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It Is All About How You View The Elephant


Stanley Feld M.D.,FACP,MACE

 I received the following comment from a reader. The comment is sincere, honest and heart felt. The dysfunction in the healthcare system affected his mother and father.   

 In the past, I have pointed out the sources of waste in the healthcare system. All the stakeholders are at fault. I have included physicians in creating waste. I have not included physicians as a primary source of the waste. Their waste is secondary cause to other dysfunctions.

“Dr. Feld,

 This is a blind spot for you and a blog that comes across as defensive versus simply acknowledging the role the Physician must play in reducing excess utilization. “

 There is no question that physicians’ delivery of medical care can be ineffective and dysfunctional creating waste.

 It does not follow that physicians are the primary source of waste. Physicians are convenient targets for causing the majority of the waste in the healthcare system because the medical interface is between physicians and patients.

 Sometimes patients have a horrible experience interacting with the healthcare system.

Most people (80%) are not sick at any given time. They are not interested in understanding the dysfunction in the healthcare system because they are well.

It is difficult for a sick person to navigate the healthcare system. When a person is sick they realize how inefficient the system is.  

 I have tried to emphasize how all the stakeholders’ incentives are misaligned. The results is this dysfunction. Physicians’ incentives are created by government, healthcare insurance industry and hospital systems rules and regulations.

 I am not interested in making excuses for some physicians’ poor behavior. I am more interested in making the public aware of every stakeholder’s role in our dysfunctional healthcare system.  

 “Either you have never had someone in your family who’s been referred around the system with no significant benefit or your Endo experience is what you apply to the rest of healthcare delivery.”

 Unfortunately, I have had that experience and have had to intervene on behalf of a family member with some logical medical decision- making.

“Either way, you accept no responsibility for Physician intervention to reduce consumption of healthcare and all the data says you’re not being objective.  There are many reasons Physicians don’t intervene to reduce consumption but to imply it’s only a small amount of $ isn’t being honest.”

 I have tried to point out some of the major reasons for physician dysfunction.


  1. Lack of tort reform results in between $300 billion and $700 billion dollars in wasted defensive medicine costs.
  2.  Most physicians do not benefit from the defensive medicine procedure fees. Hospital systems do the procedures and bill independently.   
  3. The Healthcare insurance industry benefits because it is  able to raise premiums.
  4. The legal system does because it benefits from settlement fees because of the lack of tort reform..  

         e.  Inefficiency in communication as a result of the lack of functional electronic medical records.       

         f.   Inability of patients to make timely appointments and move through the system effectively and                efficiently due to lack of the use of information technology and effective scheduling programs.

         g. There is $150 billion dollars of administrative waste.

         h. Decrease in effectiveness in reproducible laboratory results and procedure results lead to                retesting to make the correct diagnosis.

 What can seem like piling on of procedures to a patient and his family might not be a quest for dollars but a quest for a correct diagnosis.

In most cases the dollars do not go into the ordering physician’s pocket.

This is the reason the healthcare system must be consumer driven. It would incentivize patients to challenge physicians who are spending the the consumers money. The system should not be government or healthcare insurance industry driven. Patients must own their healthcare dollars. Patients must be involved in understanding the physician’s thinking.

 “My mom was referred around the system for tests, specialist visits etc. for 6 years with a very clear set of symptoms until my sister diagnosed her through web based research with a Histamine allergy/reaction.  Why in the world with classic symptoms that are available on the web would she simply be handed off Dr. to Dr. to duplicate tests over and over again yielding no care plan or plan to narrow the diagnoses?” 

 “ The answer is EVERY activity, every visit, every test, every procedure generated revenue for the providers.  My sister is a real estate broker not a Dr.”

I cannot address this problem with the data provided. Maybe your mother went to the wrong physicians.

A Histamine reaction is are usually an epiphenomenon. The reactions are usually secondary to an underlying stimulant. Sometimes the underlying stimulant is a disease that can be deadly. If diagnosed the underlying diseases can be cured. Many time the cause is benign.  Perhaps this could explain her physicians difficulty in diagnosis.

My Dad was diagnosed with lung cancer in 1995.  He had a lobe removed and recovered for a great year in 1996.  In Nov 1996 he was diagnosed with brain mets (what were his chances for survival at that point?  No one ever talked to the family.) 

At the beginning of your Dad’s illness your parents and the family could have stepped in and demanded being involved in the treatment decisions. The family could have made the decision to not try for a cure at any time. 

 “They did brain surgery, radiation and rehab and 6 weeks later the cancer was back in the same location in the brain.  Now what were my Dad’s chances for survival?  No one ever mentioned palliative care or that my Dad was going to die barring a miracle.  Instead, another brain surgery was scheduled by the surgeon, then more radiation until my Dad’s brain was fried and he stroked.” 


 “Now, if you think that surgeon isn’t part of the problem, that generating revenue with activity isn’t rampant in our healthcare system, then I simply don’t give your blog much credibility because clearly it is and it must be addressed not by outsiders, but by Physicians.” 

You have described the reason Primary Care Physicians are demanding that they be the captain of the healthcare team.

I disagree with the PCPs. Patients and their families should be the captain of the healthcare team. The Primary Care Physicians should coordinate care and follow the will of patients and their family. Primary care physicians should be the coach of the healthcare team.  .

Your father’s case is an excellent example of defensive medicine on the part of the brain surgeon. He was probably doing everything he knew to save your father and cover himself defensively. It does not sound as if the family demanded being involved in the decision making process. The family must demand involvement.

 “These aren’t isolated cases of excess utilization, they are the norm.  If Dr.’s aren’t proactively part of fixing it, then care will be rationed.  If consumers get control of their own healthcare dollars it would be the single biggest hit to revenue for all providers that could possibly take place (I support consumers armed with info making decisions).”

