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How To Neutralize The Healthcare Insurance Industry’s Attack. Part 2


Stanley Feld M.D.,FACP,MACE

Move ability to social network is legend. acted immediately with a call to action as soon as it was obvious that the healthcare insurance industry was going to attack President Obama’s healthcare plan. Its plan is to attack the healthcare insurance industry

Blue Cross Blue Shield is trying to kill "a key plank in Obama’s reform platform." So we’re trying to raise $150,000 in two days to fight back. Can you chip in $35 right now?

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“Dear MoveOn member, “

Breaking news on health care: The Washington Post is now reporting that insurance giant Blue Cross Blue Shield "is putting the finishing touches on a public message campaign aimed at killing a key plank in Obama’s reform platform."1

The Huffington Post sums it up as "Insurers Planning on Double-Crossing Obama."2 drew the line in the sand before the healthcare insurance industry using old media tactics finished its storyboard.

“We knew the insurance companies would eventually turn on the president, but this is much sooner than expected. And they’re targeting the public health insurance option—the crucial piece that will help cover everyone. So we’re immediately launching a rapid-response campaign to go toe-to-toe with Blue Cross Blue Shield and win quality health care for all Americans.” makes the point that the insurance companies turned on the President. It has prepared a rapid-response to help the President get his healthcare reform package passed in 2009.

“We need to raise $150,000 in the next two days. It’s a lot, but we’ll need every penny to take on Goliath. We’ll run ads, hold events, and work like crazy to get the real truth out to voters. AND we’ll keep the pressure on Congress to make sure they don’t get bullied into gutting the president’s plan to guarantee health care coverage for everyone. Can you chip in $35 right now to make it happen?”’s message is clear. It is asking people to send money to prevent the healthcare insurance industry from destroying a key provision, (“National Insurance Exchange”) in the President’s healthcare reform plan. President Obama’s healthcare reform plan claims it will provide a public health insurance plan option that will not subsidize neither healthcare Insurance companies CEO’s salaries nor stockholders profits therefore reducing healthcare costs. ignores the fact that our country presently cannot afford the costs of Medicare . Expanding Medicare will be a disaster.

“If we had the choice of a public plan, private insurers would have to lower rates and improve quality to compete, so they’re dead set against it. Today’s news just confirms that fact.”

You bet the healthcare insurance industry is dead set against his plan. However the healthcare insurance industry is the administrative service provider for government operated healthcare plans. Everyone will move to the public plan. The healthcare insurance industry will make a greater profit because everyone will be insured. The process of setting price will be in the hands of the healthcare insurance industry.

There will be not improvement in access to care or quality of care because the incentives in the healthcare system will not be changed.

“In the past, Blue Cross Blue Shield has been sued for underpaying doctors and fined for refusing to cover necessary medical treatments for their customers.3 Now, with what watchdog group Media Matters calls a "desperate attempt to deceive,"4 they’ve gone one step too far.”

The healthcare insurance industry has killed the goose that laid its golden egg. It is impossible for consumers or physicians to sue the government. The government will be forced to underpay physicians as well as restrict access to necessary medical treatment.

The debate is not a debate on Repairing the Healthcare System. It is a debate between the government and the healthcare insurance industry about who controls the healthcare dollar

MoveOn raised $270,000 in 24 hours surpassing the goal of $150,000. The message is loud and clear. Consumers are mad as hell and they do not want to take it any more.

“Dear MoveOn member,

Amazing! After news broke of Blue Cross Blue Shield’s new campaign to defeat Obama’s health care plan, MoveOn members responded in a huge way. Together, we smashed our goal and raised $270,000 in just one day. (Thanks!)”

Move will not stop there and set a new goal of $350,000 for the next 24 hours.

“If we can hit this mark, we’ll send a strong message to the entire industry that if they start trying to block Obama’s key health care proposal to cover everyone, we’ll be ready to fight back—hard.

This is too much for Harry and Louise to take on. When consumers realize that President Obama’s plan will not work they will demand control of their healthcare dollars.

There are three take home points.

1. The old media will not work.

2. People power using the new media is very powerful

3. Healthcare will become consumer driven.

4. The debate is focused on the wrong issues

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How To Neutralize The Healthcare Insurance Industry’s Attack. Part 1

Stanley Feld M.D.,FACP,MACE

Yesterday Blue Cross and Blue Shield of North Carolina started rolling out the healthcare insurance industry’s attack on President Obama’s National Health Insurance Exchange. The 1993 Harry and Louise attack campaign will not work in 2009. Consumers do not trust the healthcare insurance industry to look after their needs. President Obama is playing off this mistrust and counter attacking. He sent an email to 20 million consumers asking them to join his call. He wants us ask congress to pass real healthcare reform in 2009. He asked us to join and donate money. After we join his cause we could then tell our story about the dysfunction in the healthcare system. He said your voice will make a difference. He says nothing in specific terms about how he will Repair the Healthcare System.

