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Obamacare: Its Failure Increases

Stanley Feld M.D.,FACP,MACE


C-Span has provided the public with important lessons on how our government is really run by televising various congressional committee meetings.

The traditional mainstream media provides us with little of the important information that comes out of these committee meetings.

C-Span’s coverage has revealed how inefficient, political and bureaucratic our government is.

Americans should elect representatives to be our spokesmen. Our representatives should do what is right for us and not for the vested interests of various special interest groups.

The latest information about Obamacare has not been reported in the media but came out in committee.

The Obama administration had announced publicly to a subcommittee in April 2014 that its "risk corridor" plan would be revenue neutral.

In English, it means that there would be no extra taxpayer dollars available to cover the losses of the healthcare insurance companies. Those healthcare insurance companies insure enrollees through the government’s healthcare insurance exchanges.

Chet Burrell, head of Maryland insurer CareFirst told Valarie Jarrett this plan would result in premium increases of 20% or more later this year as Obamacare policies come up for renewal. 

He warned it would be "an unwelcome surprise" to the Democratic Party and Democrats running for reelection in November.

The Obama administration was very concerned about a 20% premium increase for enrollees in Obamacare. After a while, Ms. Jarrett assured Mr. Burrell the insurance industry would get 80% of the subsidy (bailout) they sought.

The 80% was granted by executive order without congressional approval. A few weeks later the healthcare insurance industry bailout was changed to almost 100% of the request with little notice from anyone.

The government guarantee affects all of the enrollees in Obamacare. It also permits the increase in private insurance plans.

There are 50 million people on Medicare, 65 million people on Medicaid, 9 million in the VA system, 7.3 million in Obamacare and an additional 149 million for employer-provided healthcare insurance.

It turns out that Obamacare is just another government subsidy program with the government throwing more money at the health care insurance industry while the healthcare insurance industry raises the premiums.

President Obama, by executive order, has created an unlimited Obamacare reinsurance program covering the healthcare insurance industry’s supposed losses.

According to some, the total subsidy to the healthcare insurance industry is $1.3 trillion dollars.

It’s no surprise that many more healthcare insurance companies are planning to participate in President Obama’s health insurance exchanges.

If a healthcare insurance company sells insurance without risk it is a great deal. Taxpayers are assuming the risk for the insurance companies. Some insurance companies are decreasing their rate to capture a larger market share. They will  cash in on the Obamacare subsidy.

This subsidy is a mistake. It adds little value in improving the nation’s health. President Obama does not seem to care about how much money he is wasting.

It is all about politics. 

The subsidy adds much political value to Obamacare because it postpones the 20% premium increase at this midterm election.

Bob Laszewski, a policy wonk and former insurance executive said,

 “The administration has succeeded in temporarily suppressing incipient Obamacare price hikes, contributing to an illusion of Obamacare sustainability.”

However, the healthcare insurance industry is finding it necessary to increase premiums an additional twenty percent despite the tremendous subsidies. This is the result of the enrollees who acquired insurance but did not pay the premiums and used the services and the terrible demographic distribution of enrollees who paid their premium.  Eighty-five percent of the people who paid premiums were high risk patients with pre-existing illnesses. 

The rules of Obamacare have turned out to be totally improvised. The Obama administration changes the contents of the law in order to keep it afloat without the approval of congress.

The plot thickens. A challenge is in the courts right now on whether the government health insurance exchanges are allowed to provide subsidies to enrollees.

The law specifically states that tax credits are only available through the state health insurance exchanges and not the federal health exchange.

Funny things are going on in the courts. One panel said yes, the subsidies may be provided by the federal health insurance exchanges. The D.C. panel of three judges said no.

Attorney General Holder appealed to the D.C. court of appeals. He wanted the judgment determined by the entire panel of 9 judges not a subpanel of 3 judges.  The 3 judges’ decision was overruled by the 9 judge panel.

I still do not understand how tax credits are given to people who do not earn enough to apply a tax credit to their income tax. Why do they receive a subsidy? They pay no federal income tax.

I hope Americans wake up soon to the fact that Obamacare is deeply flawed and cannot work. The only thing that will overturn it will be an overwhelming taxpayer protest.

This midterm election cycle is a good place for voters to start. A Republican majority of the senate might be able to stop Obamacare in its tracks.   

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

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A Bogus Attack For A Political End

Stanley Feld M.D., FACP, MACE

The New York Times continues to be a mouthpiece for the Obama administration. I suspect the editorial board thinks the only thing that will save the healthcare system in America is a government controlled single payer system.

This is President Obama’s goal even if he has to destroy the medical care system.

On September 20th, 2014 the front page top right hand column article in the Sunday New York Times was  After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know appeared.

In the past the New York Times reserved this spot for the most important story of the day.

This story was the most important news story on Sunday September 200h 2014. The Times thought it was more important than a story about the economy, ISIS, the mid-term elections, Israel, Hamas or Iran’s nuclear ambitions. 

The story intended to inflame the New York Times’ readers so they would be angry at the medical profession.

The problem is that the story is peppered with misinformation and disinformation.

The New York Times writer used a typical Saul Alinsky tactic. Her goal was to prevent the opponents of the story from responding intelligently. 

Public opinion will be on her side because the New York Times is supposed to be a credible source.

Saul Alinsky’s rules instruct one to lie if necessary. The next step is to frighten consumers into thinking the system under attack cannot work.