 I do not think it would decrease physician revenue significantly. I think it would decrease waiting times to see a physician and decrease delays in treatment.

 The major cause of excess utilization is the lack of tort reform and the resulting defensive medicine. Consumers must drive physicians to communicate effectively or move on to another physician.

President Obama has refused to recognize tort reform as an issue.

Communication could be solved utilizing my concept of the Ideal Electronic Medical Record.

The healthcare insurance industry’s control of the healthcare dollar would vanish utilizing my concept of the Ideal Medical Saving Account. It would reduce costs by the 30-60% the healthcare insurance industry takes off the top for first dollar coverage. It would make consumers wise spenders.

 “In the meantime, the fee for activity system we have now doesn’t work for anyone except industry, insurance companies and providers who do expensive things.  The patients and doctors whose expertise requires cognitive time with patients have all been shortchanged on this journey to where we are today”.

This is precisely why we have to have a consumer driven healthcare system. Consumers must control their healthcare dollars and be individually responsible for their treatment decisions.

“Sorry, you’ve touched a nerve.” Sincerely your

The same blog hit a nerve in another reader.  He wrote:

“This piece made me think of an old verse that states the case of the physicians pretty well:”

I'm not allowed to run the train
The whistle I can't blow…
I'm not allowed to say how far
The railroad cars can go.
I'm not allowed to shoot off steam,
Nor even clang the bell…
But let the damn train jump the track
And see who catches Hell!

 It is easy to see the elephant from one point of view. Incentives have to be aligned. The healthcare system must be realigned to the patients’ point of view.

 President Obama and Dr. Don Berwick think they are seeing the problems from the patients’ point of view. They feel the government has to dictate care.

They are creating a system so bureaucratic and complex that they will blow up the healthcare system. They will make the system more dysfunctional and more costly. 

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







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The Healthcare Insurance Industry Continues To Game The Healthcare System

Stanley Feld M.D.,FACP,MACE

I have described how the healthcare insurance industry loads its expenses into direct patient care expenses to increase their profits. 

The Medical-Loss Ratio calculation of is not reported by the traditional media. The healthcare insurance industry spends less healthcare dollars on direct patient care after it is permitted by federal and local agencies to load its expenses into the direct patient care column.

Simply put, the healthcare insurance industry cooks the books to increase its net profit.

Another way to increase profits is to shortchange physicians on medical claims. In fact, 20% of medical claims payments are inaccurate according to the American Medical Association’s (AMA) fourth annual National Health Insurer Report Card. Claims-processing errors by health insurance companies waste billions of dollars and frustrate patients and physicians.

This is one of the reasons the RAND report about physicians controlling waste is so absurd to me.  The healthcare insurance industry creates waste in order to increase net profit.

 The AMA released its annual report card on insurers saying, "Eliminating mistakes would save doctors and insurers $17 billion a year." 

The AMA said, “Commercial health insurance companies have an error rate of 19.3 percent, up two percentage points from last year's report.”

The healthcare insurance industry’s computer systems become better each year. At the same time, the healthcare industry has a higher error rate each year.

 The healthcare insurance industry’s explanation of benefits becomes less comprehensible to patients and physicians every year.

 When physicians discover insurers’ mistakes in reimbursement they fight the healthcare insurer for their patients or themselves. It is costly to fight and it distracts physicians from their job of diagnosing and treating patients. 

I think the error rate in reimbursement is even higher than reported. A significant percentage of physicians or their billing services do not pick up many of the errors.

The 2011 report card is based on a random sampling of about 2.4 million electronic claims for approximately four million medical services submitted in February and March 2011 to Aetna, Anthem Blue Cross Blue Shield, Cigna, Health Care Service Corp., Humana, the Regence Group, UnitedHealthcare and, for comparison, Medicare, according to the AMA.

 The claims were gathered from more than 400 physician practice groups in 80 medical specialties in 42 states.

It must be recognized that the random sample is a small percentage of the total number of claims processed. The results can have a large margin of error and result in a higher percentage of mistakes.

“The increase in overall inaccuracy represents an extra 3.6 million in erroneous claims payments compared to last year, and added an estimated $1.5 billion in unnecessary administrative costs to the health system.”

The additional administrative costs have an insurance industry’s profit component added on to reprocessing the errors.

 Why hasn’t President Obama recognized this and gone after this abuse of the healthcare system?

 "Robert Zirkelbach, spokesman for America's Health Insurance Plans, said in an e-mailed response that insurers and providers share the responsibility of improving claims payment accuracy and efficiency." 

The response is lame. The response gets worse.

 "CIGNA maintained its industry leading low denial rate of 68 percent." Notably, "lack of patient eligibility for medical services continues to be the most frequent reason for denials." 

UnitedHealthcare was the only commercial health insurer included in this year’s report card to demonstrate an improvement in claims-processing accuracy.

UnitedHealthcare came out on top of seven leading commercial health insurers with a accuracy rating of 90.23 percent. Anthem Blue Cross Blue Shield had scored the worst of those measured with an accuracy rating of 61.05 percent.  

Insurer Non-payment. 

 Physicians’ total non-payment rate for claims submitted to all commercial healthcare insurer was almost 23%. There is no reason insurance claims should not be adjudicated at the point of service. 

The insurance industry uses non-payment to hold onto the float. It results in hassling physicians and patients. Physicians are starting to demand full payment for services at the point of service from patients. This leaves adjudication of claims to the insurance company and patients. It can represent a hardship to patients. 


 Aetna, Anthem Blue Cross Blue Shield, Health Care Service Corporation and UnitedHealthcare cut denial rates in half in one year to 1.05 percent as a result of last year’s AMA report card. 

Administrative Requirements. 

There is an increase in the rate of claims requiring prior authorization. Physicians have to ask permission before performing services or treatments. 

