the country. My husband and I hosted one such group at our home in DC yesterday. Although we had been instructed to compile a list of compelling stories about system failures – instead we decided to be rebellious and discuss “what’s right with the healthcare system” and compile a list of best practices to submit to the website.

Even in Val’s attempt to be rebellious she had only one physician in her group.

“The event was attended by a wide range of healthcare stakeholders, including a government relations expert, FDA manager, US Marine, patient advocate, health IT specialist, transportation lobbyist, real estate lobbyist, health technology innovator, Kaiser-trained family physician, medical blogger, and EMR consultant. Here is what they thought was “right” with the healthcare system:”

The deck is intentionally being stacked against the private practice of medicine. It ignores the fact that eighty percent of the medical workforce is in private practice. Uwe Reinhardt said do not get your workforce mad. I would think private practicing physicians as a stakeholder should have significant input into forming a true consensus.

President-elect Obama has picked up a hardheaded political strategist in Tom Daschle for his push to overhaul the nation’s healthcare system.”

I believe President –elect Obama has a great chance of overhauling the healthcare system. The problem, in my opinion, is elements of Tom Daschle’s overhaul are wrong. The public opinion manipulation will probably get some legislation passed, but will it be the best?

“ Learning from Clinton’s mistakes, the nominee for Health and Human Services secretary favors going on the political offensive to bring about reform.”

A common denominator in this consensus building is everyone agrees something has to be done to fix the healthcare system. The next administration is close to developing this common denominator. They are not building a consensus on what should be done. This issue has already been decided by Mr. Daschle. It does not matter if what is done is wrong.

“Guided by lessons from President Clinton’s healthcare debacle 15 years ago, Daschle has put a premium on cooperation between the White House, Congress and major healthcare interest groups, many of whom agree that major action on healthcare is vital.”

Bertrand Russell said it perfectly.

What a man believes upon grossly insufficient evidence is an index into his desires — desires of which he himself is often unconscious. If a man is offered a fact which goes against his instincts, he will scrutinize it closely, and unless the evidence is overwhelming, he will refuse to believe it. If, on the other hand, he is offered something which affords a reason for acting in accordance to his instincts, he will accept it even on the slightest evidence. The origin of myths is explained in this way.”

Naomi Klein in the Shock Doctrine said in times of economic or political upheaval policies are enacted that could never have been passed in ordinary times. We are not living in ordinary times.

“Tom Daschle favors moving decisively to seize political momentum and, if necessary, cut off opposition, something he said Clinton failed to do in 1993.”

"This means going on the offensive," he wrote in "Critical," his recent book about healthcare,”

I do not believe Tom Daschle is going to repair the healthcare system. He does not fully comprehend the problems in the healthcare system. Brute force will not work. Aligning stakeholders’ incentives is the only thing that will work.

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