“Stanley –

You will note every email is personalized.

“The chance to finally reform our nation’s health care system is here. While Congress moves rapidly to produce a detailed plan, I have made it clear that real reform must uphold three core principles — it must reduce costs, guarantee choice, and ensure quality care for every American.”

Healthcare insurance premiums are constantly increasing while coverage is decreasing. Most healthcare insurance policies do not have a choice of physicians (physician networks). Quality healthcare (undefined) is not available for every American (universal healthcare). The healthcare insurance industry’s control of the healthcare system is responsible for most of these defects.

“As we know, challenging the status quo will not be easy. Its defenders will claim our goals are too big, that we should once again settle for half measures and empty talk. Left unanswered, these voices of doubt might yet again derail the comprehensive reform we so badly need. That’s where you come in.”

President Obama invites us to fight those who would derail the comprehensive reform we so badly need. He does not define the reform (Hillary Clinton’s 1993 reform?). He does not describe the route to reform. It sounds good is meaningless.

When our opponents spread fear and confusion about the changes we seek, your support for these core principles will show clarity and resolve. When the lobbyists for the status quo tell Congress to hold back, your personal story will give them the courage to press forward.

President Obama’s message is clear. The call to action is to neutralize the healthcare insurance industry’s attack.

Join my call: Ask Congress to pass real health care reform in 2009.

“After adding your name, please consider sharing your personal story about the importance of health care reform in your life and the lives of those you love.”
“I will be personally reviewing many of these signatures and stories. If you speak up now, your voice will make a difference.”

When I tried to tell my story there was only one place to tell my story to President Obama. The space was to donate and join the call to action. He promises to personally review my story yet he has not listened to my call for a system of patient responsibility or patient reward. He has not listened to the plea for major tort reform. He has not listened to the need for a free electronic medical record in the cloud paid for by physicians by the click. President Obama does not have a clear the way to achieve his goals. He is going to get a bill passed that is worse than the Massachusetts plan.

In our sound bite society one, he wins using the new media. The healthcare insurance industry does not get it.

“Last November, the American people sent Washington a clear mandate for change. But when the polls close, the true work of citizenship begins. That’s what Organizing for America is all about. Now, in these crucial moments, your voice once again has extraordinary power. I’m counting on you to use it.”

Thank you,
President Barack Obama


President Obama followed up with another email call to action. He is organizing People Power, one block at a time, one neighborhood at a time and one city at a time. His costs are minimal.

President Obama, using the new media, has the healthcare insurance industry on its heels. He used the old media to declare that the healthcare insurance industry made a commitment to reduce healthcare costs by 2 trillion dollars in the next 10 years. His sound bite is “ you’ve made a commitment; we expect you to keep it.” Now the healthcare insurance industry has backed down. Implied is how can it be trusted?

Patient power and the new media will not let this happen. When our opponents spread fear and confusion about the changes we seek, your support for these core principles will show clarity and resolve.”

“On June 6th, in thousands of homes across the country, we’ll gather to launch our grassroots campaign for health care. We’ll watch a special message from the President. We’ll build the teams and draw up the plans for winning health care reform the same way we won the election: Building support one block, one neighbor, one conversation at a time. And we’ll put those plans into action.”Please sign up today to host or attend a kickoff near you.

This time the healthcare insurance industry must do better than Harry and Louise.

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

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Harry and Louise Are Coming Back: Insurers Planning on Double-Crossing Obama

 Stanley Feld M.D.,FACP,MACE

 One week after President Obama announced that the nation's health insurance
lobby pledged to reduce healthcare costs by $2 trillion in ten years, Blue
Cross Blue Shield of North Carolina is putting the finishing touches on a public
message campaign aimed at killing a key plank in the Presidents reform

Obama had told the health care executives, “you’ve made a commitment; we expect
you to keep it.”

When the healthcare insurance lobby realized the trap it fell into it
immediately went to work to defend its control over the healthcare dollar. It is
going to roll out Harry and Louise as it did in 1993. I do not think it will
work. We are living in different times with different media tools.

From a distance
everything Barack Obama says sounds great
. The events of the last eight
years have created cynicism and despair. We are a nation thirsty for hope to
solve our many problems.”

The healthcare insurance industry is going to try to destroy President
Obama’s “National Health Insurance Exchange”. If congress
passes the National Health Insurance Exchange it will lead to a single party
payer system. The government as the single party payer is unsustainable.

“As part of what it calls an "informational website," the company has
hired an outside PR company to make a series of videos sounding the alarm about
a government-sponsored health insurance option, known as the public

The industry argues that creating a public insurance program will undermine
the marketplace and eventually lead to a single-payer style system.

