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All items for November, 2010

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Common-Sense Repair To The Healthcare System

 

Stanley Feld M.D.,FACP,MACE

As the practice of medicine becomes increasingly technology based, bureaucratized, politicized, and commoditized, we move further away from the real issues facing our healthcare system.

The real issues that must be faced to repair the healthcare system are being ignored with President Obama’s healthcare reform act. The real issues are the maintenance of the physician- patient relationship, institution of real malpractice reform, and increasing patients’ responsibility for their health and their healthcare dollars. The development of systems of care must be incentivized to decrease the incidence of complications of chronic diseases.

There must be significant changes made to the accounting rules used by the healthcare insurance industry.

Patients own their diseases. They should be responsible for maintaining their health and managing their disease. It should not be the job of employers, government, or the healthcare insurance companies. The healthcare system must be consumer driven. It should not be driven by the government or insurance companies.

President Obama’s goal is to have complete government control of the healthcare system. He is trying to control the healthcare system using untested bureaucratic methods. The process will result in increasing the cost of healthcare, decreasing access to medical care and rationing care.

President Obama has not communicated effectively how the healthcare insurance industry is ripping off Medicare/Medicaid, the private insurance industry and taxpayers.

I was in a meeting with a group of primary care physicians and human resources officers from large self-insured corporations. The discussion was focused on the human resources officer increasing healthcare costs.

They did not understand how the healthcare insurance companies were ripping off their self-insured plans. All the human resource officers outsource their administrative services to the healthcare industry. They believe the healthcare insurance company was making only 3% profit while providing the administrative services to their company.

The human resource officers agreed that physicians were receiving 10% of their company’s healthcare expenditures. They all thought the hospital systems were getting 50% of their self-insured healthcare dollars.

I asked who was receiving the other 40% of the healthcare dollar.

Someone said we were getting into the weeds now. He was correct. The devil is in the details. As a society, we are focused on the sound bites and have no patience for detail.

The healthcare insurance industry has taken advantage of that fact.

 

Below is a consolidated statement of income for WellPoint. UnitedHealth and Aethna consolidated statements are similar.

 

WellPoint, Inc.
Consolidated Statements of Income


(In millions, except per share data)

Years ended December 31

2008

2007

2006

Revenues

Premiums

$

57,101.0

$

55,865.0

$

51,971.9

Administrative fees

3,836.6

3,673.6

3,594.8

Other revenue

641.6

< /em>

617.0

613.1

Total operating revenue

61,579.2

60,155.6

56,179.8

Net investment income

851.1

1,001.1

878.7

Net realized (losses) gains on investments

(1,179.2

)

11.2

(0.3

)

Total revenues

61,251.1

61,167.9

57,058.2

Expenses

Benefit expense

47,742.4

46,037.2

42,192.0

Selling, general and administrative expense:

Selling expense

1,778.4

1,716.8

1,654.5

General and administrative expense

7,242.1

6,984.7

7,163.2

Total selling, general and administrative expense

9,020.5

8,701.5

8,817.7

Cost of drugs

468.5

432.7

433.2

Interest expense

469.8

447.9

403.5

Amortization of other intangible assets

286.1

290.7

297.4

Impairment of intangible assets

141.4

—  

—  

Total expenses

58,128.7

55,910.0

52,143.8


Income before income tax expense

3,122.4

5,257.9

4,914.4

Income tax expense

631.7

1,912.5

1,819.5

Net income

$

2,490.7

$

3,345.4

$

3,094.9

Net income per share

Basic

$

4.79

$

5.64

$

4.93

Diluted

$

4.76

$

5.56

$

4.82

Revenue from premiums are 57,101,000,000 billion dollars. WellPoint claims benefit expenses were 47,742,400,000 billion dollars. Therefore, WellPoint paid 83.6% of its premium revenue for medical care benefits.

 This financial statement satisfies President Obama’s new regulations that demand the healthcare insurance industry pay 80-85% in medical care benefits. It satisfies the new medical loss ratio. Medical loss ratio is defined as incurred claims divided by earned premiums.

The question is what is included in benefit expenses. Are benefit expenses only payments for medical care? This place where we get into the weeds and meet the devil.

The human resource officers of major corporations felt physicians received 10% of the healthcare dollars and hospitals receive 50% of the healthcare dollars. WellPoint financial statement claim 83.6% each healthcare dollar are paid for medical care benefits.

Where is the remaining 23.6% in medical care benefit expenses? Many in congress believe the healthcare insurance industry receives 40% of the healthcare dollar.

