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Chocolate Ice Cream and Vietnam


Stanley Feld M.D.,FACP,MACE

Many of you know how much I love chocolate ice cream. A few years ago, Brad and I spent a father and son weekend hanging out in South Beach, Florida. One day our breakfast and lunch was chocolate ice cream at Ghirardelli’s on Lincoln Road.

I have requested recipes for homemade chocolate ice cream on this blog. I received 12 delicious recipes.

Cecelia and I just got home from a 19 day trip to Vietnam and a 4 day trip to Cambodia with the tour company, Overseas Adventure Travel (OAT). OAT runs fabulous trips at affordable prices. The Vietnam trip was the fourth we have taken with them. Each trip seems to get better than the last.

The Vietnam trip was the best mostly because of the group leader Nguyen Huu Quang. He is a 45 year old with a knack for language and a great sense of humor. He has mastered most of American slang. He was a treasure. He was the glue that bound the 14 of us together. OAT limits their groups to 16 people per trip.

He was always singing on the bus. We decided to pick a theme song.

learned the words to the song, and rehearsed on the bus. We visited many villages and Vietnamese tribes in the countryside. When a group entertained us we reciprocated by singing our theme song. Everyone laughed a lot. Norman Cousins said laughing is therapeutic.


Cecelia and I flew to Hanoi a day early to explore Hanoi on our own. The most amazing experience was crossing the street. It was culture shock.

There are millions of motor scooters in Hanoi with very few traffic lights. Traffic never lets up. Both sides weave into each other. The only way to cross is to walk in between the motor scooters. The first day it took us about 10 minutes to get up the courage to step into the street. Quang taught us the way to cross. He told the group to bunch together. When he shouted “sticky rice” we would all march across the street without fear. The scooters stopped or slowed down to avoid us.

vietnam day 1 Jan 25 014

I discovered the Vietnamese eat everything that is not poisonous. Quang showed us how to eat duck embryo. You could see the feathers, wings, eyes of the embryo as well as the yoke. No one in our group volunteered to try one. Along the way one day, he also stopped at a cricket restaurant. The owner was very proud of his product. The crickets were pickled in rice wine. A few in our group ate them. It was not for Cecelia or me.

OAT provided us with most of the meals. We ate in handpicked restaurants and in homes during our home and monastery visits As you can see, OAT makes an adventure of its tours for people over 50. However, I think I would have had a ball on a trip at age 40.

The main dish as Qwang says is always rice except when eating pho with noodles. Vegetables were next followed by a little chicken, pork, or beef.

We visited all the major cities including Hanoi,Hue, DaNang, Dalat,Hoi An, Nha Trang, Saigon and the Mekong Delta villages.

Vietnamese are not desert freaks. A big desert is fruit in season. It was watermelon or pineapple during our trip. The most exotic was coconut rice pudding or coconut sorbet. I set out to find a place that had the best chocolate ice cream.

The dairy industry is not large in Vietnam. Ice Cream was scarce until recently. I searched for the best ice cream in every town. I was unsuccessful in the villages.

In Hanoi Fanny’s Ice Cream was the winner. I tried about three other places advertised as “western” and even “italian” and nothing came close.

You can see its popularity by the motor scooters parked inside the store. It is on a very busy street around the corner from a pseudo pizza restaurant the group ate lunch.




Romey Ice Cream and Coffee Bar was the best in Nha Trang. It was the only one I found near the beach. It was too difficult to search inland.


In Saigon, Fanny’s wins hands down. The Chocolate Chili is out of site.


However, the best I found was in a Happy Room (western restroom) stop on the way to the Mekong Delta villages.

This ice cream was deep dark chocolate gelato. It makes my mouth water just thinking
about it.

It was the ultimate discovery in my great chocolate ice cream quest on a magnificent trip.

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

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Why Is Congress So Thick?

Stanley Feld M.D.,FACP,MACE

Congress is not focused on the main problems in the healthcare debate. It is focused on the vested interests of secondary stakeholders. The people with the most money always win.

It is time for the people to speak out for their vested interests. They are trying via the Tea Party. For some reason the media is threatened by the Tea Party. The media has tried to marginalize the Tea Party. I do not think the media will be successful.

The American healthcare system has many problems. Accountability for medical care is one of them.

