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All items for September, 2009


Government Medicine Should Horrify Americans


Stanley Feld M.D.,FACP,MACE


Both noise and facts drive decision making in all areas of policy making. The trick is to separate noise from facts. The devil is usually in the details. Americans have been conditioned to sound bites. We do not have the patience to understand the details and their ramifications.

Sound bites can be misinterpreted as being valid. The healthcare debate has made the public more interested in the details and the potential unintended consequences.

A typical example is the cost of care for Type 2 Diabetes Mellitus in Dallas compared to five Texas cities. The claims data is probably noise disguised as valid facts.

The public has become very cynical about the traditional media. Reporters can easily be manipulated by government and special interest groups’ press releases. Policy should be made for the benefit of the people. It should not be made for the benefit of special interest groups or the government.

The public mistrusts the government because of its discoveries of frequent disinformation fed to the media. This disinformation extends to all areas of its daily life including the two wars, the economic meltdown, the bank bailout, and automotive bailouts. All seem to be done at the expense of taxpayers and not to taxpayers’ advantage.

What doesn’t the public know about the healthcare debate? The public does not believe President Obama’s generalities. His plans contain too much bureaucracy, inefficiency, waste, taxes, and too much tax payer dollars. Special interests groups such as the healthcare insurance industry and hospital system will gain at the expense of the taxpayers and their freedoms.

The public is very hesitant to let the government take over the management of its healthcare. It mistrusts the government and its inefficiency. It knows something must be done to repair the healthcare system. However, it does not know what. President Obama’s plan sounds too convoluted, tricky and bureaucratic. His healthcare reform plan has little chance to be efficient and fair to the public.

Americans trusted President Obama during the election campaign. They are having their doubts now especially with the implications of his healthcare reform program.

The public trusts the healthcare insurance industry less than it trusts the government. .

The easiest way to accomplish healthcare reform is to allow consumers to control their healthcare dollar and teach them how to spend it wisely.

Both the public and the physician community are unhappy that 45 million people are uninsured and many more are under insured.

Qualifications for Medicaid depend on the definition of poverty. Most states and the federal government utilize the outdated 1995 definition of poverty. The definition disqualifies people who make more than $12,000 and less than $60,000 a year. If this group is self employed they cannot afford $14,000 a year for a private insurance plan with after tax dollars.

Some states have tried to increase the poverty level to permit more patients to qualify for Medicaid. The federal government has refused to supplement these states with increase Medicaid funding.

Physicians are under reimbursed by Medicaid. Therefore most physicians do not participate in the program. Physicians cannot make a living seeing Medicaid patients unless they create Medicaid mills and see 200 patients a day per physician using lots of patient extenders.

Newt Gingrich calls this Medicaid fraud. He has proposed fining these physicians or putting them in jail. This will only intensify the primary care physician shortage for Medicaid.

Another proposal hidden in the Baucus bill is to require all physicians to participate in all government programs.

Both of these Medicaid problems are easily fixed with correct regulation by the government without a costly bureaucracy resulting in unintended consequences..

Consumers who lose their jobs cannot afford Cobra insurance with after tax dollars. Consumers over 55 years old with a pre-existing illness, even if they wanted to pay with after tax dollars, would not qualify for private insurance.

Simple federal regulations can require insurability without a massive and wasteful bureaucracy.

The enemy is the healthcare insurance industry not patients or physicians. Patients and physicians are partly to blame. However, it is a response to the unlevel playing field created by the government.

The public is convinced that a government directed healthcare system will not protect or adequately insure them. Government healthcare reform will be inefficient. It will shift medical decisions away from patients and physicians.

President Obama does not seem to care about the opinions of the people who elected him. He is convinced that government control with a single party payer is the only system that will repair the healthcare system. He is doing everything he can to evolve the healthcare system into a single party payer system.

The fact that America is even considering government medicine is equally wacky. The state guides health care for our two closest allies: Great Britain and Canada. Like us, these are prosperous, industrial, Anglophone democracies. Nevertheless, compared to America, they suffer higher death rates for diseases, their patients experience severe pain, and they ration medical services.”

The government and the pundits are telling us that we spend one third more for healthcare than other industrialized countries and do not have better medical outcomes.

I will discuss the myths about healthcare in the near future. President Obama and the Democrats are making healthcare reform decisions on the basis of the validity of these myths. They are convinced the only way to fix the healthcare system is to have the government control the healthcare system.

It makes no sense based on the experiences of others. We need only to review the disaster in Massachusetts as a result of unintended consequences.


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

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A New Defective Study: Type 2 Diabetes Treatment Costs More In Dallas


Stanley Feld M.D.,FACP,MACE

I am a retired Dallas Clinical Endocrinologist who has no financial vested interest in this new report. I also was the chairman of the American Association Clinical Guidelines on the Treatment of Type 2 Diabetes Mellitus: A System of Care Of Intensive Self-Management of Diabetes Mellitus.