The number is correct. 23.6% plus (100%-83.6%) 16.4% equals 40%.

I will explain where the missing 23.6% of benefit expenses go, shortly.

President Obama might be pulling another trick play on the taxpayer. Either that or the healthcare insurance industry is using a trick play on him. In either case the taxpayer loses.

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

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Nontransparent Healthcare Reform Act Waivers

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Stanley Feld M.D.,FACP,MACE

The health care system is broken. President Obama’s healthcare bill should be repealed. Congress should start over again using common sense. The healthcare system is a complete nightmare for all stakeholders. It consists of a series of patches to fix a dysfunctional healthcare system. President Obama’s healthcare reform act is creating a bigger nightmare.

President Obama should construct a consumer driven healthcare system with federal and state government oversight rather than a federal government driven system.

President Obama’s healthcare reform act transfers congressional control of the federal healthcare system to the executive branch of government. Nonelected officials can make rules without congressional oversight.

Checks and balances are lost. The loss of checks and balances is dangerous. Political decisions can be made by the executive branch of government without congressional input.

The McDonalds’ healthcare insurance waiver became a political embarrassment to President Obama. The healthcare insurance waiver occurred just before the midterm elections. It was clear President Obama did not want to increase the number of uninsured before the midterm election.

McDonalds said it could not afford to insure its employees under the new healthcare reform act’s regulations. The administration created a new rule to provide McDonalds and 32 other companies with a waiver from healthcare regulations that would go into effect January 1,2011.

The government’s press release about the waivers created a big stir in the blogging world. It also caused a reaction in the traditional media. The President gave in to influence by lobbying groups. Cries of favoritism resulted.

At the beginning of November the government issued 111 waivers without informing the press.

The waiver was interpreted as an admission of just how job-killing and business-crushing the new health care law really is. These new waivers were buried in the Department of Health and Human Services web site without publicity.

Below is a list of companies granted waivers so far.

 

Applicant

Application
Received

Plan
Effective
Date

Number
of
Enrollees

Application
Completed by
Applicant

Waiver
Approved

1

Protocol Marketing Group

10/4/2010

1/1/2011

454

10/25/2010

11/1/2010

2

Sasnak

9/29/2010

1/1/2011

813

9/29/2010

11/1/2010

3

Star Tek

10/1/2010

1/1/2011

1,423

10/26/2010

11/1/2010

4

Adventist Care Centers

10/1/2010

1/1/2011

725

10/26/2010

10/29/2010

5

B.E.S.T of NY

10/7/2010

1/1/2011

1,200

10/27/2010

10/29/2010

6

Boskovich Farms, Inc

10/8/2010

1/1/2011

165

10/28/2010

10/29/2010

7

Gallegos Corp

9/29/2010

1/1/2011

86

10/28/2010

10/29/2010

8

Jeffords Steel and Engineering

10/4/2010

1/1/2011

112

10/28/2010

10/29/2010

9

O.K. Industries

10/4/2010

1/1/2011

1,238

10/28/2010

10/29/2010

10

Service Employees Benefit Fund

10/12/2010

11/1/2010

1,297

10/29/2010

10/29/2010

11

Sun Pacific Farming Coop

10/6/2010

12/1/2010

1,109

10/6/2010

10/29/2010

12

UFCW Allied Trade Health & Welfare Trust

10/5/2010

1-Dec

68

10/25/2010

10/29/2010

13

HCR Manor Care

10/5/2010

1/1/2011

2,666

10/26/2010

10/28/2010

14

IBEW No.915

9/28/2010

1/1/2011

930

10/15/2010

10/28/2010

15

Integra BMS for Culp, Inc.

10/4/2010

1/1/2011

34

10/25/2010

10/28/2010

16

New England Health Care Employees Welfare Fund

9/27/2010

1/1/2011

7,454

10/26/2010

10/28/2010

17

Aegis Security Insurance Company

10/6/2010

11/1/2010

67

10/25/2010

10/26/2010

18

Alliance One Tobacco

9/30/2010

1/1/2011

138

10/21/2010

10/26/2010

19

Asbestos Workers Local 53 Welfare Fund

9/29/2010

1/1/2011

2

10/21/2010

10/26/2010

20

Assurant Health (2nd Application)