Somehow, this isn't surprising. The health insurance industry has showed it
is not serious about controlling costs by
backing away from the promise they made to President Obama

Now, it wants to eliminate the public health insurance option. The
public insurance option would provide an option for people who cannot afford buy
private insurance because of the healthcare insurance industry’s

The public
health insurance option is a key provision in President Obama's plan to help
cover all of us
. It would finally give everyone the choice between
keeping our current insurance or switching to a new, high-quality public
. And under a public health insurance plan our premiums wouldn't
subsidize CEO salaries or stockholder profits
we'd all save a lot on
health care costs

There are basic problems with private healthcare insurance. Its premiums are
a very rough calculation with large profits built in. The industry has reduced
provider reimbursement and restricted access to care while raising premium and
maintaining grotesque administrative fees. The process is opaque to all.

government will do the same as a single party payer because it cannot afford the

Obama’s thinking on cost savings is defective
. The government outsources the
administrative services of its present government healthcare programs Medicare
and Medicaid to these very same healthcare insurance companies. The healthcare
insurance companies do the same thing to the government. Its providers
(physicians and hospitals) and consumers (patients) will experience the same
reductions and rationing of care. The program will fail just as the
Massachusetts program has failed to be affordable to the state. A systemic
change in the healthcare systems payment structure must occur in favor of
patients and physicians.

“If we had the choice of a public plan, private insurers would have to
lower rates and improve quality to compete
, so they're dead set
against it.”

The crafting of a campaign by Blue Cross Blue Shield of North Carolina is the
first of many campaigns we will see in the coming months in an attempt to turn
public sentiment against the “National
Health Insurance Exchange.”

President Obama’s insurance exchange is another way of expanding the Medicare
program. His plan is to arrive at a single party payer through the back door
while promising to maintain the private insurance option. It is Hillary
Clinton’s healthcare plan of 1993 all over again. Nobody asked the practicing
physicians for solutions. Physicians’ representing associations have not done of
very good job of articulating solutions.

healthcare insurance industry is not looking to protect its customers
(consumers). It is looking to control the healthcare dollars and protect its
profits. However they have cooked the goose that laid their golden eggs by
abusing consumers, employers and physicians. Harry and Louise will not

Consumers are frustrated and angry. They do not trust government or the
healthcare insurance industry. They are looking for a creative solution.

The new media, the internet and blogs provide a chance for consumers to
express themselves.

“ Obama
will backtrack on this one, too! I don't have any hope that America will join
the 20th century to become a "progressive" democracy. We are an oligarchy and it
will stay that way. Just look how we elect people for office. Millions raised,
millions disappearing in someone's pocket. Money rules! ”

Consumers, it is time we drove the healthcare system because our surrogates
have let us down.  

“Not surprised at all by this. The health insurance companies have had an
unbelievable advantage, they can do anything they want. The only thing they need
to do is keep Congress happy with lobbyists because Congress is not their
customer, they have their own insurance paid by you and I. It's gloves off time
on health reform. These guys will pull no punches, they are fighting for their
yachts. While we lose insurance if we file a claim.”

It is time for consumers to demand control of their healthcare dollar. It is
time they have incentives to be responsible for their own health and be rewarded
for staying healthy. My
ideal medical savings account either funded by employers if the consumer is
employed or funded by the government with insurance for all is the solution that
must be demanded.

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

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President Obama’s Healthcare Reform: A Slam Dunk: No Defense

Stanley Feld M.D.,FACP,MACE


After a White House meeting with healthcare leaders, President Obama pronounced that is was “a historic day, a watershed event,”. He brought doctors, hospitals, drug makers and insurance companies voluntarily together and they offered $2 trillion in cost reductions over 10 years.

“The savings, he said, “will help us take the next and most important step — comprehensive health care reform.” The meeting’s results were announced as if President Obama engineering a political coup bringing leaders of the health care industry to the White House and built momentum for his ambitious health care agenda.”

All the proposals from the meeting are vague and unenforceable. None of the proposals guarantee cost savings to the healthcare system. It is another trick play to break down the defense of the major stakeholders in the healthcare system. It represents an attempt at consensus building.

Mr. Obama had told the health care executives, you’ve made a commitment; we expect you to keep it.”

The healthcare insurance executives and the hospital system did not realize what the President was doing. The healthcare insurance industry says nice things in order to have a seat at the table. It knows it is the real villain. The President is saying nice things in order to avoid confrontation, “build consensus ” and impress the media with a sense of agreement among stakeholders for his healthcare reform package.

“The consensus-building approach has already yielded some results. Insurance executives have offered to end certain underwriting practices, like refusing to cover individuals with pre-existing conditions or charging women higher rates than men, and they have invited Congress to impose stringent, uniform federal regulation on their industry.”

The healthcare insurance industry has made promises without realizing what it has done.

“ But even as insurers and health care providers stand shoulder to shoulder with Mr. Obama in vowing to slow the growth of health spending, they oppose him on other fronts.”

“For example, insurance companies are opposed to a new government-sponsored health plan, which Mr. Obama supports but insurers fear could drive them out of business.”