Millions of dollars have been spent by hospital systems trying to form an Accountable Care Organization. Why? Everyone thinks that is where the money is going to be. Accountable Care Organizations will not be the answer.

Effective repair of the healthcare system can only be accomplished when all the stakeholders are accountable for their part in the delivery of medical care. Those stakeholders include patients, physicians, government, healthcare insurance companies, and hospitals.

Accountable Care Organizations hold physicians and hospitals accountable for making patients healthy. Patients are the stakeholders who must be accountable for their own healt care. Patients are the only stakeholder that can force the other stakeholders to be accountable for their part in the healthcare system.

Accountable Care Organizations (ACOs) are in reality a rehashed version of the failed HMO model of the 1980s. The government must reduce the cost of healthcare. It would like to eliminate waste in the system. Electronic medical records will help except the government is wasting money trying to implement the electronic medical record. It will fail using the present implementation system.

The government’s thinking is Accountable Care Organizations will integrate the healthcare delivery system and eliminate waste. The government would rather deal with one organization rather than individual physicians. The government will give millions of dollars to private hospital systems. The hospital systems will hire physicians. It will then call itself an integrated system. The integrated system will be rewarded financially when it keeps patients well.

Ignored is the fact that the distribution of funds will be a source of bitterness between physicians and hospital systems. Hospital systems are going to own physicians skills and intellectual property. Physicians are becoming wise to the scheme. This conflict will create waste and increase costs to the healthcare system.

Once the federal dollars dry up, these entities will fail under the weight of their own bureaucracy. Patients are now being given a free ride at the taxpayers’ expense. They will develop an insatiable demand for free medical care. The administrators of these failed entities will stash away their generous salaries and add no value to the delivery of medical care. This is what happened with HMO’s. The public and physicians have not forgotten this experience.

Medicaid is a failed model. Yet 16 million more people will be added to its role under President Obama’s healthcare reform act and be taken care of by ACOs.

We will create a larger underclass of people dependent on the failed Medicaid system. Rather than being a nation of hard working independent people responsible for their own well-being, America is increasingly becoming a nation of people expecting hand outs the national budget cannot afford.

The purpose of an effective healthcare system is to keep our citizens healthy. You accomplish this by promoting the principles of good health and giving incentives to citizens to be responsible for their health and healthcare. It will not be accomplished by making people dependent on the government and its inefficient bureaucratic structure.

America must develop a healthcare system that:

1. Provides education about maintaining good health and early recognition of disease.

2. Diagnoses disease early with efficient testing.

3. Develops a treatment strategy that educates patients to participate in their care.

4. Encourages good health and healthcare choices to minimize the need for more health care.

This can be accomplished in a consumer driven healthcare system using the ideal medical savings account. It will be less costly and more efficient than the complicated structure President Obama’s healthcare reform act is in the process of creating through Accountable Care Organizations.

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

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Pharmaceutical Companies Shafting Healthcare Insurance Companies

Stanley Feld M.D.,FACP,MACE


The pharmaceutical companies are marketing kings. The large increase in generic sales has affected their bottom line. When they are up against the wall marketing gets innovative.

EXECUTIVES of a small insurance company in Albany were mystified when, almost overnight, its payments for a certain class of antibiotics nearly doubled, threatening to add about a half-million dollars annually in costs.”

The drug benefits costs for this healthcare insurance company increased as it did for others because the drug company was innovative. It started giving out coupons to cover the patients’ co-pay. It did not cost the patient to pay for this new expensive medication. It cost the insurance company dearly because patients stopped using the generics since their co-pay was covered by the drug company. The effectiveness difference between the generic and the new antibiotic was questionable.

This is not the first time drug companies have given patients co-payment coupons. The coupons paid the branded drugs’ co-pay. This is another example of consumer driven power. Consumers will seek the best price and highest quality.

The use of such co-payment cards and coupons and other types of discounts has more than tripled since mid-2006, according to IMS Health, an information company that tracks the pharmaceutical industry.

Consumers are smart. They know when they are getting a good deal. Pfizer, the maker of Lipitor, introduced a new coupon card that reduces the co-pay for Lipitor to $4 a month. The co-pay for Lipitor is about $50 for a month’s supply. The coupon card saves consumers as much as $50 a month. The coupon gives Pfizer a chance to have Lipitor compete with generic Zocor at Wal-Mart and other chains.