Before his three-hour neck surgery for herniated disks in December, Peter Drier, 37, signed a pile of consent forms.”

Peter Drier did not read or modify the consent forms. He should have made the   hospital and his doctor liable for any unauthorized expenses, providers, or events.

Peter Drier is a bank technology manager. Banks have their own small fine print intended to keep consumers liable and uniformed.

Peter Drier should have modified the consent forms before he signed them. He can refuse to authorize treatment or payment to any provider or procedure performed in the hospital that was outside of his insurance network.

In Network providers have to agree to accept the negotiated fee. If they need an additional provider it must be a provider that will accept the negotiated fee of his insurance company.

A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee.

Every consumer should find out if their providers are in their insurance network .  

All of those prices are ridiculous retail prices. The real question is how much did his insurance company pay and how much is he liable for.

Peter Drier did not do a very good job in researching his insurance company’s coverage. A third party payer would never approve a $56,000 payment to the hospital for the proposed procedure.

Hospitals bill very high retail prices. They will negotiate a price that is 50-90

5 lower than the retail fee.


The author, ELISABETH ROSENTHAL, has a list of recent articles criticizing the healthcare system about exorbitant retail pricing. 

  • COLONOSCOPY: Colonoscopies Explain Why U.S. Leads the World in Health Expenditures
  • PREGNANCY: American Way Of Birth, Costliest In The World
  • JOINT REPLACEMENT: In Need Of A New Hip, But Priced Out of the US Market
  • HOSPITAL PRICES SOAR: A Stitch Tops $5000

All of these articles criticize the retail price providers charge. They do not tell the reader what the providers receive as reimbursement by the government or the healthcare insurance company.

Consumers are the victims of the constant effort to try to reduce healthcare costs and stick consumers with the bill.

Obamacare has driven the healthcare insurance industry to raise premiums and decrease coverage in order to cover their supposed actuarial risk.

The decreased reimbursement by the healthcare insurance industry has driven providers to increase their fees for service. The hope is to occasionally catch a consumer who is uninsured and liable for the fee.

The uninsured consumer cannot afford the fee and therefore will not pay the fee. The provider then has to sue the consumer to collect whatever they can. The cost of the suit is not profitable for the provider. He usually writes off a loss.

President Obama and the government control advocates will use the resulting chaos in the marketplace to prove that a free market for healthcare system does not work. Therefore the country needs a government controlled single party payer system.

The problem with these horror articles is they frighten consumers. They do not address the reason that the healthcare industry costs $2.7 trillion dollars a year.  

The chaos in the marketplace is the result of the government (Obamacare) involvement into the free market system.

I am also not sure if the $2.7 trillion dollars is from retail charges or negotiated payments. The answer to the question is totally opaque.

The reasons for the increasing costs are many.

Americans are becoming less healthy because they are not being responsible for their health. It is hard to maintain weight when almost every restaurants main dish is higher than their daily caloric allotment. 

470 cal 9 24 2014

1200 cal 9 24 2014 jpg

The result is an obesity epidemic. Over 50% of Americans are Obese.

Obese individuals have a 40% increased incidence of chronic disease.

Eighty percent of the healthcare dollars spent are spent on treating chronic diseases and the complications of those chronic diseases.  

Controlling a chronic diseases can decrease the complication rate of those diseases by at least 50%.  

If we ran the numbers we could reduce the healthcare costs below one trillion dollars a year.

Everyone complains about the grotesque profits the healthcare insurance companies make. Everyone understands the profits result from the inflated bureaucracies and double payments made to segments of the bureaucracy.

If one insurance company wanted to be competitive it would lower its premiums and overhead. All the other insurance companies would do the same to stay competitive.

One has only to look at the cell phone industry. Not only has the cost of the cell phones been lowered but monthly charges are continually decreasing.

One should also look at what ITunes did to the music industry.

Look at what Dr. Keith Smith’s surgical center model is doing to the local hospitals’ costs for surgery in Oklahoma City. They are falling precipitously.

The government should stop feeding the public disinformation leading to confusion of the facts..

President Obama's goal is to destroy the medical system so that consumers will believe the only thing that will work is a government controlled single party system.

Single payer systems throughout the world have proven to be unsustainable.

The healthcare system is dysfunctional. Medical care has been distorted at the consumers’ expense and for the profit of the profit of the healthcare industry.

America has to become innovative and build a healthcare system to the advantage of the consumer.

The solution 

 Is about consumers becoming aware.

 Is about leadership.

 Is about innovation.

 Is about consumers being responsible for their health and their healthcare dollars.    

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

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Keeping Obamacare’s Failures Out Of The News

Stanley Feld M.D.,FACP, MACE

The Obama administration has tried its best to keep Obamacare’s failures away from the people. However, it has been almost as difficult as putting toothpaste back in the tube. The reasons are clear to me.

People are paying attention now because most are personally affected by the failures of Obamacare.

These failures along with President Obama’s other policy failures such as the IRS scandal, Benghazi scandal, Fast and Furious, border control failures, immigration failures, foreign policy failures, NSA privacy intrusions and his lying about those intrusions, attempts at Internet takeover, and unconstitutional unilateral changing of laws through executive orders have lead the American people to lose confidence and trust in whatever President Obama and the Obama administration say.