The next day the healthcare insurance industry and the hospital systems realized the impact of the President’s coup. They realized he was wooing them but not talking about the same thing they were. President Obama’s noose is tightening around the healthcare insurance industry’s neck.

Health care leaders who attended the meeting have a different interpretation. They say they agreed to slow health spending in a more gradual way and did not pledge specific year-by-year cuts.”

In separate press releases the American Hospital Association and the American Association of Healthcare Insurers clarified their positions. The American Medical Association seems to have bitten President Obama’s hook. It has not protested President Obama’s healthcare plan nor has it offered effective executable reform measures. It has offered high level goal without a path to achieving the goals.

“There’s been a lot of misunderstanding that has caused a lot of consternation among our members,” said Richard J. Umbdenstock, the president of the American Hospital Association. ”

“The A.H.A. did not commit to support the ‘Obama health plan’ or budget. No such reform plan exists at this time.”

It sounded like President Obama faked out the AHA. They came back strong and denied agreement with the form that was presented by the President.

“Moreover, Mr. Pollack EVP of AHA wrote, “The groups did not support reducing the rate of health spending by 1.5 percentage points annually.” They had agreed to squeeze health spending so the annual rate of growth would eventually be 1.5 percentage points lower.”

The America’s Health Insurance Plans had the same reaction.

“Karen M. Ignagni, president of America’s Health Insurance Plans, said the savings would “ramp up” gradually as the growth of health spending slowed.”

Nancy-Ann DeParle reply tried to appease these two powerful vested interests. Her reply and correction of her reply made things worse.

Nancy-Ann DeParle, director of the White House Office of Health Reform, said “the president misspoke”. After providing that account, Ms. DeParle called back about an hour later on Thursday and said: “I don’t think the president misspoke. His remarks correctly and accurately described the industry’s commitment.”

Few speak of the details of President Obama’s healthcare reform plan. President Obama is going to slam dunk his healthcare reform. Congress and the stakeholders will be defenseless. Everyone will be caught flat footed.

Congressional Democrats are starting to complain about the process being secretive. Only a select group is writing the legislation. Republicans are lost. They are not offering insight or executable alternatives. If they have alternatives have not told stakeholders or the public. Before Americans know it a disastrous healthcare reform plan will pass by 51 votes in the senate.

Americans: Please wake up.

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

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President Obama’s Healthcare Reform Trick Play


Stanley Feld M.D.,FACP,MACE

Healthcare policy definitions are easy to confuse. I am an advocate for universal healthcare coverage. I am not an advocate for a single party payer. I believe the only way to be successful in repairing the healthcare system is to remove control of the healthcare dollar from the healthcare insurance industry. Consumers must be in control of their health care dollars. The ideal Medical Savings account can motivate patients to be responsible for their health.

Patients with chronic disease must be motivated to control their chronic disease. If they are motivated to control their disease healthcare costs would decrease. Using the ideal medical savings account a patient with diabetes for example would be expected to spend $4000 dollars a year. It they controlled their disease well and avoided hospitalization their employer or the government could afford to provide a bonus. If they controlled their disease and avoided hospitalization they would have $2000 to put in a retirement account. They could be eligible for an additional $2000 bonus. The result is a savings of $4000 into their retirement account. Patient responsibility and motivation are the only way we have a chance to Repair the Healthcare System.

President Obama healthcare plan is going to make patients more dependent on government and less responsible for their care and choices. In fact choice will be rationed. His allies in the single party payer camp are complaining that he has “caved” in to hospitals and healthcare insurance companies.

They claim he was elected to install a single party payer system. They ignore the point that the government cannot afford to pay for the Medicare single party payer system much less universal coverage for the entire population as the single party payer.

The function of the government should be to make appropriate rules to align the incentives of all the stakeholders in the healthcare system. President Obama is confusing everyone with his position on healthcare reform in order to decrease resistance to his plan. My guess is he is doing it intentionally.

“Although Barack Obama was elected on a health care reform platform, his version ignores single payer. Nor is single payer advocated by his allies in the well-funded coalition called Health Care for America Now, composed of MoveOn, USAction, ACORN, Americans United for Change, the unions SEIU and UFCW and other liberal heavy hitters.”

President Obama is a clever politician. He understands that it would be political suicide to directly advocate a single party payer system. The American public wants choice. They do not want to have healthcare rationed. The American public understands the government cannot afford a single party payer system for all. The public outrage would dominate the debate. His healthcare plan is designed to arrive at a single party payer system by default.

The advocates of a single party payer do not understand the subtlety of President Obama’s positioning in the healthcare reform debate. .

“Journalist Russell Mokhiber, founder of the new group Single Payer Action, notes that no advocate of a single payer system was invited to the recent White House summit on health care reform. Only protests by Progressive Democrats of America and others won an invitation for Congressman John Conyers, sponsor of the United States National Health Care Act: H.R.676.”