I am disheartened the lack of science that is presented as scientific information in this new study of claims data for Type 2 Diabetes Mellitus.

An article about the report was published in the Dallas Morning News on Thursday September 12, 2009. The article demonstrates how well intended people can be mislead by data that has little scientific or social scientific validity.

Misleading data can lead to inaccurate conclusions. Inaccurate conclusions lead to incorrect healthcare policies.

The federal and state governments as well as private industry rely heavily on medical claims data to make healthcare policy decisions. Medical claims data are derived from healthcare insurance industry’s computer systems. Claims data relate variables to each other and produce data.

The study reported in the Dallas Morning News relates the diagnosis of Type 2 Diabetes Mellitus to the average cost per Type2 Diabetic patient per year in five cities in Texas. There are many defect in the claims data because they do not consider the many confounding variables that might affect the conclusions (variables that can influence the data in one direction or another). Accurate conclusions cannot be derived from the data.

Healthcare policy makers have used similar inaccurate claims data to formulate healthcare policy for years. Inaccurate conclusions lead to incorrect healthcare policy. The new healthcare policy in turn distorts the dysfunctional healthcare system even further.

Well intended corporations want to help employees improve their health and healthcare coverage. However, they adopt incorrect policies that fail to achieve their goals and increases their healthcare costs.

“Dallas-area doctors charge more to treat patients with the most common form of diabetes than doctors in any other Texas city, according to a report set for release Thursday.”

“Doctors here charge an average of $6,992 annually per patient with Type 2 diabetes, compared with $2,079 in Austin, $3,067 in El Paso, $1,578 in Fort Worth and $2,226 in Houston. “

Let us assume these claims data are correct. The implication is in Dallas physicians charge more for the treatment of Type 2 Diabetes Mellitus than in the other major cities in Texas and do not do a better job of caring for Type 2 Diabetic patients. If you are going to get Type 2 Diabetes Mellitus don’t get it in Dallas, get it in El Paso. 

What is wrong with these claims data? What are the confounding variables and their effect on the conclusion?

1. Physicians in Dallas see Type 2 Diabetics more frequently and do more tests than physicians in other cities.

What is wrong with these claims data and what are the confounding variables.

One confounding variable could be that Clinical Endocrinologists in Dallas have been teaching Primary Care Physicians how to practice evidence based medicine for Diabetes Mellitus for years

Best practices for Type 2 Diabetes Mellitus dictates that patients are followed up 4 times a year.

HbA1c levels which measure the blood sugar control over 3 months should be done four times a year. A minimum of twice a year is acceptable in some guidelines. These criteria are adopted by the NCQA. NCQA will be President Obama “expert guideline panel.

Patients with Type 2 Diabetes Mellitus in the other cities might not see physicians as frequently. Some physicians see Diabetics once a year because the Diabetic is told they have a touch of Diabetes and follow up is not that important. Type 2 Diabetics are usually not symptomatic even if they are walking around with a high blood sugar.

However, high blood sugar levels cause micro and macro vascular disease leading to the complications of diabetes such as eye disease and blindness, kidney disease and renal dialysis, neuropathy or nerve disease, leg amputations and heart disease. High blood sugars increase cholesterol and LDL (bad cholesterol), low HDL (good cholesterol) and subsequent heart attacks.

All of these complications need to be monitored according to guidelines. Effective treatment intervention can stop the progression and even reverse the onset of complications.

  1. The claims data might indicate that the physicians in other cities do not take care of patients with Type 2 Diabetes Mellitus as well as physicians in Dallas.
  2.   It might also mean that despite physicians in Dallas following up patients and  practicing evidence based medicine patients do not comply with treatment recommendations resulting in expensive complication.

Physicians can do tests, see patients often, prescribe the correct medication and diet and patients still gain weight and have very high blood sugars and cholesterol levels. Patients must be responsible for their care between doctor visits.

3. In Dallas there might be more Obesity, Type 2 Diabetes, heart attacks and renal dialysis leading to a higher cost per patient per year than other cities despite physician effort.

None of this data is reflected in the claims data collected and compared. This is great deficiency of claims data.

We have claims data about physicians in Dallas. They do a higher percentage of HbA1c’s than physicians in other cities. They probably do a greater number also.

The implication is Dallas physicians should have a lower cost than other cities because a higher percentage of HbA1c’s. Patients should be better controlled and have less complications.

The HbA1c is simply a marker of blood sugar control. It does not decrease the complication rate. It should not be a measure of quality of care. If done once a year rather than four times a year it will decrease the cost of care. Lowering the HbAic should be the measurement of the quality of care. It will reduce the complication rate of Type 2 Diabetes. Claims data does not measure the improvement in HbA1c levels.


The complications of Type 2 Diabetes Mellitus consumes 80% of the healthcare dollars spent on Type 2 diabetes.

4. The majority of Type 2 Diabetes Mellitus is discovered in the CCU after a male has a myocardial infarction. These patients are expensive patients. They are included in the diabetes claims data.