The healthcare insurance industry pays much more for Lipitor than it does for generic Zocor. The clinical evidence for a difference in the medications is small. The marketing of the clinical evidence is a gimmick. The both work the same. Lipitor is twice as potent therefore, you need half the dose to achieve the same effect.

Drug companies say the coupon plans help some patients afford medicines that they otherwise could not. “

The health insurance companies say the coupons are a marketing gimmick. In reality they are. The healthcare insurance industry is just going to pass the cost to its bottom line to consumers by raising the price of insurance premiums.

The member is somewhat insulated from the cost of the prescription,” said Kevin Slavik, senior director of pharmacy at the Health Care Service Corporation, which runs Blue Cross and Blue Shield plans in Illinois and three other states. “In essence, it drives up the total cost of providing the prescription benefit.”

President Obama, where are you when the public needs you? The Food and Drug Administration has been ineffective.

The Food and Drug Administration, meanwhile, is studying the effect of the discounts on consumer perceptions, concerned that the coupons will make consumers believe that a drug is safer or better than it really is.”

The differences in costs are astounding.

  1. Once a day Minocycline is $700 per month. The price of a twice a day generic Minocycline $40 per month
  2. In New York City in a union representing public employees, 59 percent of claims were brand-name statins whose co-pay was coupon supported. The claims cost the union $17.3 million. The other 41 percent of claims were for generic statins. It cost the union only $179,000. The union has eliminated the co-pay on generic statins to encourage their use.
  3. Jazz Pharmaceuticals has quadrupled the price of its narcolepsy drug Xyrem, to about $30,000 a year, over the last five years. In order to cushion patients’ out of pocket cost, the company recently increased its co-pay assistance to as much as $1,200 a month.

“It seems the best strategy for a pharmaceutical company is to price their drug as high as they possibly can and offer that co-pay assistance broadly” to insulate consumers, said Joshua Schimmer,

Co-payment coupons are distributed by drug company sales representatives to physicians. Physicians are made to believe they are helping their patients. The coupons are also available directly to patients over the Internet. Patients present them at the drugstore when paying for their prescriptions and receive the discount.

Medicis, the company that sells Solodyn(Minocycline extended tablet), have told investors that the co-payment card is used by an “overwhelming majority” of patients, and is largely responsible for doubling use of the drug, to 26,000 prescriptions a week.

The use of once a day Minocycline vs. twice a day generic Minocycline results in a difference in cost of $2.6 billion dollars a year for this one drug.

There is something wrong. Physicians are not aware of the drug companies’ gimmicks. They think they are helping their patients. The pharmaceutical industry is indeed the king of marketing.

Pharmaceutical Companies Shafting Healthcare Insurance Companies. Healthcare Insurance Companies in turn will shaft patients by increasing their premiums.

President Obama’s healthcare reform act should be doing something about this if it wants to keep the cost of healthcare down. It is not doing anything about this problem.

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

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Healthcare Insurance Companies Shafting Patients

Stanley Feld M.D.,FACP, MACE

Prescription drug consumption can demonstrate the power of the consumer. This can demonstrate the power of a consumer driven healthcare system. Since 2006 the use of generic drugs to reduce the cost of healthcare for patients and the healthcare insurance industry has escalated.

Consumers have demanded that physicians use generic drugs when possible. Insurance drug plans promote the demand for generic drugs by having higher patient deductibles for branded drugs as well as not covering some branded drugs. Some insurance drug plans have eliminated the patient deductible for patients using generic drugs.

Physicians are being forced by their patients to become more aware of the cost of medications. Patients (consumers) are demanding generic substitution. In the past pharmaceutical companies seduced physicians into trying their new drugs. They sold the new drug as better than the first generation drug. In some cases it was. In most cases the difference was marginal.

Pharmaceutical companies also started to manufacture many me too drugs as well as combinations of two older drugs in order to extend expiration of the drug patent. This prevented generic drug manufacturers from manufacturing blockbuster drugs at lower generic prices.

The marketing implications were that the new medications were “better” than the old medication. The Food and Drug Administration (FDA) approved many of the combination drugs.

As physicians became aware of the cost difference between branded and generic drugs they became irritated. They have switched patients to generics.