The advocates of single party payer system are now attacking President Obama. They are accusing him of caving in to the demand of powerful vested interests.

“Mokhiber quotes Dr. David Himmelstein of Physicians for a National Health Program: “The President once acknowledged that single payer reform was the best option, but now he’s caving in to corporate health care interests and completely shutting out advocates of single payer reform," even though "the majority of Americans favor single payer, and it’s the most popular reform option among doctors and health economists."

This is political spin. President Obama is not caving into anyone. The majority of Americans are do not want rationing of health care that usually follows the high cost of a single party payer by government that exists in other western countries.

The President knows the best way to achieve a single party payer system. His plan is to get there by default.

The Obama healthcare reform plan is create a National Health Insurance Exchange to help individuals who wish to purchase a private insurance plan. The Exchange will act as a watchdog group and help reform the private insurance market by creating rules and standards for participating insurance plans to ensure fairness and to make individual coverage more affordable and accessible.

I believe his National Health Insurance Exchange will drive the private insurance companies out of the healthcare insurance business. This might not be a half bad idea since the healthcare insurance industry controls healthcare cost and earns a grotesque amount of money.

It could change the healthcare insurance industry but I doubt it. It should become a 6% broker as the administrative service organization instead of 15% broker in a private insurance system. However there is no price transparency. In reality the government pays 18% for Medicare administrative services. President Obama healthcare reform proposals will not repair this abuse. Nothing will change. The government will restrict access and ration healthcare.

Watch out.

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

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Star Trek. The Movie And The Traditional Media

Stanley Feld M.D.,FACP,MACE

Saturday on opening weekend Brad and I went to the 12.10 pm showing of Star Trek. the movie in Boulder. The theater was packed on a beautiful sunny day in Boulder Colorado. We both conclude that the movie was a wonderful extension of the iconic T.V. series and movie sequels. In fact Brad tweeted that it was the best movie of the decade. I know that motivated many to see the movie on Saturday date night. American pop culture is a pacesetter worldwide. It is nothing for Americans to be ashamed of. To my dismay, but not to my surprise the media, evaluation of the movie has been negative.

The America press is on a suicidal path. They are not representing the views of the American public. Frank Rich expressed it beautifully in his op Ed article on Sunday May 10, 2009.

The cultural disconnect between the journalism establishment and the public it aspires to serve could not have been more vividly dramatized.

He said this when describing Stephen Colbert’s address at the annual White House Correspondents’ Association dinner 3 years ago.

“Mr. Colbert delivered a monologue accusing his hosts of being stenographers who had, in essence, let the Bush White House get away with murder (or at least the war in Iraq). The Washington Post reported that it “fell flat.” The Times initially did not even mention it.”

The speech became viral overnight over the internet after You tube put C spans coverage on the internet.


On Wednesday, C-Span, the nonprofit network that first showed Mr. Colbert’s speech, wrote letters to the video sites and, demanding that the clips of the speech be taken off their Web sites.

Star Trek has a complicated history with a simple plot. It has developed a massive cult following because it is “camp”. To me Star Trek glorifies American pop culture. It excites the imagination of kids and adults alike. Ever though the story plots are not innovative it stimulates the imagination to be innovative. I cannot wait for the invention of a real transporter.

An op ed piece by David Hajdu a professor at the Columbia Graduate School of Journalism highlights traditional journalism misreading of the American public.

Gene Roddenberry, was a gifted hack writer for TV Westerns like “Have Gun, Will Travel” and cop shows like “Highway Patrol,” and “Star Trek,” though set in a nominally stylized future. Star Trek was essentially a Western cop show.”

So what. The good guys always win. It is the American way. This is Star Trek’s appeal. Someone ought to tell the New York Times editorial board the American public is no longer intimidated by intellectual snobbery. The American public now has control of the distribution of information without newspapers. Blogs, social networks and Twitter will replace traditional newspapers as a form of communication. I would guess Brad’s tweet caused more than 2000 people to go to Star Trek last weekend.

To say America is exploring the universe, one B-movie at a time simply misses the point. People power has spoken. On an early count Star Trek is one of the highest grossing movies of all time in the first weekend.

Paramount’s sci-fi movie "Star Trek" opened as No. 1 at the box office in North America this weekend, taking in some 72.5 million dollars over the three-day period, a movie industry-charting firm reported on Sunday. With I-MAX revenue its gross surpassed 85 million dollars.

The film will show major legs in the coming weeks with strong word of mouth propelling it well beyond the opening weekend," said movie industry analyst Paul Dergarabedian

Today many people under 40 years old get their news of the day from the Daily Show with Jon Stewart.

Marc Andreessen in a recent video streamed of the Charlie Rose show said newspapers on dead. If the New York Times woke up and spend 90% of their budget on internet communication they would figure out how to become relevant once more.

The message should be clear. Americans want real information, not manipulated information. The media has to respect the intelligence of the public. Only then will the public support the media.