5. Physicians in El Paso might not code for Type 2 Diabetes Mellitus in a patient with a myocardial infarction. We do not know this from claims data.

Claims data tell us nothing about the care of the patients. Yet health policy makers assume studies are valid. The only thing valid about this new report is that it was done. Claims data confuses health care policy makers and leads to wrong conclusions about the quality of care. .

"This confirms what we already know from other recent studies that medical charges in Dallas are among the highest in the country," said Marianne Fazen, executive director of the Dallas Fort Worth Business Group on Health.”

“The state average is $3,399 per patient with
Type 2 diabetes, the form of diabetes that occurs when insulin the body produces doesn’t work well enough to process sugar into energy. “

The treatment of Type 2 Diabetes Mellitus is a team sport. The physician should be the coach and the patient is the player. The patient has to be taught to be a professor of diabetes care. Physicians have to measure patients’ progress and help patients make adjustments to their care.

This new report is worthless. It does not shed any light on what needs to be done to prevent the complications of Type 2 Diabetes Mellitus nor improve the quality of diabetes care in Texas.

Once we abandon the notion that claims data can tell us something about quality of care we will start making progress to improve quality of care.


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


Nothing New: Same Old Stuff Spun Slightly Differently: Part 3


Stanley Feld M.D.,FACP,MACE

There are many disconnects between President Obama’s goal and his strategy to reach the goal of universal coverage, affordable coverage and increase in quality of care.

Universal coverage is a critical element in healthcare reform. Who is going to pay for universal coverage? Should it be the government? Should the “richer” taxpayers pay for the poor? Should physicians pay for it?

Should we ration care? Former Mayor Ed Koch (New York City) is a vigorous 82 year old male with coronary artery disease. Should he be able to decide on treatment for his coronary artery disease or should the government panel make the decision? Mayor Koch, a Democrat, is upset that the governments panel will decide for him under President Obama’s healthcare reform plan.

Affordable coverage is another goal of President Obama’s healthcare reform. Can America achieve affordable premiums without increasing deductibles, increasing taxes or rationing care? If a citizen cannot afford the deductibles who is going to pay it?

It is not plausible.

Increasing the quality of care is another important goal of President Obama’s healthcare plan. What is the definition of quality of care? Is the definition of quality what the government panels decide is quality care? Should quality medical care be defined as treating people back to health and having them satisfied with the service? Quality healthcare has not been adequately defined.

The healthcare system is dysfunctional and wasteful. How much waste is in the healthcare system? Where is the waste?

President Obama is not attacking the factors that add to the majority of the waste? He is proposing a healthcare system that is destined to create more waste. Stakeholders are profiting from the waste. Those who are profiting do not want to eliminate the waste. The healthcare insurance industry profits most from the systems’ waste.

Waste should be defined as non value added services to medical care;


Even with all this inefficiency and unnecessary care the average costs for the entire Medicare population including end of life issues is $6,600.00 per person. This includes the healthcare insurance industry’s administrative services fee.

Medicare Advantage was design by the government and the healthcare insurance industry to help the government unload its Medicare entitlement liability and cost over runs. The government pays an additional $3,000.00 subsidy or $9,600.00 per person for the Medicare Advantage program..

If President Obama and his administration concentrated their efforts on eliminating this waste they would not have to concentrate on reducing costs by decreasing reimbursement of physicians and hospitals.

What exactly are we paying for when we pay insurance premiums? Figure 1 is the breakdown of the percentage each segment costs. Notice in 1988 the out of pocket expenses(17.4%) for private insurance policies almost matched the entire Medicare costs(18.8%). Increased deductibles with President Obama’s healthcare plan will double this percentage. The result will not be affordable coverage. It will result in a rationing of care for everyone but predominately seniors.



Figure 1 Sixty five percent of private insurance dollars in Minnesota went to administrative services including brokerage fees. Only 15% went to physicians and 20% to hospitals. Figure 2


Figure 2

"The social contract for medical care should be between the physician and patient. Private Insurers aggregate 32.6% of the dollars that Americans pay in the hope of getting care, and insurers pay out only 4.9% of the money collected from the nation’s Consumers to physicians. Insurers pay out only 6.5% to hospitals.  Administrative service fees could not possibly add 15% value to the care of a patient. The administrative service fee can and must be reduced markedly."


Figure 3


Figure 4

President Obama has been accused of putting the healthcare insurance industry out of business. He will not. He will continue to pay it an inflated administrative services fee. The healthcare insurance industry will be more profitable because it will have more customers and make a greater profit.

Critics of President Obama’s healthcare reform plan made these statements.


The half-dozen leading overhaul proposals circulating in Congress would require all citizens to have health insurance, which would guarantee insurers tens of millions of new customers — many of whom would get government subsidies to help pay the companies’ premiums.”