The traditional mass media has tried mightily to protect President Obama. They have tried to help him keep Obamacare’s failures out of the news.

They have been unsuccessful. If our only source for news was the traditional news media we could be fooled.

Americans must work to stay informed in order to maintain our freedoms.

I will list some of Obamacare’s failures of the last few months.

These failures have had little coverage in the traditional media.  Obamacare has continued to move forward to hobble and then destroy the medical care system in America.

President Obama’s goal is to prove that a free market healthcare system does not work. He has disregarded the fact that the healthcare system is not a free market system.

In a recent blog I presented the reasons for physicians’ discontent with Obamacare.

Survey of Physicians And Their Discontent

In July 2014 the “Physicians Foundation” published a survey sent to 660,000 physicians. Twenty thousand physicians completed the survey.

“Forty-six percent of doctors give President Obama's healthcare law a "D" or an "F," according to a new survey from the Physicians Foundation. In contrast, just 25 percent of those surveyed gave the law an "A" or a "B."

A large number of physicians complained about the vast new bureaucracy that has been added to the medical profession.

A physician comment read, "I'm a Canadian physician practicing in the United States. The politicians and policy makers need to understand that government involvement in healthcare never works."

The only newspaper that reported the survey to my knowledge was the Washington Examiner.

Enrollment Failures

President Obama and his administration are playing a numbers game with the enrollment figures. His March 31,2014 figures were inaccurate. The figures were grossly inflated.

President Obama said on March 31st, "this thing is working” successfully. President Obama claimed that 8 million enrolled in Obamacare.

“At a hearing Thursday September 18, 2014 at House Oversight and Government Reform Committee, Marilyn Tavenner, head of the Centers for Medicare and Medicaid Services, finally confessed that 7.3 million were enrolled in ObamaCare plans as of mid-August.”

The 7.3 million figure is also fiction. At least 115,000 additional enrollees have not validated their citizenship or legal status.  The validation must be completed by September 30,2014.

An additional 360,000 could lose their Obamacare subsidies because of discrepancies over their income. Eighty-five percent of the enrollees are receiving government subsides for healthcare coverage.

Most do not pay taxes because they make less than forty thousand dollars a year. They will not be able to afford the overpriced premiums.  

How many of the 8 million have not continued to pay the premiums? No one knows or is telling. Enrollees have a three-month grace period.

California reported in late August that an additional 100,000 of those who enrolled through its state-run exchange were at risk of losing their coverage over citizenship issues.

By my calculations less than three million of the forty-eight (48) million people who were uninsured pre Obamacare became insured. An additional 7 million people lost their healthcare insurance in the individual market.

President Obama provided the American public with a grossly overestimated enrollment figure.

Ms. Tavenner had to put a positive spin on this latest revelation of the fictional enrollment numbers by saying,

 "We are encouraged by the number of consumers who paid their premiums."

No one is buying this explanation.

She didn't provide answers to important details for these latest enrollment figures.

  • How many who dropped out were young and healthy?
  • How many have signed up through the so-called special enrollment process?
  • How many are keeping up with premiums?
  • How sturdy are the back-office computer programs in order to detect enrollment misinformation?
  • How will the government collect the money due to it from these non-paying enrollees?
  • Is the November 15th open enrollment period going to go smoothly?


Next Open Enrollment Disaster

It is easy to see that President Obama has delayed the open enrollment time from October 15th to November 15th for political reasons. He wants the potential disaster to occur after the mid-term elections.

 Kevin Counihan, the former chief executive of Access Health CT, Connecticut’s online marketplace, was just named head of the insurance marketplaces for the federal government.

 He said, “Part of me thinks that this year is going to make last year look like the good old days.”

 The front end of the web site looks like it will run smoothly. The back end of the web site still needs work. The government is still trying to see if the links to the IRS, the healthcare insurance industry and social security are functioning properly.

There were not enough healthy young subscribers to keep the insurance rates low. The premiums were too high for many young and healthy uninsured people.

This year the healthcare insurance premiums will be up at least 20%. Healthcare insurers fear it could be even more difficult to sign up young healthy people than it was last year.

Adding to the problem is that the sign up period for choosing a new policy this year will be shorter than last. It will be 3 months instead of six months.

President Obama will probably break the law again and extend the signup period an additional 3 months.

This year it should be more difficult to receive subsidies than last year.

People will drop out of the pool because of the increase in insurance rates. The renewal procedure has not been worked out yet.

Andrew Slavitt, principal deputy administrator for Medicare said they are working hard to make the process as easy as possible.

“We’re putting in place the simplest path for consumers this year to renew their coverage.” 

 This is another Obamacare smokescreen.

I predict it will be a price disaster.

Obamacare And Zeke Emanuel Setting Us Up For Rationing

One of the most bizarre articles imaginable was Zeke Emanuel’s article in the Atlantic Monthly  “Why I Hope to Die at 75”

Dr. Emanuel, one of Obamacare’s authors, gives all the reasons why he doesn’t want to live past 75 years old.

His argument is why should you live longer since you probably are not useful to society.

You have contributed all you are going to contribute. After 75 years old affliction will accumulate and disabilities will make life less pleasant.

It is apparent to me that he is setting us up for government rationing of healthcare for seniors.

The government controls Medicare. It is cheaper for the government not to pay for procedures such as hip replacements, knee replacements, for coronary artery surgery or cardiac pacemakers. All these procedures will extend the life of seniors over 75 years old who need them.