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

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The Electronic Medical Record (EMR) Stimulus Fiasco: Part 3

Stanley Feld M.D.,FACP,MACE


President Obama’s goal for healthcare reform is to increase the quality of medical care, increase efficiency of medical care and decrease the cost of care. The goal is admirable. The route he is taking is wrong. In the process he might destroy the medical workforce.

The route the electronic medical record (EMR) stimulus package should take should be flexible and educational for patients and physicians. It should use modern software technology instead of subsidizing old inflexible technology that is set up to be punitive to physicians and patients to the advantage of the government and the healthcare insurance industry.

The term "quality medical care’ is used loosely. It has not been appropriately defined. The practice of evidence based medicine has been used to define quality medical care. The problem is evidence based medicine is changing daily.

A better definition should be the best clinical outcome with the most efficient financial outcome. It is assumed that practicing evidence based medicine will lead to the best clinical outcome at the most efficient cost.

Clinical guidelines are defined by “experts” interpreting evidence based medicine. I am/was one of those experts and appreciate its short comings.

Some guidelines are essential and should be inflexible. Others are ever changing and must be flexible. In bureaurocratic systems it is difficult to create flexible rules. Also, all patients are different. Clinical judgment plays an important role in treatment.

Physicians should not be penalized for using clinical judgment. Nonetheless, physicians are penalized in a pay for performance evaluation for deviating from inflexible clinical guidelines. Since some clinical guidelines are always changing the weakness of the approach is obvious.

An example of an inflexible clinical guideline is the need for rules to have a sterile operating room with sterile gowns and tools to avoid surgical infection.

An example of a need for a flexible clinical guideline should be a physician’s approach to a patient with hypertension. The goal should be to normalize the blood pressure. The goal for lowering the blood pressure to normal is to avoid heart attacks and stroke. However, if the patient’s blood pressure was elevated for a long period of time and was severe enough to compromise the renal (kidney)) blood flow, lowering the blood pressure too quickly could result in the patient having a stroke from a relatively low blood pressure. This is an example of the value of clinical judgment.

Physician performance should not be evaluated on static measurements. It must be evaluated on physicians’ medical judgment. Clinical judgment is a function of a physician’s ability to relate to his or her patients. (patient physician relationship)

On the other hand, if a patient felt poorly as a physician tried to lower the blood pressure to normal the patient might stop his medication without telling the physician. The physician’s workup might have been perfect and his choice of medication may have been excellent. This physician might get an excellent mark on his performance but the patient had a stroke because the patient did not comply with treatment. The patient might not have complied because he was not taught to be a professor of his disease. Healthcare is a team sport. The patient physician relationship failed but was not measured. .

The poor performance was missed by the static digital healthcare evaluation imposed by an inflexible EMR. The importance of the patient physician relationship and not including patient responsibility in the clinical outcome should be part of any performance measurement. A performance measurement should be a measurement of both the patients’ and physicians’ performance.

Now that the federal government plans to spend $50 billion to spur the use of computerized patient records, the challenge of adopting the technology widely and wisely is becoming increasingly apparent.

There is no question we should have universal electronic medical records. It should be a teaching tool for patients and physicians. The EMR should be inexpensive and flexible. It should not a tool to judge and penalize clinical performance. President Obama is being ill advised. His EMR stimulus program is going to result in a waste of $50 billion dollars.

“In a “perspective,” Dr. Kenneth D. Mandl and Dr. Isaac S. Kohane portray the current health record suppliers as offering pre-Internet era software — costly and wedded to proprietary technology standards that make it difficult for customers to switch vendors and for outside programmers to make upgrades and improvements.”

The software the government is going to spend $50 billion dollars on is going to be too expensive, inflexible and not widely distributed.

“Instead of stimulating use of such software, they say, the government should be a rule-setting referee to encourage the development of an open software platform on which innovators could write electronic health record applications”.

EMR software platforms in the cloud should be developed. This link by Christopher Barnatt  is an excellent utube explanation of cloud computing. I suggest all watch it.Amazon uses the cloud to sell books.’s business model tracks sales force activity at a minimal cost to the company. It is flexible and maintenance free.

“Such an approach, they say, would open the door to competition, flexibility and lower costs — and thus, better health care in the long run. “If the government’s money goes to cement the current technology in place,” Dr. Mandl said in an interview, “we will have a very hard time innovating in health care reform.”

The rules can be immediately changed. The cost to a medical practice could be minimal. Its effectiveness is maximal. The cost to the government using modern software technology could be between 1-10 % of what the stimulus is proposing to spend. If it is fashioned as an educational tool to patients and physicians the payback will be maximal, quality of care will improve and the cost of care will decrease.

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

  • electronic medical records

    Thanks for such a great article to share with.I think computerized medical records will save us all:save time,reduce errors,it helps us avoid redundant tests, gather huge amounts of data for research and etc.As medical billing software said” it is also for the betterment and advancement of health care”.