"It’s a bonanza," said Robert Laszewski, a health insurance executive for 20 years who now tracks reform legislation as president of the consulting firm Health Policy and Strategy Associates Inc”.


The insurers are going to do quite well," said Linda Blumberg, a health policy analyst at the nonpartisan Urban Institute, a Washington think tank. "They are going to have this very stable pool, they’re going to have people getting subsidies to help them buy coverage and . . . they will be paid the full costs of the benefits that they provide — plus their administrative costs."

In his speech to congress President Obama essentially repeated his generalities. He did not get to the essence of creating affordable healthcare reform. His plan will fail to Repair the Healthcare System if it is passed by congress just as the Massachusetts plan has failed.

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

  • Marc D Grobman, DO FACP

    I find this topic quite interesting and I would like to use your slides for a lecture I am giving. How can I obtain them?

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Nothing New: Same Old Stuff Spun Slightly Differently: Part 2

Stanley Feld M.D.,FACP,MACE

President Obama’s speech on healthcare reform to a joint session on congress added nothing new. It was just spun differently.

He continued avoiding the issue of healthcare rationing. Sarah Palin crudely called rationing “Death Panels.” It is an effective sound bite in our sound bite society.

President Obama called her out on it and followed with his own sound bite. He said his “healthcare reform bill is not going to stand between you and your doctor.” He is disingenuous. The plan is to establish a panel of independent experts that will decide on best practices. This panel will then pass on the information to a reimbursement panel that will decide to pay or not to pay.

Barack Obama really does want to come between you and your doctor.  More precisely, he wants to change the way your doctor practices medicine, says John C. Goodman, President, CEO and the Kellye Wright Fellow of the National Center for Policy Analysis.”

“Rationing Obama-style will be done indirectly, explains Goodman.  It will be the result of administrative decisions — all ostensibly made for the best of reasons: to eliminate futile and unnecessary care.”

Physicians will be penalized by non reimbursement if they do not practice the dictated best practices. As far as one can tell the best practices will be determined by the panel decisions on the most cost effective practice. The decisions are out of the patients’ hands and their physicians’ hands. It is a clear contradiction to the Presidents sound bite that “his healthcare reform bill is not going to stand between you and your doctor.”

President Obama does not understand the dynamics of medical practice. Medical information changes by at least 10% per year. Panels take at least 2 years to determine a single best practice guidelines as evidenced by the U.S. Preventive Services Task Force (USPSTF).

USPSTF is a subsidiary of the Agency for Healthcare Research and Quality. Its backgrounder states ;

All Americans benefit from safe, effective, and efficient health care. The Agency’s mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. In support of this mission, AHRQ is committed to improving patient safety by developing successful partnerships and generating the knowledge and tools required for long term improvement.”

The day USPSTF published best practices for osteoporosis it was out of date. Some guidelines have not been updated since 2002. Can the government move quickly on the best and safest medical practices?

The osteoporosis guidelines were published in 2007 by a panel of names unfamiliar to me as an osteoporosis “expert.” The guidelines were outdated on publication.

Guidelines should be a teaching tool and not a decision making and reimbursement tool. President Obama’s plan looks like it is going to dictate the way medicine is to be practiced. It will eliminate physician judgment and patient freedom to choose.

President Obama is seeking authority to make reimbursement decisions through these “independent” panels to force physicians to make treatment decisions. His goal is to force physicians to do fewer CAT scans, MRI’s, blood tests and operations. The government will not pay for procedures its panels consider questionable.

A retired physician leader sent me a note he wrote to a friend a few weeks ago. He has no political agenda. He is only interested in the best care for patients at the lowest possible price.

Dear H

Let’s agree that Medicare and Medicaid (including 79 million beneficiaries, and did you know that Medicaid coverage varies from state to state?), left as they currently operate, are fiscally untenable.

If we can do that, we must also agree that our wizards in congress (lower case intended) are responsible for that condition, having created it, and endlessly tinkered with it for nearly 50 years.

  Hang onto that thought, because whatever happens this year must be viewed as just the beginning of a work in progress headed who really knows where.

Who will tell us what "high quality health care at relatively low cost" looks like.  There are no current standards that define the terms, or that set the benchmarks to use when measuring them. 

Who decides whether a test is unnecessary?  Often one doesn’t know that until after the results are in. Some tests really are not necessary, I agree, and some doctors are fiscally driven, but they do not represent the majority of the profession, and the majority of the costs in the current situation.

The Dartmouth Atlas and the articles of Gawande do point the way to regional non-uniformities in the delivery of care, and not all of it can be blamed on the malpractice bar, but some of it can.

Doctors are rarely sued for doing too many tests, but they sure as hell are sued for doing too few.   I’m all for paying for value, but I doubt if the congressional wizards can define value any better than you can, or than many doctors can.

The bottom line needs to be getting sick people well as quickly as possible, and back to their normal lives, and preferably leaving them satisfied with the care and attention they received along the way.