We have also heard rumors that this bureaucratic thinking is already in progress.

Don’t we live in a free country?

Isn’t it up to individuals to make their own life decisions? 

Should we leave these decisions up to the government and bureaucrats?

Should they decide our choose of treatment for us?

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

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The Practice Of Medicine Is Becoming Less Enjoyable

Stanley Feld M.D.,FACP,MACE

I think everyone got Dr. Mark Sklar’s message in "Doctoring in the Age of ObamaCare" If anyone did not get his message I suggest you read his article again.

The practice of medicine is becoming more difficult for all the reasons Dr. Sklar outlined. It has become difficult because of Obamacare’s new rules and regulations.    

Nine of ten practicing physicians discourage their children and others from going into medicine.

Increasing numbers of practicing physicians are depressed. Three to four hundred physicians will commit suicide this year. Many physicians are retiring early.       

“Simply put, being a doctor has become a miserable and humiliating undertaking. Indeed, many doctors feel that America has declared war on physicians—and both physicians and patients are the losers.”

The medical profession has lost status in the eyes of the public in the last 50 years.

Physicians were the pillars of any community. If you were smart and sincere and ambitious, at the top of your class, there was nothing nobler or more rewarding that you could aspire to become.

Medicine has become just another profession. Physicians have become insecure, discontented and anxious about the future of medicine. Obamacare has intensified that insecurity.

In surveys and articles that appear in many newspapers and online blogs the majority of physicians express diminished enthusiasm for medicine.  

“American doctors are suffering from a collective malaise. We strove, made sacrifices—and for what? For many of us, the job has become only that—a job.”

Many physicians young and old are looking for an exit strategy. Many medical students go into higher-paying specialties such as radiology and anesthesiology so they can retire as quickly as possible.

  • “Non-primary care doctors earn on average 65% more, or $116,000 more each year, than do primary care doctors (pediatricians, family medicine doctors and internal medicine doctors).”
  • Physician MBA programs permit physicians to leave their practice and go into management. These physician executive programs are flourishing.

         The Drop-Out-Club, which hooks doctors up with jobs at hedge funds and venture capital firms are also growing.

Patients need contented physicians. They do not need discontented or depressed physicians. They do not need physicians who are compelled to practice defensive medicine in order to avoid malpractice suits.

They do not need a government that relies on healthcare policy advisors with no experience in the practice of medicine to create policies. The healthcare policy advisors try to shift control from individual consumers to the government and the healthcare insurance industry.

These physicians’ feelings are stated thousands of times by physicians in the pits. No one is interested in listening because the media is the message.

Politicians and the healthcare industry have employed a methodical campaign to devalue physicians and physicians’ medical care in order to control the healthcare system.

The traditional mainstream media keeps on reporting that physicians are money grubbing crooks who do not care for patients. The traditional mainstream media believes that information technology is the key to straightening out our dysfunctional healthcare system.

The government and the traditional mainstream media are feeding consumers nonsense. 

Has anyone ever experienced an efficiently run government agency?

The government is inefficient. It is being taken advantage by the healthcare insurance industry and hospital systems at taxpayers’ expenses while adding little value to the medical care system. 

 Consider what one doctor had to say on Sermo, the online community of more than 270,000 physicians:

"I wouldn't do it again, and it has nothing to do with the money.

I get too little respect from patients, physician colleagues, and administrators, despite good clinical judgment, hard work, and compassion for my patients.

Working up patients in the ER these days involves shotguning multiple unnecessary tests (everybody gets a CT!) despite the fact that we know they don't need them, and being aware of the wastefulness of it all really sucks the love out of what you do.

I could have made my living and been more fulfilled.

The sad part is we chose medicine because we thought it was worthwhile and noble, but from what I have seen in my short career, it is a charade."

Consumer recognition of this physician’s discontent is new. Physicians have been pointing it out for years.

 The medical profession has not had an effective voice to make this discontent clear.

Consumers of healthcare are starting to listen because it is affecting them directly and they do not like it.

Maybe a consumer driven protest will occur in order to get legislation passed to restore the patient physician relationship.

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

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I Am Not The Only One

Stanley Feld M.D.,FACP,MACE

Readers ask if I think practicing medicine is becoming more difficult because of Obamacare.

 My answer has been it is becoming impossible to practice medicine. The overwhelming bureaucratic rules and regulations are becoming too difficult to understand and even harder to execute.

Patients will suffer the most because of the disappearance of a physician-patient relationship. Patients are being converted from patients to commodities.

Why don’t more physicians protest? Why don’t they describe their problems in the age of Obamacare?”

There are complex reasons that there has not been an organized physician outcry.

Organized medicine (AMA) and other organizations representing specialties in medicine and surgery are afraid to lead an outcry. Their main goal is to not lose their seat at the table.

This is strange goal. Politicians and their health policy advisers have ignored organized medicine for the last 50 years. Many smart physicians in or out of these organizations have tried to have their voice heard but have failed.

Since Medicare was passed (the last 50 years) there have been many outrageous changes proposed by non-physicians The healthcare policy changes were proposed to decrease the increasing cost of healthcare. Instead these changes have increased the cost of care.



The politicians and healthcare policy advisers are always changing the wrong policies. They are always putting more power into the government bureaucrats and healthcare industry’s hands rather that putting power into the patients’ hands.