Brand name drug patents usually last 14 years from the initial studies for FDA approval. Generic medication manufacturing undergoes the same rigorous FDA quality control study as do brand name drugs.

Both the healthcare insurance industry and Medicare/Medicaid programs have drug benefit programs. Medicare and Medicaid drug benefits are outsourced to the healthcare insurance industry by the federal government. The healthcare industry buys drugs from a Pharmaceutical Benefit Organization (PBO). Many times a healthcare insurance company owns the PBO. The payment system is very complicated. There is no way of telling what the real wholesale price of a drug is. There are many conflicts of interests involved.

There are multiple wholesale prices for a drug. Every time the drug goes through another middleman overhead and profit are also built into the drug price. In fact, the healthcare industry earns 4.7 billion dollars from the federal government per year from Medicare Part D.

There is nothing transparent about the profits made by the secondary stakeholders.

Wal-Mart almost broke the healthcare insurance industry’s cash cow by selling many generic drugs for $4 per month. Wal-Mart has recently instituted a 3 month supply cost of the drug for $10. Interestingly enough the large pharmacies, the healthcare insurance industry and the PBOs have figured out how to rip off the consumers despite Wal-Mart’s initiative.

If patients use their drug benefit insurance policy for a generic prescription, they will be charged $4 or more. The total charge toward their Medicare donut might be $30. The price the pharmacy plan (Medicare Part D) supposedly paid for a one month prescription. If seniors pay Wal-Mart cash and do not use their drug benefit plan, the total cost of the transaction to seniors is $4 as opposed to the $30 charged to their donut.

Most seniors have not figured this out. They use Medicare Part D to pay for their medications. Seniors should buy their generic medications for cash. They should not charge it to their Medicare Part D drug benefit. Since the healthcare care insurance industry probably gets the generic from the pharmacy for $4, the healthcare insurance company’s out of pocket expense for the medication is zero. Seniors have paid for the drug with their deductible. If seniors hit their donut, they will have to pay retail to the pharmacy for additional medications.

President Obama’s healthcare reform act modified the donut insignificantly. Yet he is selling the $250 increase toward the donut as a great advance.

Why is it so complicated? We are dealing with lobbies from at least three industries. None of these lobbyists represents patients or physicians.

Does President Obama’s healthcare reform act do anything to solve the cost of medications seniors need to maintain health? No.

President Obama’s healthcare reform act has done very little and very ineffectively to fix the drug benefit problem. He has not protected seniors or others from the abuses of the healthcare insurance industry.

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


    A very informative post. And true when it comes to the income in the health care industry.

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Health Care and Federal and State Deficits

Stanley Feld M.D.,FACP

Published: December 11, 2010

The basic truth is Federal and State deficits cannot be fixed unless spending for Medicare and Medicaid is decreased. President Obama’s Healthcare Reform Act‘s bureaucratic complexity of will increase the cost of the healthcare system without increasing the quality of healthcare.

New schemes such as Accountable Care Organizations will fail as did the Health Maintenance Organizations of the 1980’s and 1990’s.

None of our political leaders are interested in facing the real reasons for the escalating healthcare costs.

This year Medicare, Medicaid and SCHIP will account for more than 20 percent of all federal spending. These entitlements cost more than Social Security or National Defense.

The entitlements are being expanded inefficiently by President Obama’s healthcare reform act.

By 2035 federal health care spending is projected to account for almost 40 percent of the federal budget. At the current rate of increase in Medicare eligible aging population, a rising Medicaid population and the rising healthcare costs the federal government will collapse under its own weight.

Two bipartisan commissions have issued recommendations to sharply reduce annual deficits, in part through bold changes — some sound, others dubious — in the way health care is paid for.”

The White House commission, headed by Erskine Bowles and Alan Simpson, proposes ways to decrease entitlement spending for Medicare and Medicaid by nearly $400 billion dollars between 2012 and 2020.

A second commission, an independent panel headed by Pete Domenici and Alice Rivlin, has suggested savings of $137 billion dollars by 2020 by Medicare cost-sharing.

Both commissions have some good suggestions. Many of the ideas of both commissions are wrong.