9/29/2010

1/1/2011

19,024

10/21/2010

10/26/2010

21

Captain Elliot’s Party Boats

10/12/2010

11/1/2010

10

10/25/2010

10/26/2010

22

Carlson Restaurants

9/22/2010

1/1/2011

3,381

10/21/2010

10/26/2010

23

CH Guenther & Son

9/24/2010

1/1/2011

300

10/21/2010

10/26/2010

24

CKM Industries dba Miller Environmental

10/5/2010

11/1/2010

34

10/25/2010

10/26/2010

25

Caribbean Workers’ Voluntary Employees’ Health and Welfare Plan

10/14/2010

10/1/2010

4,500

10/18/2010

10/26/2010

26

Darden Restaurants

9/30/2010

1/1/2011

34,000

10/21/2010

10/26/2010

27

Duarte Nursery

9/23/2010

1/1/2011

283

10/19/2010

10/26/2010

28

Employees Security Fund

9/29/2010

1/1/2011

22

9/29/2010

10/26/2010

29

Florida Trowel Trades

9/27/2010

1/1/2011

297

10/21/2010

10/26/2010

30

Ingles Markets

9/30/2010

1/1/2011

917

10/25/2010

10/26/2010

31

Meijer

10/1/2010

1/1/2011

4,873

10/1/2010

10/26/2010

32

O’Reilly Auto Parts

9/23/2010

1/1/2011

9,722

9/23/2010

10/26/2010

33

Plumbers & Pipefitters Local 123 Welfare Fund

9/30/2010

1/1/2011

534

10/21/2010

10/26/2010

34

Sun Belt

9/28/2010

10/1/2010

114

10/20/2010

10/26/2010

35

UFCW Local 227

10/12/2010

11/1/2010

1,125

10/12/2010

10/26/2010

36

Uncle Julio’s

9/30/2010

11/1/2010

115

10/25/2010

10/26/2010

37

United Group

9/24/2010

1/1/2011

177

10/19/2010

10/26/2010

38

US Imaging

10/11/2010

11/1/2010

148

10/25/2010

10/26/2010

39

Vino Farms

10/8/2010

11/1/2010

152

10/21/2010

10/26/2010

40

Advanta Staff, Inc.

9/20/2010

9/1/2011

52

9/20/2010

10/21/2010

41

Agricare

9/23/2010

11/1/2010

437

9/23/2010

10/21/2010

42

Alaska Seafood

9/23/2010

1/1/2010

262

10/15/2010

10/21/2010

43

American Fidelity

9/22/2010

10/23/2010

9,358

10/14/2010

10/21/2010

44

Convergys

9/20/2010

1/1/2011

1,400

9/20/2010

10/21/2010

45

Darensberries

9/28/2010

10/1/2010

1,450

9/28/2010

10/21/2010

46

Gowan Company

9/23/2010

1/1/2011

225

9/27/2010

10/21/2010

47

Greystar

9/23/2010

1/1/2011

1,747

10/13/2010

10/21/2010

48

Macayo Restaurants

9/22/2010

12/1/2010

46

10/18/2010

10/21/2010

49

Periodical Services

9/27/2010

1/1/2011

464

9/27/2010

10/21/2010

50

UniFirst

9/23/2010

9/1/2011

2,659

10/14/2010

10/21/2010

51

Universal Forest Products

9/23/2011

5/1/2010

1,738

10/19/2010

10/21/2010

52

UFCW Maximus Local 455

10/4/2010

1/1/2011

59

10/18/2010

10/18/2010

53

American Habilitation Services, Inc.

9/22/2010

1/1/2011

400

10/12/2010

10/14/2010

54

GuideStone Financial Resources

9/21/2010

1/1/2011

354

9/21/2010

10/14/2010

55

Local 25 SEIU

9/29/2010

10/1/2010

31,000

10/7/2010

10/14/2010

56

MAUSER Corp.

9/21/2010

1/1/2011

47

9/24/2010

10/14/2010

57

Preferred Care, Inc.

9/15/2010

1/1/2011

918

9/15/2010

10/14/2010

58

Ruby Tuesday

10/8/2010

1/1/2011

3,219

10/8/2010

10/14/2010

59

The Dixie Group, Inc.