Physicians who have seen these policy changes work out for their benefit are hesitant to participate in an Obamacare protest. These physicians assume Obamacare will also work out well for them

However, physicians do not realize that their intellectual property and surgical skills have been devalued with each of the present changes in healthcare policy.

In a 2006 blog I described how to cook a frog without the frog jumping out of the pot water. Everyone knows that you increase the temperature of the water one degree at a time. When the frog realizes what is going on he is too weak to jump out.

Obamacare has increased the temperature of the water to an intolerable level. At present few frogs have the energy to jump out of the water.

Most of the changes in Obamacare are going hurt patients by decreasing access to care and rationing of care. The physician/patient relationship has also been destroyed.

Dr. Mark Sklar, a Clinical Endocrinologist in Washington D.C., had enough energy to jump out of the hot water. He launched his protest in an excellent article and got the attention of the editors of the WJS.

My hope is Dr. Sklar’s article will launch a consumer protest demanding that a change be made from Obamacare to a healthcare system that will empower consumers.

The new healthcare system should be a consumer driven healthcare system that puts consumers in control of their health and healthcare dollars. The control of the healthcare system should not be in the government’s or the healthcare insurance industry’s hands.

A consumer driven healthcare system should provide incentives to consumers to remain healthy, and provide financial reward if they do. It should also make shopper of consumers.

A consumer driven healthcare system will drive the other stakeholders into a competitive mode to vie for the business of the consumer.

The financial reward should be for consumers, not to the healthcare insurance industry, government, hospital systems or physicians.

I want to echo Dr. Sklar’s protest. I will try to help Dr. Sklar  make his article  a wake up call for consumers.

Consumers are the only stakeholders that can turn the destruction of the medical system around.

Consumers elect politicians. Politicians like the advantages and perks they receive from their elected positions. Politicians are afraid of the consumers that vote to reelect politicians. They will comply with their voters demands.

Below is Dr. Sklar’s article listing most of the issues that are making the delivery of healthcare very difficult.

"Doctoring in the Age of ObamaCare"

"Endlessly entering data or calling for permission to prescribe or trying to avoid Medicare penalties—when should I see patients?


Sept. 11, 2014 7:35 p.m. ET

‘It has been four years since the passage of the Affordable Care Act, so I thought it may be useful to provide the perspective of a physician providing daily medical care. I am an endocrinologist in Washington, D.C., and have been in solo private practice for 17 years after seven years at an academic institution. Since 1990, the practice of medicine has changed significantly, seldom for the better.

In the 1990s insurance companies developed managed-care plans that greatly increased their profits at the expense of the physician. With the Affordable Care Act, we are seeing new groups profiting from changes to the health-care system. Entrepreneurs and hospital executives are capitalizing on organizing physicians into groups called Accountable Care Organizations from which they will take a very substantial percentage of collected income. Now that physicians are being required to use electronic medical records, the companies that develop them are harvesting money from physicians' practices and from hospitals.

The push to use electronic medical records has had more than financial costs. Although it is convenient to have patient records accessible on the Internet, the data processing involved has been extremely time consuming—a sentiment echoed by most of my colleagues. To save time, I was advised by a consultant to enter data into the electronic record during the office visit. When I tried this I found that typing in the data was disruptive to the patient visit. My eyes were focused on the keyboard and the lack of direct contact kept patients from opening up and discussing their medical and personal problems. I soon returned to my old method of dictating notes and pasting a print-out of the dictation into the electronic record.

Barrier between patient and physician
 David Klein

Barrier between Patient and Physician

Yet to avoid future financial penalties from Medicare, I must demonstrate "meaningful use" of the electronic record. This involves documenting that I covered a checklist of items during the office visit, so I spend 90 minutes each day entering mostly meaningless data. This is time better spent calling patients to answer questions or keeping updated with the medical literature.

If electronic records ever allow physicians to obtain data from previous laboratory and imaging testing, it will improve costs and patient care. So far, however, the data in electronic records—like paper charts—can't be shared unless physicians work in the same health-care system.

My practice quickly adopted the new Medicare requirements for electronically prescribing medications. Yet patients often do not want their prescription sent electronically. They want a physical copy—either because they don't trust the Internet or because they don't need to fill the prescription immediately. If I don't electronically prescribe for a certain number of Medicare patients, I am penalized with a decrease in reimbursement that can rise to a maximum of 5%. Patients should have a choice in how their prescriptions are delivered, and physicians shouldn't be penalized for how the patients choose.

To prevent physicians from prescribing more costly medications and tests on patients, insurers are increasingly requiring physicians to obtain pre-authorizations. This involves calling a telephone number, often being rerouted several times and then waiting on hold for a representative. The process is demeaning and can take 30-45 minutes. Rather than having physicians pre-authorize expensive medications, the outrageous costs of many non-generic medications must be addressed. I understand that pharmaceutical companies need to make profits to cover investments in drug development. However, they should have some compassion for their customers.

To avoid Medicare penalties, I also must participate in the Physician Quality Reporting System program. Initially, this involved choosing three codes during the patient visit to reflect quality of care, such as blood pressure or blood-sugar control, and reporting them to Medicare. In 2015, the requirement will increase to nine codes.