The real reasons for escalating healthcare costs are;

  1. The grotesque profits of the healthcare insurance industry as a result of the federal government outsourcing the administrative services for Medicare and Medicaid. (See 40 billion dollar per year growth)
  2. The lack of states limiting premium rate increases for the healthcare insurance industry.
  3. The absence of promoting rate competition among healthcare insurance companies.
  4. The extremely high cost (estimated 300 billion to 750 billion dollars a year) for defensive medicine as a result of President Obama’s refusal to deal with effective tort reform.
  5. The lack of incentives for consumers to maintain their health. The obesity epidemic represents one example where incentives are lacking.
  6. The lack of effective public education that would teach people the principles of health maintenance.
  7. Discourage confusing media coverage of clinical research studies. The media is interested in the sensational contradictions inherent in serious clinical research.
  8. These contradictions are supported by the publication of shabby clinical research in medical journals and other publications.
  9. The lack of effective public service announcements about health.
  10. The lack of consumer incentives for maintaining good health and utilizing medical services wisely.
  11. The ideal Medical Savings Account would solve many of these problems instantly.
  12. Few healthcare policy makers think consumers are smart enough to understand how to use the ideal Medical Saving Account effectively. Therefore health policy “experts” dismiss Medical Saving Accounts.
  13. Medical Savings Accounts are different than President Obama’s restricted health savings account.

Both commissions are promoting the same ideas of redistribution of wealth and cost shifting. Both increase the cost to those that can afford it. Neither commission deals with consumer incentives.

President Obama’s healthcare reform act does not deal with consumer incentives. It deals with government control and consumer dependence on regulations.

All of the ideas of the commissions are cost containment ideas, not health promoting ideas.

Both commissions shift much of the burden of insurance coverage from the federal budget to individuals or to the states.

The commissions’ recommendations are the typical political shell game. They produce no real reduction in the cost of health care. They are a political ploy because they make the federal deficit look better while not doing a thing to repair the healthcare system..

One suggestion is to require wealthier older people to pay more for Medicare coverage and more of the cost for their own health care. Medicare already uses means testing to set the Medicare premium. The means testing is calculated using IRS tax returns. The distributions of IRA funds are taxed twice. Medicare costs more in after-tax dollars than ordinary group insurance for many seniors.

The problem is that means testing doesn’t work to reduce the deficit. Half of all Medicare beneficiaries live on low incomes and pay minimal premiums. Cost-shifting will undermine the health or financial security of senior Americans of modest means. Beneficiaries might have to pay hundreds or even thousands of dollars in additional out of pocket expenses.

The Domenici-Rivlin commission is advocating ending employer pre-tax exemption for healthcare coverage. This will increase federal revenue and lower the deficit. It will also increase taxes and decrease discretionary income. The result will be a decrease in consumer spending. A decrease in consumer spending will hurt the economy. Ultimately it will increase the federal deficit and decrease our standard of living.

It is time for common senses and sound economic thinking to Repair the Healthcare System.

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

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President Obama Tries To Make Nice To State Governors


Stanley Feld M.D.,FACP,MACE

President Obama is starting to believe. State Governors, both Democratic and Republican, are serious about trying to balance their budgets. He also understands that the proposed cuts in services and reimbursements for Medicaid eligible patients will torpedo his healthcare reform act.

President Obama cannot afford to lose state support for his Medicaid law.

Kathleen Sebelius , Secretary of Health and Human Services said in a letter to state governors that the administration understands the governors budgetary concerns. She also emphasized the administration’s understanding that states already has substantial discretion to alter benefits and establish or increase co-payments.

She went on to instruct governors on how to save money by selectively and judiciously reducing benefits, curbing overuse of costly prescription drugs and attacking fraud all at the states’ expense.

She refused to say whether President Obama would allow states to adopt stricter eligibility standards. President Obama understands that changing the eligibility requirements would, in effect, throw low-income people off the Medicaid rolls. It would destroy his objective of “universal coverage.” The states have realized that his objective of “universal coverage” was going to be at the states’ budgetary expense.

The states are hamstrung by federal prohibitions against lowering Medicaid eligibility, governors from both parties are exercising their remaining options in proposing bone-deep cuts to the program during the fourth consecutive year of brutal economic conditions.”

Please know that I understand fully the impacts of this rollback, and it is with a heavy heart that I make this request,”. Arizona governor Jane Brewer wrote this week in seeking a waiver, the first of its kind, from Kathleen Sebelius, the secretary of health and human services. “However, I am left with no other viable alternative.”