This increased requirement has many effects. It undermines the physician patient relationship and the patient’s confidence in the physician. It delays or interrupts medical services to patients. It consumes a significant amount of the physician’s time. It complicates medical decisions. It should be patients who question their physician’s decisions and have their physician justify the treatment to them. 


The healthcare insurance industry agrees to contracted reimbursement fees. The fees vary depending on how much the healthcare insurance company needs particular physicians in its network. Healthcare insurers have been notorious about not processing claims accuracy.  

It seems to me that with the state of the art of information technology being what it is, contracted fee reimbursement should be automatic and accurate. Most insurers have gotten better over the last year.

The exception was Anthem Blue Cross Blue Shield, which scored 14 percent lower on this measure than it did four years ago.”

This is inexcusable. It might be purposeful in communities where Anthem Blue Cross Blue Shield is the dominant insurer.


The AMA report card has been effective in exposing response time for adjudication of claims by physicians to the healthcare insurance company. CIGNA and Humana have cut their median claims response time in half in the last four years.

 Response times varied for commercial health insurers from six to 15 median days.

The resulting waste in the healthcare system from all of these tactics is enormous. Total healthcare insurance industry administrative waste (unnecessary expenses) is about $150 billion dollars a year.

If President Obama really wanted the present system of employer sponsored insurance to survive, he would be putting resources toward solving these problems.

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










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The Role of Physicians in Controlling Medical Care Costs and Reducing Waste

Stanley Feld M.D.,FACP,MACE

The Role of Physicians in Controlling Medical Care Costs and Reducing Waste by the RAND Corporation and David Geffen, University of California Los Angeles School of Medicine, Santa Monica was just published in the Journal of the America Medical Association (JAMA).  I do not think the JAMA should have published this article.

1.Why would the JAMA publish such an article?

2. Why are physicians blamed for all the waste in the system?

3. Why is it the physicians’ responsibility to eliminate waste when they are not the cause of the greatest percentage of the waste?

“The amount of money spent on medical care is increasing faster than the gross domestic product (GDP), and the federal deficit is increasing.”

The initial statement assumes that the government deficit is increasing because physicians control government spending for healthcare.

This is only partly correct. The question I have is maybe patients should drive medical costs and not the government.  

The government bureaucracy and the healthcare insurance industry has created this cost monster.

 “Budget experts believe that the deficit cannot be reduced unless medical spending can be controlled. What role will physicians play in controlling health care cost growth? Are physicians even willing to play a role?

The article outlines the steps physicians must take to reduce waste and therefore the budget deficit. The assumption is physicians are the main source of the healthcare system’s waste.

The RAND Corporation does not consider the waste of the government bureaucracy, the healthcare insurance industry’s excessive fees, the hospital systems’ excessive billings, nor the pharmaceutical companies excessive charges for medication. Not considered is the excessive waste that results from the forced practice of defensive medicine because of the lack of tort reform.

If all these issues were addressed, waste and costs would be markedly decreased. There would be no need to try to commoditize physicians’ medical decisions.

I cannot visualize success in trying to commoditize the physician’s decision-making processes.

The healthcare system should be consumer driven with the consumers owning their healthcare dollars and making their own healthcare decisions. The government must help teach consumers to make appropriate medical care decisions with their own money. The government could provide the money. It would eliminate all the bureaucratic waste and secondary stakeholder abuse because it would create a true marketplace driven by consumers and not an artificial marketplace driven by government inefficiency. Consumers must make their own medical care decisions and be responsible for their actions. 

The authors of the article suggest that physicians have three options for participation in controlling healthcare costs. The problem is it assumes the burden for controlling costs are the responsibility of physicians.

     1.     "Physicians can do nothing."

      2.    "Health care can be rationed."

     3.   " Physicians take the lead in identifying and eliminating waste in US health care system."

    4. (We have tried to lead.)

    5. (President Obama has ignored us.)

“Physicians could define waste by assigning all services to 1 of 4 types of care—inappropriate, equivocal, appropriate, or necessary”.

This is subjective busy work that is destined to fail. It will also stifle creativity, thinking, problem solving and innovation.

Physicians try to practice evidence-based medicine. There are defects in determining best practices. In many cases the conclusions drawn from clinical results are inaccurate. It is arbitrary based on the bias of the experts picked to be the judges.

1.Inappropriate care, the potential health benefit to the patient is less than the potential harm caused by the procedure, device, or drug

2. With equivocal care, potential harm and benefit are about equal.

3. With appropriate care, potential benefit to the patient exceeds potential harm.

Necessary care is appropriate, represents the only viable option, and produces a large health benefit.

Who decides appropriate and necessary care?

An excellent example is the difficulty deciding appropriate and necessary care in the use of post-menopausal hormonal replacement therapy. The study design of the Women’s Health Initiative (WHI) was defective, the execution of the study was ineffective and the statistical analysis was inaccurate. The conclusions of the WHI are suspect. Yet the WHI has been heralded as evidence based medicine for best practices. It has changed the course of women’s health forever.

A tool to measure clinical waste across all clinical services does not exist. This is because the definition of “clinical waste” is ever changing. Today’s best practices can be tomorrow’s clinical waste.

Physicians are constantly trying to define best practices. It must be the job of physicians. Physicians are constantly trying to teach other physicians best practices. Physicians are constantly trying to learn to keep current.

The best practices have to be put into context with changing scientific concepts. Potential bias must be evaluated.

The clinical decisions should not be the interpretations of policy wonks or bureaucrats.

None of this is black and white. Policy wonks, economists and bureaucrats have little understanding of the complexity involved in clinical decisions.

Their interest is to somehow try to quantitatively measure physicians’ clinical decisions against an artificially created set of standards defined as waste.

“Physicians prefer the medical definition. But it is not known how much clinical waste is in the system.”

