Stanley Feld M.D., FACP, MACE Menu

All items for October, 2014


An Obamacare Ineffective Premise

Stanley Feld M.D.,FACP,MACE

Obamacare’s goal is to improve the quality of medical care while reducing the costs of medical care. Big government believes it can accomplish this goal by controlling medical care using rules, regulations and guidelines.

My fear is Obamacare is just creating opportunity for secondary stakeholder to rip off the healthcare system.

The result will be higher costs of delivering medical care while lowering its quality.

President Obama and his administration must reexamine their premises and start thinking pragmatically.

Patients’ adherence to recommended treatments is a huge issue in assessing the cost of care. Obamacare does not provide incentives to patients to adhere to recommended treatments. If patients do not adhere to recommended treatment they will get sicker and cost the healthcare system more.

Obamacare’s emphasis is to change the payment paradigm to medical outcomes based system. Physicians and hospitals will be responsible for the patients’ outcome and be penalized for poor outcomes.

Patients’ adherence to treatment is less than 50%. Physicians have little influence on patient adherence.

“Physicians have always had to deal with patients who refuse to follow treatment recommendations, but this age-old quality and patient-care issue is about to become a pressing financial concern for doctors.”

The non-adherence rate of patients to treatment is anywhere from 30-60% depending on the disease, complexity of the treatment, duration of the treatment and side effects of the treatment.

The adherence rate also depends on the psychological state of patients at the time of treatment.

Patients who don't take their medications or don't adhere to treatment recommendations are at risk of getting sicker and requiring more services.

The added cost of care would come out of physicians’ reimbursement unless physicians know how to get around the rigid but inaccurate rules that measure outcomes.

Adherence to treatment is a vital part of correctly measuring outcomes. Nowhere in Obamacare’s rules and regulations is patient’s adherence to recommended care dealt with.

Some patients have perfected the art of non-adherence. I learned this early in my medical career.

Forty-six years ago I was working in the hypertension clinic at Parkland Memorial Hospital in Dallas. I had just arrived from the Massachusetts General Hospital where most of the clinic patients were caucasian Irish or Italian. There were a small percentage of black people in that clinic.

Ismelin was a popular antihypertensive drug in America at that time.  Physicians did not have much else with which to treat hypertension. The problem with Ismelin was 25mg could cause patients to have orthostatic hypertension (blood pressure drops to very low level when standing) causing patients to pass out.

When I got to Parkland there was a high percentage of black male patients. Many were on up to 200 mg of Ismelin a day. I could not understand it. I got friendly with a couple of patients and told them that in Boston the dose needed was only 25 mg to treat high blood pressure. In Dallas patients received up to 200 mgs a day and were still uncontrolled. I asked if they had an explanation.

Three guys told me what the problem was. The chief of the hypertension clinic was very smart, a very good person, and very concerned about their health. He also had the pharmacy calculate the time these patients needed a refill.

The patients loved him for his sincere concern for their health. They would do nothing to hurt his feelings.

One 25 mg Ismelin pill would lower their blood pressure to intolerable levels. They would not take the medication or take it every other day or every third day. They knew he was counting the pills they took. They always refilled their medication on time. The medication was free to them at Parkland.

When they came into the clinic for an office visit their blood pressure was high. The chief would increase the dose to 50 mg a day and doses of up to 200 mg per day.

 The chief did not understand why he could not control their blood pressure with these massive doses.

They told me after many months of friendship that 25 mg would affect their nature (sex drive and ability to have an erection). They did not take any of the medication even though they refilled it.  

The moral of the story is patients will not tell you the truth at times and sophisticated measurements can fool you. The result will be bad outcomes and higher costs to the healthcare system.

This is only one example of non-adherence affecting outcomes. Uncontrolled hypertension is the primary cause of heart attacks and strokes.

Should physicians be penalized financially for patient non-adherence when there are many factors that affect patient non-adherence? Physicians will try to avoid treating non-adherent patients to avoid negative outcomes.

The growth of concierge medicine is the result of physicians desire to avoid government regulations, government decreases in reimbursement and government penalties.

Physicians will be cherry picking for the best and most adherent patients. The result will be a further shortage of physicians to care for the expanding Medicaid and treatment population resulting from Obamacare.

President Obama, please re-exam your premises and your policy wonks’ premises.

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

Please have a friend subscribe

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Incentives and Mechanism Design

Stanley Feld M.D.,FACP,MACE

Why are Obamacare’s initiatives failing? There are several reasons.

1. Government is inefficient. It outsources all of its administrative services.  

The contractors, in turn, subcontract out most of the work. The overhead for each function increases non-transparent costs. The execution of tasks decreases.

2. President Obama’s healthcare policy advisors are academics. They have little clinical experience. It is clear they have little experience in the trenches.

The healthcare policy advisors have no idea how to create incentives for physicians and hospitals.

They have no idea how destructive to clinical practice the lack of tort reform is.

3. Without clinical experience the policy advisors do not know how to create effective incentives for patients.

I have emphasized that patients must be responsible for themselves and their diseases. They must become professors of their diseases. They have to be provided with adequate incentives to become professors of their diseases.

Physicians must be provided with incentives to teach patients to be professors of their diseases.

4. The government outsources the administrative services to adjudicated Medicare and Obamacare billings. The government has little idea of the actual profits built into the fees the insurance companies charge the government. At intervals insurance companies are required to enter another bidding process. The government probably picks the lowest bidder.