Coming down the pike, but thankfully postponed from the October 2014 deadline, is something called ICD-10. This is a newer system that will contain about 70,000 medical diagnostic codes used for billing insurance. The present ICD-9 system has about 15,000 codes. The Physician Quality Reporting System and ICD-10 requirements are intended to benefit population research, but the effect is to turn physicians into adjuncts of the Census Bureau who spend time searching for codes—and to further decrease the amount of direct contact with patients.

The practice of medicine in the current environment is unsustainable. The multiple bureaucratic distractions in my day consume so much time that I have to give up what little personal time I have in the morning, evening and on weekends if I want to continue to provide excellent care during office hours.

If high-quality medical care is the goal, the bureaucracies need to be tamed. Our government and insurance companies understandably want to measure outcomes of health-care dollars spent. However, if the health-care system rewards data entry, that is what it will get—the quality of care seems an afterthought.

The patient should be the arbiter of the physician's quality of care. Contrary to what our government may believe, the average American has the intellectual capacity to judge. To give people more control of their medical choices, we should move away from third-party payment. It may be more prudent to offer the public a high-deductible insurance plan with a tax-deductible medical savings account that people could use until the insurance deductible is reached. Members of the public thus would be spending their own health-care dollars and have an incentive to shop around for better value. This would encourage competition among providers and ultimately lower health-care costs.

By contrast, the Affordable Care Act's plans for establishing "medical homes"—a team-based health-care delivery model—and accountability-care organizations will only add more bureaucracy and enrich the consultants and companies organizing these entities.

To improve quality, we need to unchain health-care providers from the bureaucracies that are strangling them fiscally and temporally. We can better control medical costs if we strengthen physicians' relationships with their patients rather than with their computers.”

“Dr. Sklar is an assistant professor of medicine at the Georgetown University Medical Center and at the George Washington University Medical Center.”

I hope all the consumers of healthcare can feel the pain physicians are experiencing in delivering care on their patients behalf because of Obamacare.

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

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When Will We Ever Learn

Stanley Feld M.D.,FACP,MACE

When will President Obama ever learn?

His ideology blinds him to the facts. I vividly remember him telling John Kerry and Barney Frank not to worry about not having a Public Option.

Barney Frank said we need a Public Option for the Affordable Care Act to work. The only way Obamacare could work is by ending up with a single-payer system.



President Obama had a clandestine “Public Option” built into Obamacare.  

Progressives believe deeply in their ideology. They do not consider past history, present reality or facts. 

All progressives have to do is look at what is happening to socialized medicine all over the developed western world.

It is failing even as some people believe it is succeeding.

 The Commonwealth Fund (a private progressive foundation) with a focus on healthcare is certain that a single party payer system is the only viable healthcare system.

The report ranked healthcare systems throughout the developed western world.  In its published ranking the National Health Service of Great Britain was considered the best medical system among the 11 of the world's mostadvanced nations, including Canada, France, Germany, Switzerland and Sweden.

 The United States came in last.

 Few have the time or patience to read the complete report or pick out the defects in the study.

Most people reads the summary. The summary in this study is not close to the evidence presented.


The Commonwealth Fund’s rankings of countries are contradicted by objective data about access and medical-care quality in these countries in peer-reviewed academic journals.

The Commonwealth Fund’s methodology is defective. Its conclusions relied heavily on subjective surveys about "perceptions and experiences of patients and physicians."

Kenneth Thorpe made an important point by examining differences in disease prevalence and treatment rates for ten of the most costly diseases between the United States and the ten European countries with a single payer system.

He used surveys of the non-institutionalized population age fifty and older. Disease prevalence and rates of medication and treatment are much higher in the United States than in these European countries.

Why would that be?

There are many reasons for this finding. The main one is the availability of care in the United States compared to the ten socialized western countries.

Another is lifestyle and incidence of obesity in the United States. Both lead to the onset of chronic disease and increased treatment.

 “Efforts to reduce the U.S. prevalence of chronic illness should remain a key policy goal.”

“Americans are diagnosed with and treated for several chronic illnesses more often than their European counterparts are.”

Americans diagnosed with heart disease receive treatment with medications and procedures more frequently than patients in Western Europe.

In the past local peer review was all that was needed along with confidence in the treating physician’s judgment. This confidence in physicians’ judgment has been destroyed by excessive media sensationalism. The real percentage of abuse is small and easily discoverable by peers and the use of the new social media.

Cancer treatment survival rates in America are far greater than the survival rates in Britain, and countries in western Europe.

The reasons for the higher cure rates are the availability of early detection and treatment.

Cancer treatment costs are high. The government should look into the reasons for this high cost and try to lower the cost.

The Commonwealth Fund’s report does not consider any of these factors.

The NHS has a waiting list of 3.2 million people for admission to the hospital. In London alone over 500,000 patients are on a waiting list for diagnosis and treatment.

A large percentage of patients triaged as urgent after being diagnosed with suspected cancer have a 62-day wait time to receive therapy.

The British Health and Social Care Act 2012 authorized the use of the small private sector of healthcare to help the NHS with its problems.

The share of NHS-funded hip and knee replacementsby private doctors increased to 19% in 2011-12, from a negligible amount in 2003-04. Each year there is an increase in NHS funded care by the private sector.

It sounds like the VA Healthcare System’s solution to its problems.

Englishmen who can afford private care and private healthcare insurance to avoid the NHS are switching to private insurance even though they have to pay $3,500 for each man, woman and child in a family into the NHS.