Another excellent clinical example of the controversy is the treatment of choice for Graves Disease (hyperthyroidism). There are cogent arguments for the treatment of choice for Graves Disease with either radioactive iodine or medications such as PTU or Tapazole. There is no unequivocal scientific evidence for an advantage of either treatment.

Attempts have been made to prove an advantage of one treatment over the other. When there is a lack of unequivocal evidence for best practices, patients must be given a choice of therapy.

A defect in the attempts to determine best practice in clinical research is the elimination of patients’ freedom to judge and choose or participate in the best treatment choice for that individual. 

It is physicians’ responsibility to defend and maintain that freedom for their patients. The reasons for waste in the healthcare system should not be determined arbitrarily by bureaucrats.   

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











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StrikeOuts: A New York City Street Game.


Stanley Feld M.D.,FACP,MACE

One of my favorite street games while growing up in the Bronx was "Strikeouts." Strikeouts is not a well know game nor has it been well described in the "literature."  It was difficult to play on most neighborhood streets. It needed a wide field such as a concrete softball field to be played properly.


(Inaccurate photo because the guys were older than 10-12 years old, pitcher is throwing a tennis ball rather than a spaldeen, and the strike zone is painted on the wall. We had none of this. However photo gives you the idea.

I lived across the street from Claremont Park. It had a large softball field.  In Strikeouts a pitcher pitches to a batter and tries to strike the batter out. It can be played by 2 to 20 kids with one on a side to 10 on a side including a short centerfielder.

The only equipment needed is a Spaulding (Spaldeen) and a broomstick as a bat. The Spaldeens were never perfectly round. The pitcher could try a vicious curve ball with a Spaldeen. The ball can produce a natural curve when thrown more that 50 feet. If the ball had a slight rubber seam, a ten year old could throw a successful curve ball, slider, cutter, or sinking ball will a slight twist of the wrist.

I had a friend we “nicknamed” Glue. He could catch a Spaldeen by sticking his hand in the air. The Spaldeen just stuck like glue to his hand. Hence, the nickname Glue.

 Glue had a wicked curve ball and a phenomenal knuckle ball. His knuckleball danced in front of your eyes until you were dizzy. He was impossible to hit.

 The game was about pitching and hitting. All the rest of the guys were fielders. The more guys you had the more positions you filled.

 With one on a side, a strikeout was a strikeout. The ump calling balls and strikes was the pitcher. It was not exactly fair but we tried to be honest.  A home run was a shot over the fence. A triple was hitting the fence. A double was a one bounce to the fence. A single was anything hit past the pitcher.

Most of the outs were the result of a strikeout. This was the reason for the game’s name. The broomstick could not be more than an inch in diameter. I remember finding a one-inch diameter stick in the sewer on my cousin Albee’s block while playing stickball in his neighborhood. I took that stick everywhere.

 Pitching a Spaldeen did not hurt a young kid’s arm. The ball was light and it took more skill than force to throw an effective pitch.

 A pitcher could pitch 20 innings easily. There was usually no reason to stop the game at 9 inning.

We played until it was dark or our mothers called us in to eat.

The most memorable Strikeout game of my career was the time my friends needed an extra guy for a six on a side game. I walked home late from school that day. Everyone was home already, had milk and cookies and changed into their sneakers and jeans. They were outside ready to play.

They spotted me walking home. They asked me to join their game.

 I told them I have to go home and change my new shoes. I had just gotten a pair of “Miles leather shoes.”  I did not want to ruin the shoes. The usual brand of shoes my parent bought my brother and me was Tom McCan Shoes. Miles shoes(Does not exist anymore) were supposed to be really special. I was not allowed to play ball in my school shoes in any case.

 My mother was working. No one was home. My friends convinced me to play now. They said my parents would not notice that I played ball in my school shoes.

 In the middle of the third inning it started to rain. It didn’t just rain. It poured. We continued the game in the rain. I hit a ball into the outfield. In a six-man Strikeouts game you had to run the bases. 

 After running to first in my new drenched Miles shoes, the shoes fell apart. They  fell off my feet. Obviously, the shoes were not leather. They were made out of cardboard. So much for the quality of Miles shoes. I ran the bases in my socks.

 The only thing left was to explain my predicament to my mother and father. It was not an easy task. Thank god I didn’t get killed.

 That particular Strikeouts game lives vividly in my memory. 

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





  • Joe D'Ambrosio

    Nicely and accurately rendered. I played this game in Brooklyn schoolyards growing up. We used a fat stick of chalk to mark the strike zone on the brick wall. Close calls would produce a puff of chalk dust, so no umpire needed.
    Those Spaldeens could sure move around, too!

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Nation’s Health Care Bill Predicted To Double By 2020

 Stanley Feld M.D.,FACP,MACE

Massachusetts has experienced a sixty percent increase in healthcare costs since “Romneycare” was enacted in 2006.  The total cost of medical care in 2005 was $350,100,000. In 2009 the total cost of care had risen to $587,900,000. This represents an annual growth rate of 13.7% per year.

The Medicare Office of the Actuary reported it expects healthcare costs to increase from the $2.6 trillion dollars in 2011 to $4.6 trillion dollars by 2020 under President Obama’s Healthcare Reform Act.

“The Medicare Office of the Actuary estimated that health spending will grow by an average of 5.8 percent a year through 2020, compared to 5.7 percent without the health care overhaul. With that growth, the nation is expected to spend $4.6 trillion on health care in 2020, nearly double the $2.6 trillion spent last year.

I believe the Medicare Office of the Actuary growth rate estimate of healthcare costs is low. Obamacare is about expanding healthcare coverage for the uninsured. It is actually about driving the entire population into a “Public Option” which will be subsidized by the federal government. President Obama’s goal is to have total government control over the healthcare system.