  • Medical Practice Management Software

    Excellent stuff. Many thanks for sharing this informative resource. In my opinion there are lots of benefits in using Medical Practice Software. It helps in improving patient care and saves time as well as money.

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War On Obesity: Part 12

Stanley Feld M.D.,FACP,MACE


Obesity is a major problem for the healthcare system. I am waging a War on Obesity. This article is Part 12 of my War on Obesity.

It is essential that a public service campaign at every socioeconomic level be mounted to explain the long term danger of obesity and how to combat its occurrence. Obesity is responsible for many chronic diseases and their complications. Its cost to the healthcare system is not sustainable. Diets might work short term. Lifestyle change is the only thing that will work long term.

The new administration should join me in my War on Obesity. It has been very responsive to the potential swine flu pandemic. The media has been very responsive to this important news story. Why can’t the administration develop a public service campaign to create an important healthcare story about the obesity epidemic? It might precipitate lifestyle change.

Neither President Obama nor the congress has suggested such a plan. The main message of my public service campaign would be:

2.2 pounds of fat equal 9000 calories

In order to lose 2.2 lbs weight you must eat 9000 calories less than you burn or burn 9000 calories more than you eat.

9000 calories is hard to lose and easy to gain

The federal government subsidizes school lunch programs in schools K-12. These school lunch programs were set up 50 years ago to counter malnutrition in under-privileged families. In 2009 the problem is childhood obesity. A new approach must be taken.

“The federal school lunch program, which subsidizes meals for 30 million low-income children, was created more than half a century ago to combat malnutrition. A breakfast program was added during the 1960s.”

The federal school lunch program is trying to produce healthy meals. They fail for two reasons. First, many schools do not control portion size. Second, those same schools still have snack bars, vending machines and à la carte food lines.

Federal rules that govern the sales of these harmful foods at schools are limited in scope and have not been updated for nearly 30 years. Until new regulations are written, children who are served healthy meals in the school cafeteria will continue to buy candy bars, sugary drinks and high sodium snacks elsewhere in school.

This is an example of a perverse outcome to a government mandate. The idea is good. The rules to execute the mandate are poor. The government will respond to people power (public opinion).

Public opinion can influence government policy and the media. If the people are passive they will have an environment that is good for vested interests. In the case of school food intake the vested interests are the candy, soda and junk food manufacturers and the school systems. The vending machines are a profit center for school districts that are underfunded by government. The profits are used to finance important school projects.

“Many states’ school districts have taken positive steps. But others are likely to resist, especially districts that sell junk food to finance athletic programs, extracurricular activities, even copier expenses.”

I did a Google search to see the breakfast and lunch menus of some independent school districts. Each has a disclaimer to avoid liability. Most provide between 650 and 1200 calories for lunch and 250 to 600 calories for breakfast depending on the portion size and the number of items a child can pick up.

Menus meet recommended dietary guidelines and may change due to product availability or other market changes. In accordance with Federal law and U.S. Dept. of Agriculture policy this institution is prohibited from discriminating on the basis of race, color, national origin, sex, or disability. To file a complaint of discrimination, write USDA,

Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Ave., SW Washington, DC 20250-9410 or call 202-720-5964. USDA is an equal opportunity provider and employer.

An obese child needs to burn 9000 calories in order to lose 2.2 pounds. An intake of 900 to 1800 calories for two meals is not going to help when a inactive obese child may burn only 1500 calories per day.

In an attempt to increase academic performance test scores, physical education has been eliminated from many school curriculum because of “school funding”. The lack of exercise increases the obesity epidemic.

It is going to take a national educational program for parents and children understand the basic etiology of obesity and caloric intake and output to conquer the obesity epidemic. It is going to take a coordinated effort by local parent teachers associations (PTA) to eliminate vending machines and snack bars from the schools. It is going to take a PTA protest to reinstitute rigorous physician education in school districts. It is going to take “People Power” with educational help from the federal government.

The federal government has the ability to do this in a public service educational campaign. It could use the money for this campaign from the money it saved using my universal EMR and my ideal medical savings account rather than wasting it on ineffective new bureaucratic institutions.

If President Obama doesn’t do something, chronic diseases resulting from obesity are going to continue to drive healthcare costs through the roof.

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

  • Medical Billing Software

    It is true that obesity is fast becoming a major health problem throughout the world. More and more people should come forward and support you for the war on obesity.

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The Electronic Medical Record (EMR) Stimulus Fiasco: Part 2

Stanley Feld M.D.,FACP,MACE

President Obama is counting on electronic health records (EMR) to help modernize the nation’s dysfunctional health care system, improve the quality of care and reduce its cost. He should understand the real costs of an EMR. The cost of disruption of the work flow, the issue of incompatibility and connectivity with other EMRs, and the costs of maintenance, service and software upgrades are all important barriers not taken into account in his stimulus package. If President Obama must think that throwing money at the conversion to electronic medical records (EMR) is going to work, he is wrong. He is using the wrong route.