The single party payer system (NHS) is struggling with unsustainable costs even though we hear from progressives how great socialized medicine is in England.

The key ingredient missing in all these systems is patient responsibility for their health and their healthcare dollars. Both are powerful motivators to healthy living and detecting disease early.

There are big problems in Canada that have been undisclosed in the United States.

There were two articles in American newspapers in 2011 that applaud the Canadian system.

 Article 1. Debunking Canadian health care myths – The Denver Post                                                                                                                         

Article 2. Everything you ever wanted to know about Canadian health care in one post. Washington Post

Both articles are opinion articles and lack concrete evidence. The articles contain both misinformation and disinformation.  

The Fraser Institute is a well-respected Canadian think tank. Its research is considered accurate with a libertarian slant.

Its 2011 report contradicts the statistics in these articles on the Canadian government healthcare costs.

 Article 1. “Ten percent of Canada's GDP is spent on health care for 100 percent of the population. The U.S. spends 17 percent of its GDP but 15 percent of its population has no coverage whatsoever and millions of others have inadequate coverage. In essence, the U.S. system is considerably more expensive than Canada's.”

Article 2.  “In 2009, Canada spent 11.4 percent of its Gross Domestic Product on health care, which puts it on the slightly higher end of OECD countries.”

This is not true according to the Fraser report. Six of ten Canadian provinces are on track to spend half of their revenues on health care, according to the Frazer Institute. To be specific, in 2011, health care spending consumed 50% GDP in Canada’s two largest provinces, Ontario and Quebec.

“Total federal, provincial and territorial government health spending has grown by 8.1 percent annually, while the national GDP in Canada rose by only 6.7 percent during the same period.”

 The provincial governments have raised taxes and rationed care, while increasing patient wait times.  

“Provincial drug plans have also more often refused to pay for most of the drugs that are certified as “safe and effective” by Health Canada.”

“Unsustainable rates of growth in health care spending crowd out the resources available for other purposes including education, public safety, and economic growth-enhancing tax relief,”

One has only to think about the Obama administration’s initial propaganda and the stunning reality we are facing presently.

The VA is now asking for additional funding to clear up the disaster.

The problem is entitlements are too expensive for a government.  Entitlements do not work because governments cannot legislate behavior by directives. Individuals must be responsible for their health and healthcare dollars.

The other problem is government entitlement programs generate a large bureaucracy. The bureaucracy stimulates the development of inefficiencies and corruption. The new bureaucracy practically guarantees failure of the entitlement.

The Government can help people be responsible for their health with incentive programs.

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




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The Reality Of Price Transparency. It Is Non-Existent

Stanley Feld M.D., FACP,MACE

The price transparency of healthcare costs is non-existent unless a consumer works very hard to determine the costs.

I am sure many interested consumers have experienced the price disparity of what hospitals, physicians and “other providers” charge and what Medicare and healthcare insurance companies allow. The allowed charges are the contracted and negotiated prices.

The retail charges have been the subject of many published studies. These charges have nothing to do with the reimbursed charges. Consumers without healthcare insurance are liable for the retail charges.

Consumers with healthcare insurance are liable for the negotiated and contracted charges only.

Those contracted and negotiated prices are the prices that are opaque to the public.

In response to my last post “The Charade Of Price Transparency” a reader sent me a description of his experience dealing with price transparency. I have reconstructed the essential points in his note to me in order to make it easy for readers to understand the problem.

This reader’s healthcare insurance policy is a high deductible ($6,000) healthcare insurance policy with a health saving account (HSA) feature attached to it. He is responsible for the first $6,000 of his medical bills.

The healthcare insurance industry has been creating many inventive healthcare insurance policies that give the illusion of saving consumers money.

The government, through its health insurance exchanges, is creating the same illusion of inexpensive insurance.

This reader’s healthcare insurance policy pays 90% of all negotiated fees from $6,000 to $10,000.  The total out of pocket expense is up to $10,000 a year plus the cost of the insurance policy premium’s cost. After the patient has spent $10,000 he gets first dollar medical cost coverage.

The reader said, “The good news is,since I was on an insurance plan, my total charges for this procedure and hospital stay should be closer to $4-5k vs without insurance (and their negotiated rates) it would be closer to $20-25k.

Plus by using my HSA account to pay with pre-tax dollars, I effectively save myself about 30% or $1200.”

The health insurance premium is not inexpensive but is less than having a traditional healthcare policy with first dollar coverage.

 This healthcare insurance is best if you do not get sick and do not have to pay the initial $6,000.

The reader has a partial urinary obstruction. A transurethral resection prostatectomy was recommended.

He was given a choice. He could either have green laser TURP surgery or traditional TURP. He was told he would be in the hospital overnight.

He knew about the difference between the billed prices and the contracted prices. He also knew he would be liable for his insurance company’s contracted negotiated price and not the providers billed price.

His goal was to figure out what his liability would be for the procedure. 

His overall impression was,

 “What a horrible nightmare it was trying to find out the negotiated prices. Who is the main person responsible for this as a whole?! Why do I have to guess at what pieces might be involved in this, and then go track down from different places?”  

These were the steps he had to go through to figure out his liability for his upcoming surgical procedure.