The total rate of growth of healthcare costs will be greater than 5.8% per year. President Obama is not going to be able to decrease costs by insuring at least 30 million more people. Obamacare has done nothing to restrain the healthcare industry’s billing policies. The healthcare industry’s profit will escalate even further as the federal deficit escalates.

President Obama declared that Accountable Care Organizations, Pay4Performance and Electronic Medical Records would reign in costs. I believe this is a pipe dream.  These programs are in the developmental stages and have an excellent chance of failing as the entitlement expands.

President Obama has continued to ignore an important healthcare cost generator.  Defensive medicine generates between $300 billion and $700 billion dollars a year in costs. Tort Reform if done correctly could decrease the cost of defensive medicine to the healthcare system markedly.

“The federal health law, which will expand coverage to 30 million currently uninsured Americans, will have little effect on the nation's rising health spending in the next decade, a government report said today.’

I hope the American people do not let President Obama trick them again with his demagogary. Last week he told us he was going to decrease the federal deficit by 4 trillion dollars in ten years. It is not true because he is going to increase the federal debt by 9 trillion dollars or 4 trillion less than he had planned. Deficit spending continues unabated.

 Everyone has to watch closely. He is bankrupting the country.

 White House Deputy Chief of Staff Nancy-Ann DeParle tells us not to worry. "The bottom line from the report is clear: more Americans will get coverage and save money and health expenditure growth will remain virtually the same,"


She stated that the new programs that administration officials said they hope to implement would change the way Medicare and Medicaid pay doctors and hospitals. (ACOs, Pay4Peformance and EMRs). Doctor’s and hospitals are only part of the problem. A bigger part of the problem is the administrative service providers (healthcare insurance industry) expenses, the cost of government bureaucracy, and the increase in defensive medicine

“Meredith Rosenthal, a health economist at Harvard School of Public Health, said it is difficult to predict what impact the health law will have on slowing national health spending.  "Many of the components of the law that are intended to control costs are still in draft form,"

The key to President Obama’s deception to the American people is to distract Americans from connecting the dots. Fifty per cent of employers will drop employer sponsored insurance programs and pay the penalty. Employees will buy insurance through the state insurance exchanges. States are refusing to participate in the insurance exchanges. The federal government is picking the ball up for the states and will have total control over the insurance exchanges.

Baby Boomers are joining the Medicare roles in increasing numbers by the minute. The cost of Medicare will escalate. Seniors are not going to be able to find physicians who accept Medicare because President Obama is going to decrease reimbursement by thirty percent January 1, 2012.

President Obama believes physicians are the problem. He refuses to believe the reality of the dysfunctional healthcare system. All the stakeholders are the problem. Some stakeholders donate more to his reelection than others. He has a strong record of playing favoritism to those that support him.

Americans are waking up to his tricks. The healthcare system has to be reformed. He has the wrong approach. I hope the electorate does not fall for his charm again. 

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





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RomneyCare: Does It Work?

  Stanley Feld M.D.,FACP,MACE

 In 2010, Massachusetts State Treasurer Timothy P. Cahill, an independent candidate for governor, offered a wide-ranging and scathing criticism of the state’s universal health care law (RomneyCare). “ It is bankrupting Massachusetts and will do the same nationally, if a similar plan is passed in Congress.”

I predicted this result when the RomneyCare was passed in 2006. Mitt Romney can deny the results of his plan all he wants. The results are the results and it is his plan. It was an ill-conceived plan. His plan was the model for Obamacare. The media forgets that the (CMS director) Dr. Don Berwick and his untested “idealism” was the architect of both plans.

“We haven’t done anything about driving down costs,” Cahill said. “We haven’t helped small business. We haven’t changed the way we pay for health care and the way we deliver it.”

“The real problem is the sucking sound of money that has been going in to pay for this health care reform,”

Timothy Cahill pointed out that the Obama administration had subsidized the state Of Massachusetts plan so it looked good. All of RomneyCare’s defects were camouflaged.

And I would argue that we’re being propped up so that the federal government and the Obama administration can drive its healthcare reform plan through Congress.”

Commonwealth Connector, the independent state agency established to help residents find health insurance, has “totally failed” to create competition and connect people with affordable insurance. Cahill pointed out that 68% percent of the residents RomneyCare serves receives subsidies from the state.

Patients do not have ownership in and responsibility for their illness. The state of Massachusetts does. It is logical that there would be a rise in costs and overuse. Romneycare creates another uncontrolled entitlement.

The state's health care reform law dramatically reduced the number of uninsured individuals.  At the same time federal, local and state funding for safety-net hospitals was dramatically reduced. In Massachusetts, the thinking was the uninsured, now insured, would go to private facilities for their healthcare needs.

There would be less need for safety-net facilities. The state of Massachusetts could then save money by decreasing funding for these facilities.

Massachusetts’s survey data showed the opposite. The survey of data between 2005-009 found:

  • The number of patients receiving care at Massachusetts Community Health Clinics (CHC) increased by 31.0%,
  • The share of CHC patients who were uninsured fell from 35.5% to 19.9%.
  • Nonemergency ambulatory care visits to clinics of safety-net hospitals grew twice as fast as visits to non–safety-net hospitals from 2006 to 2009.
  • The number of inpatient admissions was comparable for safety-net and non–safety-net  hospitals.
  • Most safety-net patients reported that they used these facilities because they were convenient (79.3%) and affordable (73.8%).
  • Only 25.2% reported having had problems getting appointment elsewhere.

 Our findings indicate that, although health care reform substantially increased the number of people with health insurance in Massachusetts, the demand for services from safety-net facilities (CHCs and hospitals) also grew, particularly for ambulatory care. 

“CHCs have become an even more important source of primary care, perhaps because of increasing difficulty obtaining care from other primary care physicians' offices.”


Surveys are a tool of social science and are not necessarily scientific proofs. They have a tendency to miss important findings within the data.

