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.
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.
All items for November, 2010
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
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
8. All contracts with past and present Congressmen are void effective
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.
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?
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.
“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.
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.
Stanley Feld M.D.,FACP, MACE
Waste occurs because of:
- 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
- A lack of patient responsibility in preventing the onset of chronic disease. The obesity epidemic is an example.
- A lack of patient education in preventing the onset of complications of chronic diseases. Effective systems of chronic disease self- management must be developed.
- 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.
- 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.
- 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.
- 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. .
- 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.
- 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.