        1. He called the insurance company and asked what the reimbursed fee would be for a TURP to his         physicians and the hospital. His insurance company told him that he needed to tell them the         hospital and physician’s billing codes in addition to the hospital and physician’s identification         number.

  1. He could never get the information needed to figure out the negotiated price for the surgeon.
  2.  “The surgeon’s fee is $1500. I don't know negotiated contracted fee. I was told by the healthcare insurance company that most fees are reimbursed at 50% of the submitted fee.”
  3. He next called the hospital’s billing department and was told to call “same day surgery department.”
  4. The same day surgery department could not give him a price until after the procedure.   However they could give him an estimated price if everything went well. The price includes pre-surgery testing, surgery, drugs, operating room fees, recovery room fees and pharmacy fees.
  5. The price did not include the anesthesiologist’s fee or the pathologist’s fee. 
  6. The price would be $18,485. He was also given the billing code and facility id number.

        7.He then called the healthcare insurance company. After three calls to different departments he             finally got to a person that would give him the average contracted reimbursement for a day             surgery TURP.

        8. Thirteen hundred and eighty-two dollars ($1,382) was the average negotiated price for the             TURP. It was less than 10% of the billed price. I am sure the hospital has figured out the way to             add onto the final reimbursement.

            9. He next called the anesthesiologist group. The billing department told him many of the                 anesthesiologists bill different prices. She could not give him a price. The anesthesiologists                 bill in15 minute intervals. She could not assign him to a particular anesthesiologist because                 they go in rotation.


The following are quotes from the reader’s note to me.


  • “I placed at least 8 calls to doctors, hospital, insurance and estimators to try to figure this out. I think I made it halfway through before I gave up.”


  • I gave up trying to figure out all the charges.”


  • “What you should understand is I decided to prioritize where I
    put my energy. Given the stress of the upcoming surgery and the stress of my ongoing discomfort, I decided it wasn't worth trying to figure
    out what the 15 min incremental charge would be for an



  •  I just think the system is flawed. Like I said I don't think they were malicious or purposefully confusing. They don't know what the doctor or hospital will put through as charges until they are put through.”


  • “If this were just an academic exercise perhaps I would have gone
    further. But when I understood the charges well enough to know the
    range of my liability, I was done researching.”

This is the reality of price transparency, as it exists today. It is non-existent! Most consumers do not care about price transparency because it does not affect their pocketbook.

Most consumers believe they can go to the doctor or hospital and their healthcare insurance policy we pay the bill. Their personal cost will be small.

Obamacare’s influence on the cost of healthcare insurance is causing employers to provide insurance with higher deductibles and co-pays. They are receiving less insurance coverage resulting in higher out pocket expense.

Consumers are realizing that they are being forced to be responsible for their healthcare costs.

It is these changes that will heighten the awareness and demand for real price transparency and price competition among insurers, hospitals and physicians.

If consumers are to become educated consumers, the charade of price transparency must cease to exist.

 The real prices for healthcare must be made easily available.

 It will only occur by consumer action.

Consumers must remember they are the customers.

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

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The Gourmet Group, a.k.a “Gourmet”

Stanley Feld M.D.,FACP,MACE

Last Saturday night our Gourmet Club met for the 350th time since 1971. We started as five couples. The men started their medical practices in Dallas, Texas in the summer of 1970.

One couple, unfortunately, died and so now we are four couples.

Four fifths of us did not know any one in Dallas when we arrived. We all met at a newcomer’s party organized by one of the national medical school fraternities. We were all invited even though none of us were fraternity members.

The five couples hit it off instantly. The woman got together. They thought it would be a good idea to start a five couple Gourmet Group. They wanted to become gourmet cooks.

They all became gourmet cooks. The Gourmet Group’s dinners are the best dinners in Dallas.

Last week I realized the wonder of the Gourmet Group when I was in our kitchen at clean up time. The guys were washing the multitude of dishes a four course gourmet diner generates.

In the beginning, Gourmet’s goal was to prepare a meal from every country on the globe and every region of the United States.

The women would have Gourmet planning. They brought cookbooks and cooking magazines (i.e. Bon Appetit, Food and Wine, Gourmet), and decided on the country or region. Men were not allowed to attend. These meeting lasted up to four hours. I have no evidence but I think they must have discussed more than just the menu.

The houses are rotated in alphabetical order. The hostess does the main dish. The previous hostess brings the wine and bread.  Now that we are down to four couples the previous hostess might have to prepare one of the courses.

In recent years, with all of us traveling as much as we do, Gourmet planning has been eliminated. The hostess plans the menu and gives out assignments.

All the meals remain as interesting as they were forty-three years ago. These women are serious cooks.

The couples all feel that we are extended family.

We watched all our kids grow up, go off to college, get married, start their professional life and have their own kids. We are watching these kids grow up. We celebrate life cycle events.

We celebrate some holidays together. We have traveled together.

We schedule dinner about every four to six weeks. The rule is to not schedule anything once the date is set. If a change is essential the couple responsible for the change has to coordinate the new date since the firm date was scheduled when everyone was at the previous dinner.

During dinner we eat, have a couple of bottles of appropriate wine, catch up on our lives, travel, our kids and their kids and sometimes politics.

We are close friends and try to get together as often as possible in addition to the “official “ Gourmet Group's dinners.  

Gourmet has been a wonderful life experience for all of us. I would like to encourage others to start a Gourmet Group like ours.

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

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