 The state and federal governments have subsidized 68% of the uninsured. Private physicians’ offices in Massachusetts are overcrowded. The insured now have first dollar coverage. Patients overuse the system by seeking more medical attention raising the costs of care.

In Massachusetts patients have speculated with physicians’ appointment times. Physician appointment times have been sold on the secondary market.

In Massachusetts some insurance reimbursements are so low that physicians do not accept certain insurance policies. Patients then have to go to the safety-net hospitals.

Special reimbursement deals have been made with certain physician groups and hospital systems. The Boston Globe has published these deals in the past.

 The total money spent by the state has increased beyond affordability. The increase is the result of overuse of the healthcare system. Patients have no skin in the game.

Revenue 1 8 11 11

 The losers have been patients, the state and small businesses. The winner is the healthcare insurance industry. 

Americans will see the same results with ObamaCare.

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











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Some of Obamacare’s Complicated Mistakes


Stanley Feld M.D.,FACP,MACE 

President Obama appointed Dr. Donald Berwick as head of CMS during the congressional recess last August. It was my impression it was a one-year appointment. He does not seem to be leaving anytime soon.

 President Obama made this appointment to avoid congressional hearings and the publicity of disapproval.

 Dr. Berwick’s goal for healthcare reform is a single party payer. He also believes in redistribution of wealth. I believe Obamacare will be repealed either by the Supreme Court or the next election.

 CMS’s execution of their initiatives is poor.

 Dr. Berwick believes in increasing bureaucratic structures to administer central control over physicians and their patients by regulations and penalties. 

 Accountable Care Organizations are not a bad idea if they could work. They would increase the measurability of good care. There are too many organizational barriers in the way of execution of ACOs.

Physicians and hospital systems will be fighting with each other over distribution of reimbursement and quality care judgments. Family practitioners and internists will be fighting with specialist over the distribution of reimbursement. I do not believe physicians will be satisfied with a salary determined by hospital systems.

Patients will suffer as access to care decreases. Federal funds will be wasted and the federal deficit will increase further.

ACO’s are in really HMO’s on steroids. Patients were dissatisfied with HMOs in the late 1980s to early 19990s.

The Pay4Performance formula creates penalties and not incentives for physicians and hospital systems. There are no incentives or penalties for patients’ performance.

Health Insurance Exchanges are supposed to be a way to increase insurance availability for patients who are uninsured. It is in really the “Public Option” in disguise. The Exchanges will turn out to be very costly. They will increase the federal deficit as well as state budget deficits.

 The states are objecting to the Health Insurance Exchanges for two reasons. The federal government is trying to shift the economic burden to the states while decreasing state control over of their insurance policies. HHS has even threatened to take total control of the Health Insurance Exchanges. 


Electronic Medical Records remain too costly for physicians. EMRs are not completely functional despite President Obama’s $100 billion dollar subsidy. Most hospitals and physician offices are trying to comply with the government mandate. The subsidy is not enough to purchase the best EMR.

No one has acted on my suggestion to put the ideal EMR software in the cloud and charge hospitals and physicians by the click. A fully functional universal Electronic Medical Record would be available instantly at an affordable cost.

These are some of the layers of complexity. I predict these initiatives will not be fulfilled by 2013. There are too many new things to adjust too all at once. All the initiatives need a reason for total cooperation.

Making things worse is the requirement to use ICD-10 to file claims. 

ICD is a claims coding formula going into its tenth iteration in 2013. It is much more complex than ICD-9.

 “The differences between the two versions are significant. Whereas ICD-9 CM provides approximately 13,000 diagnosis and 3,000 procedure codes, the version of ICD-10 diagnosis and procedure codes to be deployed in the United States are roughly 68,000 diagnostic codes and 87,000 procedure codes.”

 In January 2009, HHS and CMS mandated ICD-10 codes be used by all healthcare plans, providers, and clearing houses for all diagnosis and inpatient procedures effective October 2013. It seems like there would be enough time to adjust. However, healthcare system adjustment will be huge.

“ICD-10 is one key piece to the overall success of the larger puzzle. More granular

Data will better reflect the patients’ condition and help us manage their care better. At least, that’s the idea.”

I do not think ICD-10 will happen in 2013. These initiatives are federal mandates. They have two things in common. They rely heavily on IT, both for transactions and analytics, and they impose significant changes on organizational workflows, specifically those of clinicians.

 Any workload changes are difficult to adjust to. Too many changes at once are lethal to an initiative.  Dr. Berwick’s timing introducing the changes will be lethal to the changes. When this change comes at physicians from so many different angles they become passively aggressive and resist change. 

 ACOs, Electronic Medical Records and Health Insurance Exchanges fulfillment is behind schedule. ICD-10 will also be behind schedule.

 CMS has declared the ICD-10 compliance date will not be moved.

 The vast majority of respondents (72%) believe ICD-10 will have a positive impact on quality in the long term.

• While they see the long-term benefit, many respondents (41%) also believe ICD-10 will strain physician relationships.

 • Most (60%) expect short-term cash flow to be negatively impacted both in terms of project resources and lost revenue. 

• Only a third of the respondents believe payers will be ready by October 2013 and most believe physician cooperation will be their biggest barrier.

 Although the knowledge that ICD-10 is coming has sparked action by healthcare leaders—most (84%) have started their ICD-10 projects—as a group, less than a third (29%) have moved beyond the assessment phase into implementation.

 ICD-10 is creating many levels of complexity to coding. It will require an increased office staff along the care continuum. The staff must learn and use the new diagnostic and procedure codes. It will also require someone to assign appropriate codes that reflect physicians’ notes. Someone will be needed to create an appropriate claim for the medical encounter. ICD-10 will increase overhead as reimbursement decreases. It is naïve to believe the EMR will automatically accomplish this

Unquestionably, ICD-10 introduces an added layer of complexity to the multitude of challenges for physicians and hospital systems that are already at hand as a result of Obamacare.