8/27/2010

6/19/2010

269

10/12/2010

10/14/2010

60

UFCW Local 1262

9/20/2010

10/1/2010

5,390

9/20/2010

10/14/2010

61

Whelan Security Company

9/23/2010

1/1/2011

287

10/12/2010

10/14/2010

62

AMF Bowling Worldwide

9/14/2010

1/1/2011

295

10/7/2010

10/12/2010

63

Assisted Living Concepts

9/17/2010

1/1/2011

1,174

9/17/2010

10/12/2010

64

Case & Associates

9/17/2010

1/1/2011

87

9/17/2010

10/12/2010

65

GPM Investments

9/17/2010

1/1/2011

275

9/17/2010

10/12/2010

66

Grace Living Centers

9/14/2010

10/1/2010

534

9/14/2010

10/12/2010

67

Mountaire Corporation

9/17/2010

1/1/2011

2,074

9/17/2010

10/12/2010

68

Swift Spinning

9/16/2010

1/1/2011

240

9/16/2010

10/12/2010

69

Belmont Village

9/10/2010

1/1/2011

785

10/4/2010

10/8/2010

70

Caliber Services

9/13/2010

1/1/2011

606

9/13/2010

10/8/2010

71

Cracker Barrel

9/9/2010

1/1/2011

16,823

9/17/2010

10/8/2010

72

DISH Network

9/13/2010

3/1/2011

3,597

9/23/2010

10/8/2010

73

Groendyke Transport,  Inc

9/2/2010

1/1/2011

1,322

9/2/2010

10/8/2010

74

Pocono Medical Center

9/24/2010

1/1/2011

3,298

9/24/2010

10/8/2010

75

Regis Corporation

9/10/2010

3/1/2011

3,617

10/1/2010

10/8/2010

76

The Pictsweet Co.

9/13/2010

1/1/2010

694

9/13/2010

10/8/2010

77

Diversified Interiors

9/28/2010

10/1/2010

300

9/28/2010

10/1/2010

78

Local 802 Musicians Health Fund

9/29/2010

10/1/2010

1,801

9/29/2010

10/1/2010

79

MCS Life Insurance Company

9/20/2010

10/1/2010

6,635

9/23/2010

10/1/2010

80

The Buccaneer

9/22/2010

10/1/2010

125

9/28/2010

10/1/2010

81

CIGNA

9/17/2010

9/26/2010

265,000

9/30/2010

9/30/2010

82

Greater Metropolitan Hotel

9/16/2010

10/1/2010

1,200

9/24/2010

9/30/2010

83

Local 17 Hospitality Benefit Fund

9/16/2010

10/1/2010

881

9/24/2010

9/30/2010

84

GS-ILA

9/15/2010

10/1/2010

298

9/15/2010

9/28/2010

85

Allied

9/13/2010

10/1/2010

127

9/13/2010

9/27/2010

86

Harden Healthcare

9/9/2010

1/1/2011

874

9/29/2010

9/27/2010

87

Health and Welfare Benefit System

9/16/2010

10/1/2010

41

9/16/2010

9/27/2010

88

Health Connector

9/20/2010

10/1/2010

3,544

9/24/2010

9/27/2010

89

I.U.P.A.T

9/16/2010

10/1/2010

875

9/23/2010

9/27/2010

90

Sanderson Plumbing Products, Inc.

9/22/2010

10/1/2010

326

9/22/2010

9/27/2010

91

Transport Workers

9/20/2010

10/1/2010

107

9/23/2010

9/27/2010

92

UFT Welfare Fund

9/16/2010

10/1/2010

351,000

9/27/2010

9/27/2010

93

Aegis

9/16/2010

10/1/2010

162

9/21/2010

9/24/2010

94

Aetna

9/16/2010

10/1/2010

209,423

9/16/2010

9/24/2010

95

Allflex

9/20/2010

10/1/2010

34

9/22/2010

9/24/2010

96

Baptist Retirement

9/10/2010

10/1/2010

127

9/17/2010

9/24/2010

97

BCS Insurance

9/13/2010

9/24/2010

115,000

9/22/2010

9/24/2010

98

Cryogenic

9/20/2010

10/1/2010

19

9/20/2010

9/24/2010

99

Fowler Packing Co.

9/8/2010

10/1/2010

39

9/17/2010

9/24/2010

100

Guy C. Lee Mfg.