“His stimulus package will provide $19 billion over the next two years to promote the adoption and use of health information technology, and he has pledged to spend some $50 billion in all over five years.”

Both hospitals and physicians offices have been slow to adopt EMR’s. Most physicians would love to have EMR’s to decrease paperwork and medical errors. However, many practices have legacy EMR systems that do not provide functionality necessary. These practices are struggling with the notion to reinvest in a new EMR as their reimbursement is decreasing, cost flow is ebbing, and physician income is decreasing

“PwC estimates that the average three-physician practice can expect to invest between $173,750 and $296,000 over two years to purchase and maintain an EHR system. “

A three man ophthalmology practice was quoted $65,000 per physician plus service and maintenance. The final figure was $95,000 per physician. The EMR is fairly functional. It would not qualify for a rebate from the stimulus package.

The physicians initially complained about the disruption in their work flow. After three months they started to accommodate to the change in work flow. Now they feel they need an upgrade to add functionality. The physicians are now concerned about the maintenance and service charge per year.

“Individual physicians, not practices, can receive up to a total of $44,000 each for adopting certified EHRs.”

President Obama’s subsidy is helpful but many physicians still cannot afford the upfront cost.

“Hospital systems main impediment is money. Many hospitals simply do not have the capital to buy systems that can cost $20 million to $200 million, especially when so many are struggling to remain solvent. Hospitals also worry about high maintenance costs, an uncertain payoff on their investment, and a lack of staff with adequate technical expertise.”

There is a perverse outcome to installation of an EMR. Physicians and hospital systems may realize some return on their EHR investment. The primary returns on the physicians’ and hospital systems’ investment is expected to mostly accrue to private and public payers.

“The federal government estimates that the conversion to digital records will save $12 billion in healthcare spending over 10 years.”

The federal government saving twelve billion dollars over 10 years is a small return on a $50 billion dollar investment. The investment risk is compounded by the uncertainty of implementation of a fully functional EMR.

The survey also found that:

  • 82% of hospital CIOs have already cut IT spending budgets in 2009 by an average of 10%, with one in 10 making more drastic cuts of greater than 30%.
  • 66% of CIOs say they expect to be asked to make further cuts in IT spending before the end of 2009.

It is not difficult to understand that hospitals want to cut costs. They are reporting cash flow and profit margin problems. The government cannot afford Medicare and Medicaid in its present form. President Obama’s plan is to expand both Medicare and Medicaid while decreasing patient coverage and provider reimbursement. Premiums for Medicare and deductibles have been increasing steadily.

  • 64% of CIOs agreed that it is impossible to balance demand with the need to cut costs.
  • One-half of CIOs with more than 500 beds say that federal funding is "crucial" to their ability to implement EHRs.

The stimulus formula for subsidizing hospital systems is a function of the hospital system’s volume of Medicare and Medicaid patients. With government reimbursement decreasing, hospital systems are reinventing themselves to attract paying customers. They are developing high productivity profit centers such as back centers, cardiovascular centers, and gastric bypass centers. Hospital systems “lose money” on acute illnesses. Hospital systems are trying to move away from their dependence of Medicare and Medicaid patients.

It should be obvious that President Obama’s EMR stimulus plan has not been well thought out.

The American Medical Association seems to be on the right track. It is clear to me that someone is listening to me.

“The American Medical Association is developing a Web-based service offering doctors electronic prescribing, up-to-date reference material and other resources.

The idea is to make it easier for physicians to adopt technology President Obama is promoting for health care reform, to streamline their workload, and improve patient care.”

“Doctors will be able to use it to access numerous electronic medical services, including the latest science on diseases, and electronic health records, said Dr. Joseph Heyman, chairman of the AMA’s board.”

There are no details available yet. It is encouraging that the AMA is trying to be proactive.

President Obama, this is not rocket science. If you put a totally functioning electronic medical record in the cloud in the next few months, the most it should cost the government (taxpayer) is about 5 billion dollars.

The software could be serviced and upgraded at no cost to the providers of healthcare services. The taxpayers return on the dollar would be at least three times that amount in the first year if the providers paid by the click. Payment by the click would not be a burden to physicians or hospital systems.

Physicians and hospital systems would instantly have a fully functioning EMR. The government could use the same business plan credit card companies use. It could even set up an auto pay system.

President Obama, I hope you read this and arrive at an "ah ha" moment and change the route you are taking to convert medicine to an electronic information system.

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

  • Electronic Medical Records

    patients should keep copies of their electronic medical records thorugh services like ours.
    This way, they will be in control and it could actually reduce their health care bills.

  • Stephen Holland, MD

    Those two comments look like paid advertisements. I encourage my patients to put their records on a usb thumb drive and take it with them. This is great for college kids. BTW, all my records are kept as PDF’s. so it is trivial to put the records on the patient’s thumb drive.

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