 ICD-10 puts revenue at risk for the sake of data the government might use misuse.

 I predict physicians will not participate fully. The physician shortage will intensify as more people enter the healthcare system and fewer physicians are available to treat Medicare patients.

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




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Pretenses, Pretenses, Pretenses


Stanley Feld M.D.,FACP,MACE

During the last few weeks I have discussed the problems with Medicare Part
B, D and F.

The problems are the result of abuse of the healthcare system by the various secondary stakeholders protecting their vested interests. The stakeholders use their resources to influence our elected politicians. The peoples’ votes should be their only influence.

Politicians take the money from these various lobbying groups because they need the money to campaign for re-election. Media advertising is not cheap.

“The media exercises its greatest influence during elections . Candidates who lack an effective media strategy are likely to be destined for failure.”

“Candidates routinely spend 80 percent of their “war chests” on television and radio advertising. In larger states such as California, Texas, and New York, television advertising is the only way for candidates to reach the tens of millions of voters. In 2000, political novice John Corzine spent a mind-numbing $60–80 million of his own money — most of it on television commercials — to win a Senate seat in New Jersey.”

These two outstanding sound bites summarize the issue:

“The media is the message. Marshell McCluen.”

‘If you tell a lie enough times, it becomes the truth. Carl Sandberg.”

I can imagine the number of jobs created in advertising and in the media during the election season. The media are not willing to relinquish jobs and revenue for unbiased reporting.

President Obama has already been funding his reelection campaign on the taxpayers’ dime. His goal is to raise $1 billion dollars. The goal of the $1 billion dollars contributed by donors implies the purchase by these donors of political influence to support their vested interests.

The traditional media has not been criticized this practice. Campaign advertising is a large part of the traditional media’s yearly revenue. The media is cautious about criticizing large donors for fear of losing the campaign advertising revenue.

The voices of American voters are being drowned out by special interest money. Millions of dollars are poured into campaigns each election, and the amount continues to climb. Instead of turning to their constituents, members of Congress look to wealthy individuals and businesses to fund their campaigns.

Public Citizen is working hard to change the current system of campaign finance so that members of Congress are responsible to their voters, not to their contributors.  

President Obama has been beholden to these special interests. He has used trick plays to fulfill his obligations to his donors. He has disguised his intentions by claiming he is doing everything for the interest of the little guy.

I have difficulty believing anything President Obama says anymore. I also have difficulty believing Democrats and most Republicans in congress.

The recent raising of the debt limit tied to deficit reduction is a case in point.

It is a total fake.

Let us assume a person makes $50,000 a year. He spends $150,000 a year. That means he spends $100,000 a year more than he makes. He must go to the bank to borrow the $100,000.

Will any bank lend him $100,000?  No! He would have to prove how he would pay the $100,000 back.

He promises the bank he will reduce his “deficit spending” of $100,000 by 10% a year over the next ten years. That means that next year he will spend $90,000 more than he earns. He will only have to borrow $90,000.  In ten years I would increase his deficit by 680,000 rather that the 1,000,000 if he did not promise to decrease his deficit spending by 10% a year for 10 years. The banker would still say no.

The United States is not decreasing its deficit or balancing the budget with this latest deal. It is increasing the deficit will decreasing the “deficit spending.” The net effect is creating more debt.

 Why the deal is a fake. President Obama and the congress are not interested is being serious about being fiscally responsible. President Obama has faked out the American public once again.

There are many things government can do for the American public.  Everyone would agree that corporate interests, if given a chance, would take advantage of the public’s interest and the government. The government must protect the public from corporate interests and itself.

It can be accomplished by aligning corporate interests with the public’s interests. The use of force and penalties (price controls) always fail.

An example is food inspection and the Cargill turkey scandal. How are the complex food safety regulations enforced? They were not enforced in the turkey scandal. The inefficiencies and possible corruption that exist in government bureaucracy made the regulations impossible to enforce.

Did the government correct the deficiency? I think not. Last year’s hamburger scandal should have created the incentive and opportunity to correct the deficiency.

Would the pharmaceuticals companies step out and not sell the antibiotics to Cargill? They have not.

How does this relate to the dysfunctional healthcare system?

Why is Medicare so expensive and healthcare costs rising so fast?

Growth of Medicarice. 8 4 2010png

 Physician fees are not rising. Why penalize physicians? Healthcare insurance fees are rising. Bureaucratic infrastructure is increasing, as it is becoming less efficient. As this is happening the waste, fraud and abuse is mounting.

The only way to get out of the healthcare mess is to let consumers own, control and be responsible for their healthcare dollars. Social networking will be the driver of consumers’ demand for independence from government control.

The government bureaucracy’s role must be to create appropriate rules to protect the consumers from abuse.

The conundrum is the government’s bureaucracy is the biggest part of the problem

Government must also create educational programs to help consumers make wise choices.

 Consumers should be given incentives to make wise healthcare decisions.  

Increased government control will only create a bigger government mess.

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


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Easy Things to Do To Fix Medicare Part D


Stanley Feld M.D.,FACP,MACE 

Twenty seven million individuals were enrolled in Medicare Part D as of December 2009. The government spent $51 billion to subsidize Medicare Part D in 2009. The $51 billion dollars spent is in addition to seniors’ premiums and co-pays. The government subsidy was $1,889 per individual subscriber. 

Who is making the money?

 “A provision in the Medicare Modernization Act (MMA), known as the "noninterference" provision, expressly prohibits the Medicare program (the government) from directly negotiating lower prescription drug prices with pharmaceutical manufacturers.”

 This was a gift to the healthcare insurance industry by the government as a result of intense lobbying efforts. 