Gov. Nathan Deal, the new Republican leader of Georgia, proposed this month to end Medicaid coverage of dental, vision and podiatry treatments for adults.

A number of states, Texas and California among them, are considering further reductions of as much as 10 percent in payments to providers. Medicaid reimbursement is already so low that many physicians refuse to accept the coverage.

South Carolina is considering going a step further by also eliminating hospice care.

Rick Scott in Florida is proposing a 5 billion dollar budget cut for Medicaid.

Even with increase in federal payments for Medicaid aid to states from President Obama’s economic stimulus package, state budget deficits from Medicaid were so great that 39 states cut Medicaid payments to providers in 2010 according to the Kaiser Family Foundation. The economic stimulus package subsidy was unsuccessful and is scheduled to disappear in July 2011.

MITCH DANIELS ,governor of Indiana wrote a brilliant op-ed piece in the Wall Street Journal on February 3.

“Unless you’re in favor of a fully nationalized health-care system, the president’s health-care reform law is a massive mistake.

It will amplify all the big drivers of overconsumption and excessive pricing: "Why not, it’s free?" reimbursement; "The more I do, the more I get" provider payment; and all the defensive medicine the trial bar’s ingenuity can generate.”

His article represents the position of twenty-one governors representing more than 115 million Americans. They have written to Kathleen Sebelius asking for more flexibility on health-care reform.

President Obama’s healthcare reform act has provided Kathleen Sebelius massive power without the need for congressional consent.

All the claims President Obama made for his healthcare reform act were false. It will add trillions to the federal deficit. It will lead to a de facto government takeover of health care faster than most people realize.”

“As millions of Americans are added to the Medicaid rolls and millions more employees (including, watch for this, workers of bankrupt state governments) are dumped into the new exchanges many trillions of dollars will be added to the federal deficit.”

The traditional media has not articulated this impending disaster. It will get worse. Governor Daniels has expressed his concerns gently. He also hit the nail on its head for the states.

The law expects to conscript the states as its agents in its takeover of health care. It assumes that we will set up and operate its new insurance "exchanges" for it.

“The federal government want us to use our current welfare apparatuses to do the numbingly complex work of figuring out who is eligible for its subsidies, how much each person or family is eligible for and re-determining this eligibility regularly, and more.”

“Then, we are supposed to oversee all the insurance plans in the exchanges for compliance with Washington’s dictates about terms and prices.”

States do not have the infrastructure to accomplish most of this. The federal government does not have the apparatus to accomplish this. The point was proven recently by the federal fiasco when the states refused to participate in setting up high-risk pools.

“ As widely reported, it went poorly, with costs far above predictions and only a tiny fraction of the expected population signing up.”

“If the feds can’t manage this little project, what should we expect if they attempt it on a scale hundreds of times larger and more complex?”

Either we have a bunch of rookies in the White House who do not know what they are doing, or we have a bunch of geniuses who have choreographed the destruction of the healthcare care system in such a way that America will have no choice but to permit President Obama to install a completely socialized medicine system with the inefficiency inherent in government run bureaucracies.

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President Obama’s Disrespect For The Judicial System

Stanley Feld M.D.,FACP,MACE

Twenty-six states joined Florida’s legal challenge on the constitutionality of President Obama’s healthcare reform act. The sub-plots of the law suit are states’ rights vs. federal control, the constitutionality of a mandate to force individuals to purchase insurance and forcing states to create increases in budget deficits. President Obama’s healthcare reform act is going to cause fiscally responsible states to fund fiscally irresponsible states through increased federal taxes. The result will be an increase in state taxes.

President Obama’s mandate has greater significance than forcing everyone to have healthcare insurance. Federal Judge Roger Vinson struck down President Obama’s entire healthcare reform act last week on all counts. He essentially ordered President Obama to cease implementation of his healthcare reform act.

“A federal court issued a binding judgment voiding the law, with Judge Vinson noting that he trusted the Administration would obey the "long-standing presumption" that such a judgment is "the functional equivalent of an injunction."

The White House and Health and Human Services announced they’ll continue to implement “ObamaCare” as if nothing has changed.

This is disgraceful.