As for "prevention", there is really very little doctors can do to prevent disease.  They can detect disease early with timely and appropriate examinations, some of the time. When they can detect disease early, chances are that outcomes will be better.

If patients want to stay well, they can improve their chances of doing so by not getting fat and not smoking, and that is about all there currently is to prevention.

Come back to your son-in-law to wind this up.  He was offered a procedure by his physician (doctors can sell people their own shoes, and often do) that is not yet an approved procedure.

Who does the approving?  A variety of entities do the approving. One being the Institute of Medicine, and one being the National Science Foundation. The National Science Foundation is always looking at new procedures.  There is not official, stepwise review and approval process, just the evolution of peer reviewed studies over time that eventually come to be recognized as representing an improvement in outcome.

There are large numbers of people walking around with a history of spinal fusions who have done quite well, so how one predicts a life of disability for someone is not clear to me. What is clear to me is that for a patient to opt for a procedure his insurer won’t cover is the same as having no insurance at all.

Dr. D

Think about it. President Obama’s solution to achieve his goals are wrong. His route will destroy physician judgment, patient choice and the physician patient relationship.

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

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Nothing New: Same Old Story Spun Slightly Differently: Part 1


Stanley Feld M.D.,FACP,MACE

President Obama’s speech on healthcare reform to a joint session of congress added nothing new to the healthcare reform debate.. It was just spun differently.

He did give a tepid nod to tort reform. Defensive medicine results from a defective tort system. The defective tort system generates between $300 and $700 billion dollars a year in excessive diagnostic testing. Lawyers and insurance companies make large sums of money from the malpractice system. The tort system adds little value to the health of citizens.

President Obama said he will set up a few demonstration projects. Government demonstration projects have not worked in the past. His tort reform projects are too few and will have little effect. Everyone knows the problem as well as the solution. Our healthcare system needs significant tort reform immediately. The President is protecting the plaintiff attorneys because he doesn’t want to take them on. They have been large contributors to Democratic Party member election campaigns.

President Obama said the “Public Option” is the best way to control costs. However, he will not have a Public Option if he gets a bill passed. He is going to try to sneak a single party payer system through the back door as Barney Frank has stated.

The President said no one will have to spend more than $5,000.00 a year in out of pocket expenses.

Who is going to pick up the costs after consumers spend $5,000.00? I assume the government will. Consumers have to buy government mandated and approved healthcare plans.

Consumers will have to pay for policies that have a 40% deductible with after tax dollars as opposed to the 20% deductible with pre-tax dollars. The Obama administration has been convinced by the healthcare insurance industry that it needs the increase in deductible percentage in order to produce a lower “affordable” premium.

Consumers, by paying with after tax dollars, will be paying 35% more for their healthcare policies and 20% more in deductibles expenses. If the tax rate goes up to 40% they will pay 40% more for both. This is a hidden increase in consumers’ taxes and a government increase in revenue.

The big winner is the healthcare insurance industry, not consumers. The healthcare insurance industry will have a greater number of people insured on its roles because of a presidential mandate that he had promised to avoid.

President Obama said he will subsidize businesses and individuals who cannot afford healthcare insurance.

Who is going to make that judgment? The government will make that judgment. He asks us to stop being skeptical and trust his administration. He will take care of consumers in the spirit that made our country great.

President Obama, how can we trust your administration with our healthcare needs when we have had experience with so much false hope from your administration in the last 8 months?

He is leaving the control of the healthcare dollars in the healthcare insurance industry’s hands. The healthcare insurance industry provides administrative services. Can we trust the healthcare insurance industry to be fair and look out for the well being of consumers? No!!

President Obama said there are almost 400 insurance companies in the nation. He claims his plan will force them to be competitive. There are only five major healthcare insurance companies (Unitedhealthcare, Aetna Blue Cross/Blue Shield, Cigna, and Humana). Most of the other healthcare insurance companies are subsidiaries of those five major companies.

There will be no competition. The administration says a “Public Option” is the only effective way to lower the costs of healthcare. It will make healthcare insurance companies compete. However the insurance industry will define the costs and the price of the government’s public option. It has done so for Medicare Part D at the expense of taxpayers and it will do it again.

Medicare Part D is another failed government entitlement whose monthly premium has gone from $14 to $37 in three years. The patient deductibles have increase and the onerous donut still exists.

In addition to increasing the premium price the government subsidizes Medicare Part D with of billions of dollars a year. I predict the premiums for the “Public Option” will slowly escalate at tax payers’ expense.

The only creative way to break this healthcare insurance industry stranglehold is to institute a system with Medical Savings Accounts. The government or employers, as providers, should give consumers first $6,000 for their healthcare needs and teach them how to spend it wisely. What consumers do not spend they keep. The second $6,000 would be used to buy high deductible first dollar healthcare coverage.

This is the only way to reduce the healthcare insurance industry’s influence and grasp on healthcare spending. Medical Savings Accounts will provide consumers with incentives to use their healthcare dollar wisely. It will also provide incentives for patients to comply with medication and treatment prescribed. America might even make serious progress combating our obesity epidemic.