9/15/2010

10/1/2010

312

9/15/2010

9/24/2010

101

HealthPort

9/17/2010

10/1/2010

608

9/17/2010

9/24/2010

102

Jack in the Box

9/17/2010

10/1/2010

1,130

9/21/2010

9/24/2010

103

Maritime Association

9/17/2010

10/1/2010

500

9/21/2010

9/24/2010

104

Maverick County

9/21/2010

10/1/2010

1

9/23/2010

9/24/2010

105

Metro Paving Fund

9/20/2010

10/1/2010

550

9/20/2010

9/24/2010

106

PMPS-ILA

9/19/2010

10/1/2010

15

9/23/2010

9/24/2010

107

PS-ILA

9/19/2010

10/1/2010

8

9/23/2010

9/24/2010

108

QK/DRD (Denny’s)

9/16/2010

10/1/2010

65

9/22/2010

9/24/2010

109

Reliance Standard

9/14/2010

10/1/2010

varies

9/14/2010

9/24/2010

110

Tri-Pak

9/20/2010

10/1/2010

26

9/20/2010

9/24/2010

111

UABT

9/17/2010

10/1/2010

17,347

9/17/2010

9/24/2010

 

total

   

1,175,411

   

What does it say about an the administration’s healthcare reform act when it grants so many exemptions from a law? Didn’t President Obama tell us this healthcare reform act would be ultimate solution to our health care problems?

Shouldn’t the waivers be automatically to companies and unions without application?

Wouldn’t companies that are granted the waiver have a competitive advantage over other companies in the same industry that do not have an exemption?

Last week the Department of Health & Human Services published a set of new guidelines for those seeking to apply for a waiver.  As news of these waivers starts to spread the Department of Health & Human Services will swamped with applications for waivers.

The Office of Consumer Information and Insurance Oversight’s sub-regulatory guidance on the process for obtaining waivers of the annual limits requirements may be found at: http://www.hhs.gov/ociio/regulations/patient/ociio_2010-1_20100903_508.pdf

The administration says it is responding to concerns of employers and others. Many workers would not have a healthcare insurance alternative.

President Obama’s healthcare reform act is causing more problems than it is solving.

Just think about the administrative bureaucracy, costs and inefficiency generated by this unintended consequence.

Other unintended consequences will be generated by President Obama’s healthcare reform act.

President Obama needs to start all over again and develop a consumer driven healthcare system that aligns all the stakeholders’ incentives.

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

 
   
   

 
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Congress Is Broken! THIS IS HOW YOU FIX CONGRESS!!!

Stanley Feld M.D.,FACP,MACE

The healthcare system is broken. Repairing The Healthcare System was created to make suggestions to congress and interested parties on ways to repair the healthcare system.

During a contemplative moment, it dawned on me that congress, over the last 60 years, through laws and regulations, has broken the healthcare system.

Medical care should be between patients and physicians. It should not be between congress and powerful vested interests with patients and physicians being marginalized.

It dawned on me that congress is broken. Congress needs to be repaired before the dysfunctional institutions in America can be repaired. Congress men and women should be working for the people and not for themselves.

I received the following email the other day. The Congressional Reform Act Of 2010 is almost perfect.


Congressional Reform Act Of 2010
1. Term Limits.
   12 years only, one of the possible options below..
   A. Two Six-year Senate terms
   B. Six Two-year House terms
   C. One Six-year Senate term and three Two-Year House terms
2.  No Tenure / No Pension.
A Congressman collects a salary while in office and receives no pay when
they are out of office. 
3.  Congress (past, present & future) participates in Social Security.
All funds in the Congressional retirement fund move to the Social
Security system immediately.  All future funds flow into the Social
Security system, and Congress participates with the American people.
4. Congress can purchase their own retirement plan, just as all
Americans do.
5. Congress will no longer vote themselves a pay raise..  Congressional
pay will rise by the lower of CPI or 3%.
6. Congress loses their current health care system and participates in
the same health care system as the American people.
7. Congress must equally abide by all laws they impose on the American
people.
8. All contracts with past and present Congressmen are void effective
1/1/11. 
The American people did not make this contract with Congressmen.
Congressmen made all these contracts for themselves.
Serving in Congress is an honor, not a career.  The Founding Fathers
envisioned citizen legislators, serve your term(s), then go home and
back to work.
If you agree with the Congressional Reform Act Of 2010, pass it on. People have to demand that our congressional delegates work for us and not themselves.

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

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Federal Coordinating Council for Comparative Effectiveness Research

Stanley Feld M.D.,FACP,MACE

What is the Coordinating Council for Comparative Effectiveness?

The mission of the Council for Comparative Effectiveness will be to decide on best practices and most cost effective practices. The council will recommend cost effective treatments for diseases to The National Coordinator for Health Information Technology (NCFHIT). The NCFHIT will determine treatment at the time and place of care. It is charged with deciding the course of treatment for the diagnosis given by the doctor.