Over 300 private plans (Medicare Plan D sponsors) enter into negotiations with pharmaceutical manufacturers separately to deliver Medicare Part D benefits.

Medicare Part D eligible seniors are forced to deal with an overwhelming number of private plans with varying formularies, premiums, deductibles, and co-pays in order to receive prescription drug coverage. The differences in prices are available but it is difficult to make comparisons.

The government negotiates directly with the pharmaceutical manufactures for the VA system. The VA system pays 42% less than Medicare plans for prescription drugs. The high volume contracts save money for the government and are lucrative to the pharmaceutical companies.

The various Medicare Part D plans cover about 85% of the most popular 200 drugs on average. The VA’s national formulary covers 59% of the most popular 200 drugs.

If Medicare Part D negotiated the same drug prices as the VA, the government would be able to decrease its subsidy $510 per beneficiary per year or a total of $14 billion per year (2009 prices).

Research by respected economist Dean Baker shows that the federal government and Medicare beneficiaries would save $600 billion between 2006 and 2013 if Medicare were allowed to directly offer a Part D benefit and to negotiate prices with pharmaceutical manufacturers. 7Such significant savings could be used to close Part D's donut hole and to lower cost-sharing for Medicare beneficiaries.

There are reasons for the twenty-six percent difference in formulary. Either the government-negotiated prices are too expensive and deemed marginally more effective than the drug ordered or the less expensive drug is determined to be just as effective. 

The judgment is made by the procurement system that negotiates price.

Is the cheaper drug as effective for a particular patient? This decision should be made by the patients’ physicians and patients and not by bureaucrats. It should be the patient’s choice to pay the difference. 

The procurement systems bureaucrats could be wrong.  

If the government negotiated for all the Medicare Part D participants the government’s purchasing power should be greater than the VA system. Its negotiated price would be better. The savings should reduce the government’s Medicare Part D subsidy significantly.

President Obama sort of understood this concept. He included the government’s right to negotiate drug prices in his Healthcare Reform Act. He subsequently removed the provision from his Healthcare Reform Act in exchange for the healthcare insurance industry’s and the pharmaceutical industry’s support of “Obamacare.” Seniors and the Medicare Part D program have lost.

It is obvious that there is much fraud, waste and abuse in Medicare Part D. February 2011; the Government Accounting Office published an example of CMS bureaucratic inefficiency and waste.

The Government Accounting Office (GAO) has designated Medicare as a high-risk program. The size, nature, and complexity of the Part D program make it particularly vulnerable risk to fraud, waste, and abuse. The GAO and the Inspector General of HHS requires all Part D sponsors (healthcare insurance industry) to have programs to safeguard Part D from fraud, waste, and abuse.

 CMS is responsible for managing and overseeing the Part D program. CMS regulations require Part D sponsors to have compliance plans that must include measures that detect, correct, and prevent fraud, waste, and abuse. 

 Congress asked the GAO to examine the extent of CMS's implementation of the oversight of Part D sponsors' (healthcare insurance industry) compliance programs to avoid fraud and abuse.

  CMS bureaucrats have written extensive documents containing many rules and regulations to combat waste, fraud and abuse.  CMS then outsources the Medicare Part D audit to Medicare Drug Integrity Contractors (MEDICs) to support its Medicare Part D audit efforts.

 The 2010 audit was supposed to be finalized in early 2011. It has not been completed as of July 30,2011.

CMS officials reported that they conducted only 33 audits out of 290 Medicare Part D sponsors (Healthcare insurance industry) in 2010.

“The 33 sponsors represented 11 percent of Part D sponsors, 56 percent of plans, and covered 62 percent of enrolled beneficiaries in 2010 according to agency officials. As of February 2011, CMS had not made all audit findings available but had taken formal enforcement actions against several sponsors resulting from the on-site audits according to agency officials.”

 “As of December 2010, officials reported that the agency had issued five marketing and enrollment sanctions and one contract termination action based, in part, on the results of these audit findings noting failure to comply with CMS compliance plan requirements.” 

 It is hard to imagine how many deficiencies exist among the other 257 Medicare Part D sponsors not yet audited. How long should these audits take? How severe will the penalties be? How can seniors know if their Part D plan is sound?

CMS has not been able to audit or enforce its own regulations that are suppose to protect seniors from fraud and abuse efficiently and effectively.

What can possibly go wrong with ‘Obamacare” with 256 new bureaucratic agencies and many thousands of new regulations?

The only healthcare system that could work is a consumer driven healthcare system with alignment of all the stakeholders’ interests.

Unfortunately, that is not going to happen anytime soon. Seniors are starting to take things into their own hands.

After investigating several Canadian pharmacies, my wife and I paid $624.77 for a three-month supply of drugs at an online Vancouver registered pharmacy. These same drugs cost us $1,208.04 buying at Walgreen's, Target, and Kmart where we shopped for the lowest prices.”

"What's the catch? If Big Pharma had its way, customs and the FDA would be confiscating all imported drugs, crying that the government can't guarantee their safety."

"But that just isn't the case. Your pharmaceuticals come in the same sealed packages you get at your corner drugstore."

"Anyway, it would be politically incorrect to arrest grandma for trying to make ends meet. Some members of Congress even encourage the practice by listing Canadian pharmacies on their Web sites."

The Wal-Mart $10 prescription fee for generic drugs also works if your physician accepts generic substitution. 

A reader sent me a link to a website.

 I reviewed the web site. It is based in San Francisco. The site offers large discounts on branded and generic medication. It is much less expensive than Medicare Part D. Senoirs could afford to buy the medication without using up credits toward the donut and use Medicare Part D only when needed.

It is going to take proactive approaches by seniors (consumer driven) to force the government to serve their vested interests and not the vested interests of the healthcare insurance industry and the pharmaceutical industry.

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







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