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Public Option vs. Ideal Medical Savings Account: Part 4


Stanley Feld M.D.,FACP,MACE

Politicians and healthcare policy makers have not included consumer driven healthcare in the healthcare reform debate. They have not included tort reform in the debate either.

The debate is about a public option. President Obama is going to redefine his meaning of the public option in his message to congress. He will make it sound benign. It will not sound like a government takeover of healthcare. He will omit the details and consequences of the bill.

President Obama must know the government cannot afford a public option. He knows he must control costs somehow. His policy makers believe the only way to control cost is by total government control over the healthcare system. Ultimately the goal is a single party payer system.

This way of thinking about the problem is wrong. Government control does not reduce costs in most projects. It usually increases costs. The President is focused on reducing physicians’ and hospitals’ reimbursement. He believes they are the reason for increasing costs. Medicare has continually decreased reimbursement to physicians and hospitals. Yet costs have increased.

To some extent decreased reimbursement leads to increased utilization but it is not the principle reason for the increase in utilization. A principle reason is an increase in the need to practice defensive medicine. Plaintiff attorneys deny it. The Massachusetts study confirms that defensive medicine leads to a large increase in utilization and costs.

Physicians are an easy target because they are not well organized. The Democrat controlled government is timid about attacking the plaintiff attorneys and tackling tort reform. Defensive medicine results in about a $700 billion dollar a year cost to the healthcare system

Howard Dean said it a few weeks ago. “Congress will not face the issue of tort reform because it does not want to take on plaintiff attorneys.” Consumers can solve this for congress by signing a valid limited liability waiver. Patients can put their own cap on damages. It would not require any courage on the part of congress or the President to face this difficult political issue. All congress and the President have to do is declare the waiver valid.

Texas and California have had the courage to place caps on damages. It has been very successful. If there were caps on damages and they were effective the need for defensive medicine practices would decrease.

The public does not trust congress or the President with control over its healthcare coverage. The public experience with unintended consequences of government control is obvious to all.

Recent examples are the unintended consequences of the bank bailouts, Goldman Sachs bailout, the economic stimulus package promise, the auto bailout, and the war in Afghanistan. All these bailouts are increasing the deficit at the expense of the taxpayers and future generations.

The public mistrusts the healthcare insurance industry as much as it mistrusts the government to control healthcare. The healthcare insurance industry has restricted access to care and rationed care. It has not reimbursed physicians and hospitals in a timely fashion. It has found it is cheaper to pay the negotiated settlement rather the medical bills for its insured.

Nancy Pelosi is right about one thing and only one thing. The real villain is the healthcare insurance industry. However, she does not understand with a public option she is not controlling the healthcare insurance industry fees for administrative services. The government outsources administrative services to the healthcare industry and will still be subject to grotesque administrative services fees.

The healthcare insurance industry has lobbied to change the law to increase co pays to 35-40% of bills so it can lower premiums to affordable levels. Increasing deductibles and lowering premiums would satisfy President Obama’s goal of affordable premiums. At the same time, it will increase the out of pocket cost of medical care for consumers who might need to use their “affordable healthcare insurance.”

The healthcare insurance industry will be forced to offer insurance to consumers with preexisting illness at an affordable cost. Some states have a high risk pool. The premiums in the high risk pools are at least 11/2 times higher than normal premiums and have higher deductibles. High risk patients must be put into the general insurance pool.

There has not been a word in the healthcare reform discussion about patient responsibility for their health. We are in the middle of the worst Obesity epidemic in American history. President Obama should declare a War on Obesity. He should promote legislation that could help eradicate obesity. He should provide patients with financial incentives to eliminate obesity and adhere to prescribed therapy. Obesity is a leading driver of increasing healthcare costs. The costs will only become grater as the obesity epidemic continues.

It is time consumers took control of their own health care dollars and their own health and well being. The defensive medicine/tort reform issue can be solved by consumers. Obesity can be solved with the government rewriting farm subsidies and a substantial public service health campaign to change our eating habits.

A consumer driven healthcare system along with the ideal medical savings accounts could solve many of the healthcare system’s problems without total government control. The government’s job should be to help with educating the public, negotiating prices that are transparent and fair and enforcing regulations to create a level playing field for consumers among the other stakeholders.

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

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Public Option vs. Ideal Medical Savings Account: Part 3


Stanley Feld M.D.,FACP,MACE

Dear President Obama;

Please listen. The American public doesn’t want the public option. They know America cannot afford another entitlement program. Americans do not want increased taxes. They are afraid China is lending us too much money. If and when they pull out it will be doomsday.

The healthcare insurance industry would love you to get your healthcare reform bill passed. It would increase their profits at taxpayers’ expense. The healthcare insurance industry did it to Massachusetts. The federal government had to bail out Massachusetts. Why not the entire country?