The U.S. Department of Health and Human Services announced the formation and membership of the Federal Coordinating Council for Comparative Effectiveness Research that will be funded by President Obama’s stimulus program the American Recovery and Reinvestment Act (ARRA). The council was allocated 1.1 billion dollars to set up comparative effectiveness of medical practice.

Why was this 1.1 billion dollars funded from the economic stimulus package?

Unknown

The missions are based on the premise that practicing physicians do not have the ability to recommend the most cost effective medical treatment for their patients. (see executive summary)

Who are the members of the Federal Coordinating Council for Comparative Effectiveness?

The members of the committee were picked without congressional approval immediately after the economic stimulus bill was passed. They are all bureaucrats working for the government in one capacity or another. There are no practicing physicians on the panel.


  1. Anne C. Haddix, Ph.D.
    Chief Policy Officer, Office of Strategy and Innovation
    Centers for Disease Control and Prevention,
 

2.Thomas B. Valuck, MD, MHSA, JD
Medical Officer and Senior Advisor, Center for Medicare Management
Centers for Medicare & Medicaid Services

 

3.Peter Delany, PhD, LCSW-C
Director, Office of Applied Studies, SAMHSA,

 

4.Carolyn M. Clancy, M.D.
Director, Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services,

 

5. Deborah Parham Hopson, PhD, RN, FAAN
Associate Administrator, HIV/AIDS Bureau
Health Resources and Services Administration,

 

6.David Hunt, M.D.
Chief Medical Officer, Office of the National Coordinator,

 

7.James Scanlon
Acting Assistant Secretary for Planning and Evaluation,

 

8.Elizabeth Nabel, M.D.
Director, National Heart, Lung, and Blood Institute
National Institutes of Health,

 

9.Garth N. Graham, M.D., M.P.H.
Deputy Assistant Secretary, Office of Minority Health,

 

10.Jesse L. Goodman, M.D., M.P.H.
Acting Chief Medical Officer, FDA
Director, Center for Biologics Evaluation and Research, FDA,

 

11.Rosaly Correa-de-Araujo, M.D., M.Sc., Ph.D
Acting Deputy Director for Office on Disability/Office of the Secretary
U.S. Department of Health and Human Services,

 

12.Joel Kupersmith, M.D.
Chief Research and Development Officer
Veterans Administration,

 

13. Michael Kilpatrick, M.D.
Director of Strategic Communications for the Military Health System
Department of Defense,

 

14.Ezekiel J. Emanuel, MD, PhD
Special Advisor for Health Policy
Office of Management and Budget

Ezekial Emanuel M.D. is Rham Emanuel’s brother. He is a chair of the bioethicist at the NIH. His book Healthcare, Guaranteed: A Simple, Secure Solution for America and his article “Principles Of Allocation Of Scarce Medical Intervention” (Lancet 2009:373:429-431) explains the principle for rationing of care. He uses the complete-lives system, .

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Dr. George Thomas wrote in response to my last article on electronic medical records;

The problem remains that it still takes me 25 minutes to admit a patient using the EHR, and only 5 minutes using pen and paper. If I admit 3 patients, it adds one hour to my day. Where do I get the extra hour, and who pays me for it? So far the main beneficiaries seem to be the HMO’s who can use the computer info to hassle you.”

I think Dr. Thomas stumb
led on to something. The government wants to be able track in real time treatment decisions of physicians with the use of the EMR. The government can automatically decide on whether physicians are practicing best practices as defined by the council for comparative effectiveness. If physicians are not practicing best practices that are cost effective, the government will force physicians to comply using penalties.

The sentiment about this issue is express by a physician in the following You Tube. It is a worthwhile watching.

The losers are patients and physicians. The healthcare insurance industry’s profits are unharmed and government power over the healthcare system is enhanced.

There are many defects in President Obama’s point of view on how to measure quality and appropriate care. It is a monetary viewpoint. It is not from a medical care viewpoint. President Obama’s approach will lead to many unintended consequences.

Another reader wrote in response to the electronic medical record article;

Hi Dr. Feld,

Refresh my memory please, what is your perspective on how am I going to determine how good a Dr. is in the future?  I want competition based on value and I know there is a wide difference between physicians in terms of skills, adopting technology and innovation etc. and results or outcomes.  How do you propose I determine the best value for my money?

How do you pick a restaurant, a dry cleaner, a plumber, an electrician or a builder? Each vendor competes for your business. If the vendor does not provide satisfactory service it will lose patrons and go out of business.

Websites such as Open Table and Trip Advisor help us with making wise choices. Angie’s list has been a transformational website. It has changed the way consumers choose contractors. Consumers are very interested in expressing opinions both good and bad. Contractors read every entry and improve to become more competitive.