It tells us something about President Obama’s respect for the law of the land. If President Bush had said the judicial rulings against his policies on wiretapping and some civil liberties would be ignored the traditional media would have been all over him.

State governments have decided to obey Judge Vinson’s injunction and are suspending implementation of the new regulations and mandates.

"For Wisconsin, the federal health-care law is dead," Attorney General J.B. Van Hollen said in a statement, unless Judge Vinson’s decision is stayed by the 11th Circuit Court of Appeals.

Florida Governor Rick Scott said he had no intention of wasting "time and money" executing the for-now defunct law, and his insurance commissioner returned a $1 million federal assistance grant.

Idaho will also freeze implementation, and we hope the remaining 23 states will join the rejectionists.

President Obama’s healthcare reform act has previously demonstrated disrespect for the will of the people. Its passage also demonstrated a lack of respect for the congressional process. Now President Obama is demonstrating his disrespect for the judicial process. His web site dismissed the judgment as a decision by an activist judge.

President Obama’s arrogance is obvious. He knows best. He knows what the people need regardless of what they want.

I have pointed out continuously that President Obama’s goal to reform the healthcare system is admirable. He wants universal coverage, more affordable care and an increase in quality of care. His strategy to achieve his goal is wrong.

President Obama’s methodology is not practical. It will destroy America’s healthcare system. If permitted to proceed it will not only expand the federal deficit, it will decrease the quality of medical care as well as decrease access to care and result in rationing of care.

Attorney General Holder can file an appeal asking the 11th Circuit for a stay. The prediction is he will. When he does, President Obama will be admitting that his administration has ignored the rules of the judicial process.

The traditional media has failed to describe effectively the issues individual states face and the threat to individual freedom.

President Obama has made so many “deals” and granted so many waivers that his healthcare reform act is becoming a joke.

The legal and political challenges against President Obama’s healthcare reform act are becoming increasingly more complex daily. The American public is starting to understand the horrible process used to pass the bill and the actual meaning of terrible legislation. It is not going to Repair the Healthcare System.

The best way to fix “Obamacare” is to repeal it, provide an alternative that will express the will of the people and align all the stakeholders’ vested interests.

Most importantly, we must put Patients First.

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

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One Size Doesn’t Fit All

Stanley Feld M.D.,FACP,MACE

Prior to the passage of his healthcare reform act President Obama removed a provision dealing with reimbursing physicians for end of life counseling. There had been a great public uproar over this provision.

It was viewed at a first step toward end of life rationing of care. It was really a signal that most care would be rationed.

When a proposal to encourage end-of-life planning touched off a political storm over “death panels,” Democrats dropped it from legislation to overhaul the health care system.

Sarah Palin called it death panels.” A government panel would decide whether Medicare would pay for the treatment of patients deemed hopeless regardless of the patient’s will.

Sarah Palin’s use of “death panels” was sensationalistic. In our sound bite society this was an effective sound bite.

The words “death panel” illustrated the truth about a world of finite resources and infinite entitlements.

The government cannot afford entitlements much longer. Yet President Obama’s healthcare reform act is going to expand the Medicare and Medicaid entitlements.

President Obama plans to control entitlement spending by defining what he will pay for. The result will be rationing of care.

There are other ways out of the mess. President Obama is not attacking the root of the problem. One way is a consumer driven healthcare model using ideal medical savings accounts. It would place the responsibility on patients and their family. Patients would be in a position to choose rather than having the third party (the federal government) choose their medical care. Patients and their family might decide to limit hopeless care when they are spending their own money..

A system of sensible tort reform would decrease the large cost of defensive medicine. The result would be lower healthcare costs. President Obama has ignored tort reform.

These two changes can help attack a few of the root causes of the increasing healthcare costs.

I have objected to President Obama’s healthcare reform act. It places all the decision making power in the executive branch and out of the hands of congressional oversight.

The Obama administration has the power to effect change through regulation rather than legislation . An example is Dr. Donald Berwick, chief of CMS, instituting the same policy by regulation that was removed from the bill by legislation. The new regulations go into effect January 1 2011.

At a stroke, Medicare chief Donald Berwick has revived the "death panel" debate from two summers ago.