Americans want healthcare reform. They would love to provide universal care, have affordable insurance coverage, and increased quality of care. Your strategy is wrong.

There is another way to accomplish these things. It requires you to have faith in the intelligence of the American public. The strategy would decrease the cost to the healthcare system instantly. It would decrease the obscene costs for administrative services to the healthcare insurance industry. It would diminish the need to develop a massive government bureaucracy.

It eliminates the influence of lobbyists for vested interests. It would create competition among physicians, hospital systems and healthcare insurance companies. The healthcare insurance industry is drooling over your healthcare reform plan.

Americans know government bureaucracy can be cruel and inefficient. There are too many generalities that are wide open to abuse.

I received this note from a reader summing up America’s mistrust of government control. This person is neither a Republican nor Democrat. He is an American.


To sum up the recent post you can simply remind readers of the laughable old line, "I am from the government and I am here to help".

It was gaggy enough to see all the pigs at the trough getting 100’s of billions.  It will make everyone wretch just watching the same participants helping themselves to trillions of dollars worth of slop.

Heaven help us.  Neither the press nor the Obama fans can see through this smokescreen.  God, haven’t people figured out that when the government doles out money poor people don’t get helped, rich people do.  Does foreign aid help poor people in other countries.  If it did poverty in Africa would have ended decades ago.

Go back to the days of Lyndon Johnson.  We fought the war on poverty and lost that.  We lost the Drug War.  We lost the Vietnam War, we are losing the Afghan and Iraq Wars and we are well on our way to losing the war on the high cost of healthcare.  All of these efforts were lost not because they weren’t laudable goals, but because they were not properly considered.  As you know, some we should not have fought, others we should have fought differently.

Interestingly, the only real win we have had in the last forty years was the war on welfare and it came about because something was taken away, not added. 

Is there a lesson here?


How do you accomplish your goals and have the American public trust you once more? You can accomplish your goals of universal care, affordable insurance and increase in quality of care by putting individuals in control of their health and healthcare dollars.

This must sound radical to a liberal. If you permit consumers to drive the healthcare system they will drive the prices down.

How would a consumer driven healthcare system work using an ideal medical savings account?

Employers, states, and the federal government are currently paying healthcare premiums at very high administrative service fees to the healthcare insurance industry. Many self employed are paying the entire healthcare insurance premium with after tax dollars making their cost at least 35% higher than employer based coverage. Most cannot qualify for insurance because of preexisting illness.

The healthcare insurance industry controls the premium dollars. Patients have no financial incentive to be responsible for their health or healthcare dollars. The goal of a consumer driven healthcare system is to create a system that would provide incentives for consumers to be a watchdog for their healthcare dollars.

If these payers gave half of the $12,000 per family per year to consumers and permitted them to keep monies unspent in a retirement account, then patients would be motivated to use their healthcare dollar wisely

If consumers with chronic diseases perform well (weight loss, diabetes control, asthma prevention, COPD and heart disease prevention) and stay out of the ER or hospital because of proper maintenance they should receive a bonus for their retirement fund.

The fees for services would have to be negotiated beforehand as we presently do. All fees should be totally transparent. You would have 300 million people watching and reporting their costs or care.

The remaining $6,000 would buy high deductible coverage that would provide first dollar coverage. The healthcare insurance industry would do very well. If they quit Fidelity or Vanguard could do the bookkeeping.

Think of all the administrative costs saved on the first $6,000. Think of all the middlemen expenses avoided.

Medicare cost per patient in only $6600 per year including the last 30 days of life. The average cost of younger persons is much lower. Cost of care would be decreased because physicians would be paid at point of service. If the cost for medical care was over $6000 for a patient’s care first dollar high deductible insurance would take over.

Medical care is the relationship between the patient and the physician. If you provide the tools and money to create a transparent relationship without middlemen the patients would make the cost decrease as we have seen in other industries. America would have an affordable system.

If the employer became an extender of the physicians care and a patient advocate the costs would drop.

Employers, patients and physicians have the same goals. All are at the mercy of the middlemen (healthcare insurance industry).

This is the American way. It can be done.

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

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Healthcare Insurers Get The Upper Hand: Part 2

Stanley Feld M.D.,FACP,MACE

There is good reason for the negative approval rating polls of the congress and the President. They have proven over and over again what they tell us is not what they mean. The public does not trust the Congress or Senate. The public is starting to mistrust President Obama. I suggest he not say trust me anymore. He needs to give the public reason to trust him.

The healthcare insurance industry has little desire to repair the healthcare system. It wants want the healthcare system to generate increased revenue and profits.

In the first half of 2009, the health service and HMO sector spent nearly $35 million lobbying Congress, the White House and federal healthcare offices, according to data from the Center for Responsive Politics.”

The healthcare lobbying effort has been extremely profitable for healthcare lobbyists. President Obama had promised to decrease the influence of lobbyists.