Physicians have to be made to compete for patients. Only he consumers of healthcare can force physicians to compete. Consumers need to be given control of their health care dollars, not the government, or a third party.

Patients should make choices based on quality of care and reputation of the physicians. Patients should be incentivized to get the most value for their healthcare dollar. Value of medical care should not be determined by a government bureaucracy using inaccurate criteria.

Websites are available for consumers to make intelligent evidence based choices. Other websites can be developed to teach consumers how to evaluate physicians and their care. These websites must be interactive. Patients can share their experiences with others. The costs of services have already been negotiated by the healthcare insurance industry and the government. These fees should be made available to patients.

I believe consumers are smart. They can drive prices down in a consumer driven healthcare system.

Physicians are not the problem with the healthcare system. It is the healthcare insurance industry and its control of the healthcare dollars.

It is a mistake for the government to make decisions for consumers of healthcare.

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

  • EMR Saves Lives

    Two things bother me about this. The diagnosing physician’s say in the treatment plan and the patient’s rights to help make decisions about their medical care. I’m concerned that this isn’t the best course of action for the patient or their doctor.

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Getting Closer To The Ideal Electronic Medical Record

Stanley Feld M.D.,FACP,MACE

Over 70 % of physicians use smartphones. Physicians are not resistant to learning how to use an iPhone or one of the Android smartphones. The network speed is the irritation. Networks are confusing the public with 3G and 4 G network speed. They should just do it!

We are rapidly approaching the time when a smartphone will be an appliance. The best applications will survive. Medical applications will become fully functional.

Most individual physicians and group practices have had at least one electronic medical record (EMR). None has fulfilled its promises. None has been fully functional. The price paid for the EMR was high in the era of decreasing reimbursement.

Most practices need a fully functioning EMR. The practices are hesitant to endure the pain of conversion once more.

President Obama’s multi-billion dollar subsidy program is bogus. The amount of the subsidy is well below the cost of the EMR and its continuing service and upgrades. I believe the program will have little impact on adoption of EMRs.

If President Obama provided the ideal electronic medical record along with upgrades and service to physicians for a monthly fee, physicians could afford to sign up. They would not worry about an unaffordable capital expense. Physicians would be charged by the click just as MasterCard charges by the usage.

Instantaneously, the system proposed, would result in America’s physicians converting to a government certified fully functional EMR at minimal cost or risk.

Patients’ data could be kept on a hard drive in the physicians’ office to maintain patient privacy. Physicians would have to agree to release certain data to be used for educational purposes without compromising patients’ privacy.

Instead, President Obama’s new agencies are going to use inaccurate claims data to judge physicians’ care and impose penalties on physicians.

With the increasing development of cloud computing, President Obama could provide the software in the cloud with servicing and upgrading. It would cost the government less and the government would have created an income generating business.

Electronic medical records software producer ClearPractice has developed a SAAS (software-as-a-service application) for the Apple iPad to help doctors manage their workflow, from scheduling to prescribing to billing.

A fully functioning EMR can be developed with physicians using the functionality of an iPad and upcoming Android tablets.

I have not had the opportunity to study ClearPractice’s product. ClearPractice has the right idea. Its Nimble EMR cloud product is the first comprehensive EMR application designed to run on the iPad.

I think its distribution and storage model needs refining. It also should build iPad applications to interface seamlessly with an Android system Pad.

The software can be accessed from the cloud. Patient data files can be accessed from the physicians server using a Pogoplug. This would permit physicians to be in control of their patients’ data.

“In designing Nimble, ClearPractice tackled the slow implementation of EMR software, which costs physicians time and money and disrupts their workflow. "Traditional EMR systems slow down busy doctors."

A tablet can easily keep physicians connected to their patients’ data in their office, in the hospital and at night in their home.

ClearPractice claims its software-as-a-service application has scheduling, tracking in-patient rounds, prescribing, lab review/ordering and messaging applications. It also connects to the physicians’ billing system to automatically capture and submit charges for payment.

Nimble does not sound fully functional. The software must have the ability to connect financial outcomes with clinical outcomes to be appealing to physicians. Physicians must be able to use the data they generate to augment their value to the patient. They are hesitant to submit data to a third party that will use it to devalue their worth.

ClearPractice’s fee schedule is vague. Nonetheless, ClearPractice is on the right track. President Obama could save his subsidy money if he would start listening to physicians. He is going to ahead and will waste the money from the stimulus package. He will not make progress toward the goal of developing universal use of fully functioning electronic medical records.