CMS will enact the same policy removed from the bill through regulation. Congress has had no input. There will be a never ending series of steps to give government control over both patients’ and physicians’ freedom to make medical decisions. Some regulations seem benign on the surface. President Obama has been given complete control over the healthcare system by his healthcare reform act.

It is the reason there is such an outcry to repeal his healthcare reform act. President Obama has tried to hide the new regulations from stakeholders involved.

The office of Oregon Democrat Earl Blumenauer, the author of the original rider who then lobbied Medicare to cover the service, sent an email to supporters cheering this "victory" but asked that they not tell anyone for fear of perpetuating "the ‘death panel’ myth." The email added that "Thus far, it seems that no press or blogs have discovered it, but we will be keeping a close watch."

President Obama has used a number of tricks to achieve his goal. He appointed Dr. Berwick during congressional recess without congressional hearing after he withheld the request for a congressional hearing and approval for 3 months.

Dr. Berwick now slips through a regulation about reimbursement that Congress explicitly rejected. The email slipped out illustrating the scheming with his political patrons to duck any public scrutiny.

“Expect many more such nontransparent improvisations under the vast powers ObamaCare handed the executive branch.”

Administrative spokesmen, when challenged, immediately declared “the rule-making is not coercive and gives seniors more autonomy, not less.” Nothing could be further from the truth.

The facts are a panel of medical experts decide on treatments or service that are worthy of reimbursement. They then tell the administrators what to pay for. Some treatment won’t be paid for it even if it is in the best interests of patients.

Can a panel of medical experts be wrong? They certainly can. The experts judgments might be correct. However, their opinion and exceptions to the regulations cannot be incorporated into the healthcare system by inflexible bureaucratic machinery.

The bureaucrats put the experts’ decisions into a rules based computer program. Reimbursement is driven by this inflexible system , not by medical circumstances or medical judgment.

Last month a group of Clinical Endocrinologists received a Medicare denial code 151 stating;

“Payment adjusted because the payer deems the information submitted does

not support this many/frequency of services.”

This had not happened to this group in 20 years of endocrine practice. It concerned serially measuring thyroid function to regulate thyroid replacement therapy after patients are rendered hypothyroid with radioactive iodine of surgery. Initially patients have to be followed with thyroid function testing every month or two.

Medicare allowed payment for the first laboratory service, then denied the next three tests as “too frequently.”

CMS also describes in its National Coverage Determination (NCD).

Thyroid testing may be covered up to two times a year in clinically stable

patients; more frequent testing may be reasonable and necessary for patients

whose thyroid therapy has been altered or in whom symptoms or signs of hyperthyroidism

or hypothyroidism are noted.

The “medical experts” got the exceptions correct but did not define the frequency of testing to permit the CMS to incorporate into the reimbursement system..

An endocrine practice can submit for redetermination within 120 days. If redetermination fails physicians have 80 days to file for reconsideration.Reconsiderations are the second level in the appeal process and are conducted by the Qualified Independent Contractors (QICs). If physicians receive an unfavorable reply at the reconsideration level, there are three more levels of the appeal process, the Administrative Law Judge (ALJ) Hearing, Appeals Council Review and the Judicial Review in U.S. District Court.

Imagine all the costs involved on both sides in order to adjudicate treatment that is evidence based and totally indicated. Imagine the frustration of physicians treating patients. .

From past experience these hassles will increase as the government gets more and more control over the healthcare system. Patients’ medical care is not first. Federal rules and regulations are first.

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

  • Tom in NH

    You are wrong about this myth of a death panel. This is nothing more than Republican policical theatre. The proposal is only to get the doctor PAID to sit down and discuss the THE PATIENT’s WISHES are. So both can make informed decisions. As Atul Gawande pointed out recently,
    Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit:
    25% of Medicare spending is on 5% of patients in their final year of life. Then there’s the study in 2008 by Coping with Cancer that showed terminaly ill cancer patients had WORSE quality of life when pulling out all the stops than those who opted out. And then there was the family members 6mos after death that had a 3x higher rate of depression when the patient opted for agressive care vs paliative care.
    So getting back to the point, aren’t these topics you’d like to sit down with YOUR DOCTOR and develop a plan that works FOR YOU? Oh, sorry, the doctor can’t get paid for this type of meeting right now. Your doctor is busy scheduling paying appointments. You’ll have to go it on your own. Good Luck.

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