“With more than 900 lobbyists, that sector — whose top spenders are insurance giants UnitedHealth, Blue Cross Blue Shield and Aetna — was poised to spend more than in 2008, a record lobbying year.”

President Obama promised America a change. The president’s directives against lobbyists were among his first official acts. His stated goal was to make government more open and accountable to the public.

“We are here as public servants, and public service is a privilege,” Obama said, addressing his White House staff and Cabinet on his first full day in office. “It’s not about advancing yourself or your corporate clients.”

Tom Daschle is an unregistered and highly paid lobbyist. He is President Obama’s go to man for healthcare reform. Yet he is a consultant for a lobbying firm Alston & Bird whose clients are the healthcare insurance giants like UnitedHealth and hospital associations.

President Obama said; “We need to close the revolving door that lets lobbyists come into government freely and lets them use their time in public service” to promote their own interests when they leave.”

The public does not forget Presidential candidate’s promises. They have recognized the contradictions in President Obama’s actions. His actions only lead to the public’s increasing cynicism and mistrust in him and his administration. There is great public hesitation to trust the government to take care of their healthcare needs.


“The LA Times article that the "change" being supported by the White House is going to make the for-profit companies fatter and wealthier at the expense of a healthcare system bloated by the excessive administrative, profits, and grossly high salaries of the health insurance and drug companies.”

The public protests are not only about the public option. They are about the government offering “affordable” public insurance to all. An entitlement the government cannot afford. The protests are about the control over our freedom of choice.

The healthcare insurance industry will make more money when the insurance pool is increased. The government will subsidize all policies to keep the price “affordable”. The healthcare insurance industry’s profit will increase. President Obama will raise taxes and inflate the economy.

“Undermining support for the public option wasn’t the only gain scored by insurance lobbyists.

Public option was a diversion by the healthcare insurance industry. Its purpose was to frighten and distract the public from the healthcare industry’s other goals. The healthcare lobbyists have made deals with congress and the President. The deals are not transparent.

“In May, the Senate Finance Committee discussed requiring that insurers reimburse at least 76% of policyholders’ medical costs under their most affordable plans. Now the committee is considering setting that rate as low as 65%, meaning insurers would be required to cover just about two-thirds of patients’ healthcare bills. According to a committee aide, the change was being considered so that companies could hold down premiums for the policies.”

You bet. President Obama promised to provide affordable premiums. He also promised to regulate the healthcare insurance industry. The terms are favorable to the healthcare insurance industry and not favorable to consumers. President Obama has said nothing about the increase in out of pocket expenses.

“Most group health plans cover 80% to 90% or more of a policyholder’s medical bills, according to a report by the Congressional Research Service. Industry officials urged that the government set the floor lower so insurers could provide flexible, more affordable plans.”

The healthcare insurance industry is going to get its wishes. Healthcare insurance premiums might be more affordable but out of pocket expenses will be higher.

"It is vital that individuals, families and small-business owners have the flexibility to choose an affordable coverage option that best meets their needs," said Robert Zirkelbach, spokesman for America’s Health Insurance Plans, the industry’s Washington-based lobbying shop.”

Isn’t that disingenuous? The greater tragedy is our representatives are going to approve the change in the deductibles. President Obama will call it a victory for healthcare reform. The Democratic party’s goal is to ultimately have a single party payer system.

Who is roping which dope? Who is the dope? The government thinks it is manipulating the healthcare insurance industry. The healthcare insurance industry thinks it is manipulating the government.

The net result is they are both manipulating consumers of healthcare. Consumers will get less healthcare coverage at greater out of pocket expense and higher taxes. The American consumer is the dope.

“Consumer advocates argue that a lower government minimum might quickly become the industry standard, placing a greater financial burden on patients and their families.”

"These are a bad deal for consumers," said J. Robert Hunter, a former Texas insurance commissioner who works with the Consumer Federation of America.”

Consumer advocates have seen through the charade. However they do not have enough money and consumer support to make others aware of what is going on behind the scenes. AARP is not providing awareness. Consumers know they have been promised transparency by President Obama but they have seen little transparency.

"They have beaten us six ways to Sunday," said Gerald Shea of the AFL-CIO. "Any time we want to make a small change to provide cost relief, they find a way to make it more profitable."

Meanwhile, companies would probably see a benefit by providing less insurance "per premium dollar," Hunter said.
Taxpayers do not want more government control over their lives and freedoms. They do not trust government to do things efficiently. Recent experience has confirmed consumer distrust. One only has to look at the inefficiencies in the bank bailouts, the economic stimulus package, the two wars, and the mounting deficits. All theses inefficiencies are at the taxpayers’ expense.

It is time for consumers to take over and demand control of their healthca
re dollars and their own healthcare decisions no matter what socioeconomic level they are in.

The government’s role should be to encourage and incentivize consumers to pursue a path toward better health without permitting them to be taken advantage of by the other stakeholders. This will be the only way to control healthcare costs.

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

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