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

  • Fudley Bezuidenhout

    Very good pertainent points you have raised here, but I think you’re preaching to the choir.

  • Smart Circle

    Good day! This is my first visit to your blog! We are a team of volunteers and starting a new project in a community in the same niche. Your blog provided us useful information to work on. You have done a extraordinary job!

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Additional Barriers To Accountable Care Organizations.

Stanley Feld M.D.,FACP, MACE

Accountable Care Organization(ACOs) are not going to decrease the waste in the healthcare system.

Waste occurs because of:

  1. Excessive administrative service expenses by the healthcare insurance industry which provides administrative services for private insurance and Medicare and Medicaid. A committee is writing the final regulations covering Medical Loss ratios for President Obama’s healthcare reform act. The preliminary regulations are far from curative
  2. A lack of patient responsibility in preventing the onset of chronic disease. The obesity epidemic is an example.
  3. A lack of patient education in preventing the onset of complications of chronic diseases. Effective systems of chronic disease self- management must be developed.
  4. The use of defensive medicine resulting in over testing. Defensive medicine can be reduced by effective malpractice reform.

A system of incentives for patients and physicians must be developed to solve these causes of waste. A system of payments must also be developed to marginalize the excessive waste by the healthcare insurance industry. Patients must have control of their own healthcare dollars.

By developing ACOs, President Obama is increasing the complexity of the healthcare system. It will result in commoditizing medical care, provide incentives for rationing medical care, decrease access to care, and opening up avenues for future abuse.

The list of barriers to ACOs’ success is long and difficult to follow.

  1. The government would rather deal with a few hospital systems than with individual physicians. Hospital systems would receive a lump sum payment for the care of attributed patients. The hospital system would control the money. Physicians would fight with hospital systems for equitable distribution of funds.

The idea has multiple problems. Most physicians in practice do not trust their hospital system. In the past physicians who became employed by hospital systems became disenchanted with the relationship. The hospital systems overloaded the expenses to the benefit of the hospital systems. The result was multi- million dollar salaries to hospital administrators and decreasing physician salaries.

It will be hard to get all physicians to be employed by hospital systems.

  1. The Dartmouth group’s results are based on claims data. Claims data is notoriously inaccurate. Government policy decisions using claims data will lead to policy mistakes.
  2. ACO patients are attributed to an ACO on the basis of their pattern of services used. Patients see a primary care physician who belongs to that ACO. All that patient’s care and expenses are attributed to that ACO’s lump sum payment.

If the costs incurred by the ACO’s “attributees” are sufficiently below Medicare’s spending projections for that population, the ACO shares in the savings realized by Medicare; if the costs are too high, the ACO loses nothing.

This represents a shift in incentives. The ACO, run by the hospital system, would want employed physicians to do less for the patients to earn more money. The result would be decreased access to care. Physicians have to be incentivized to do the right thing. .

  1. A problem will be the selection of attributed patients. There is no risk weighting of patients’ disease burden. Some patients are at greater risk of disease and its complication.

If one ACO gets sicker patients than another ACO that ACO’s chances of making money are less than the second ACO. Risk weighting of patients and their diseases is complicated but essential.

If a patient with the same coded illness as another patient does not follow instructions his chances of having complications from a disease are higher and his cost of care more expensive than another patient that follows instructions.

Attribution of the cost of medical care will be further complicated by the need to consider reasonable patterns of patient visits.

The nature of the attribution rules will have enormous implications to ACOs’ medical management.

  1. Hospital systems that salary physicians receive fixed payments for diagnosis-related groups under Part B (physician payment for Medicare). Medicare also reimburses hospital based physicians for part of the costs of very expensive cases.

ACOs will be held fully accountable for outlier patients. Hospital systems will be hesitant to take on this uncontrollable risk. Accountability for costs under Medicare Parts A and B look like they are becoming daunting. After hospital systems realize the challenges of ACOs few hospital systems will choose to become an ACO.

N Engl J Med 2010; 363:1389-1391October 7, 2010

6. President Obama’s healthcare reform law directs ACOs to be permeable to all patients. At the same time, they are held accountable for services by their patients obtain from outside providers. The financial risk is shifted from the government to the ACO. Once this is fully understood hospital systems and medical groups will not be willing to participate.

President Obama’s ACOs are creating a level of complexity that will make the healthcare system’s problems worse than they are now.

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

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