It is not an efficient way to pick an insurance company. This is especially true when the government guarantees the insurance company‘s profit. The government does not know what the insurance company’s profit actually is. The profit is about 40% of the healthcare dollars.

President Obama’s ideological goal leads to these errors. His only concern is for the government to control the healthcare system.

Government control of a healthcare system has not been successful. The V.A. healthcare system is on example. Medicaid and Medicare’s increasing deficits has been another example.

None of the countries in the developed world have a financially viable universal healthcare system except Switzerland.

A few years ago I learned about “Mechanism Design.”  My first reaction was “what is that?”

Leoid Hurwicz, Roger Meyerson and Eric Maskin received a Nobel Prize was  for this economic theory in 2007.

Mechanism Design is a brilliant economic theory. If the theory was applied to the healthcare system it could solve much the system’s dysfunction.

When I wrote about Mechanism Design I felt that few people understood it.  

What is it?  Mechanism Design is the art and science of designing rules of a game to achieve a specific outcome, even though each participant may have a separate vested self-interest.

The design of the game is to align all the stakeholders’ vested self-interests.  

 Each stakeholder has an incentive to behave as the game designer intends. The game can then implement the desired outcome.

 The strength of such a result depends on the solution concept used in the game.  

None of the stakeholders’ vested interests are aligned in Obamacare except the vested self-interest of President Obama and his ideology.

The healthcare insurance industry thinks it has President Obama over a barrel.

Some of the hospital systems have figured out that they will be at the mercy of Obamacare.

 Physicians already feel they are at the mercy of President Obama’s ideology.

Medical device companies and pharmaceutical companies have figured out they are dead already. It is only a matter of time until they cannot move. They are working around the system to come back from the dead.  

None of the stakeholder’s vested interests are are aligned. This non-alignment will lead to destruction of the healthcare system.

Mechanism designers commonly try to achieve the following basic outcomes for stakeholders: truthfulness, individual rationality, budget balance, and social welfare.

 With those four outcomes for stakeholders in the healthcare system one could get close to aligning stakeholders incentives.

Lodi Hurwicz’ point is the way to get as close to the most efficient economic outcomes is to design mechanisms in which everyone does best for themselves.

He says this can be achieved by sharing information truthfully (Price Transparency). It is easy to understand that some people can do better than others by not sharing information or lying in the short term. It will not serve all the stakeholders’ vested self-interest in the long term.

If everyone’s incentives are aligned you have a much more efficient economic system.

The example given in the military is defense contracting. If you agree to pay on a cost plus basis you have created incentives for the contractor to be inefficient.  

If you do not you have incentives aligned and truthful information you create the incentive to be overcharged. Most people can do better by not sharing truthful information.

Many have observed that Obamacare has not been transparent or truthful.

If the rules of the game require truthful information you can get close to an efficient market driven solution.

The concept of Pareto efficiency means no one can be made better off without someone becoming worse off.  

Hurwicz observed, as had others, that the dispersion of information was at the heart of the failure of a planned economy.

He observed that the free market economy can get us closer than central planning to incentive compatibility because in the end the consumer can drive the discovery of truthful information

A free market economy is by no means immune to the Pareto efficiency concept.

However, the free market mechanism was far less afflicted than central planning bureaucracy. A consumer driven system serves to force truthfulness.

Empowering consumers is the key to an efficient system. Customers determine success of an enterprise by creating demand. In a transparent environment they can get closer to incentive efficiency. They create the rules of the game for compatible incentive.

How does Mechanism Design relate to the Repairing The Healthcare System?

The rules of the games can align all the stakeholders’ incentives without one stakeholder taking advantage of another.

In our healthcare system everyone is pursuing his vested interest in a game that has rules that do not lead to “incentive compatibility.”

Some politicians think central planning will straighten out the rules. Historically, central planning has not worked. These Nobel Prize winners in economics have proven this fact.

A  consumer driven healthcare system using the ideal medical saving account. Will be a good start in achieving alignment of all the stakeholders.

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

Please have a friend subscribe


  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


President Obama Doesn’t Listen

Stanley Feld M.D.,FACP,MACE

President Obama does not listen to the thoughts of the people who elected him. The middle class and independent voters under great economic distress and are frightened.

They are not better off than when President Obama took office.

They have no confidence in President Obama’s promise or desire to help them even though he continues to say he is out to protect the welfare of the middle class.

He claims to be for income equality, yet income inequality has increased in the last six years.

The people do not trust President Obama to make good decisions for them.

The people are scared stiff about the Ebola virus. They do not believe his explanations for letting people into this country from countries that have the Ebola epidemic are logical.


Why would he take the chance of letting more cases into the country? It is completely illogical to me.

People have felt the hysteria spreading throughout the nation because of one case. They are feeling the economic effects of so many people quarantined and held in isolation for 21 days. They see economic activity slowing down while they are experiencing a weak recovery after six years. Shopping malls are disserted.

The more he does the less the people trust him. The appointment of a public relations person as the Ebola czar is a mind blower to most people.

The Ebola czar knows nothing about medicine, or transmission of viral disease or human illness.

The Ebola czar knows everything about spinning disinformation.

This is not a good formula for increasing confidence and trust in President Obama’s ability to handle this crisis.

The people are noticing and reacting to crisis after crisis and scandal after scandal. President Obama calling an obvious scandal a phony scandal makes things worse for his being able to convince the voters that he knows what he is doing.

President Obama does not listen to the people who got him into office.

Is his agenda to ignore the people, the constitution and the law in order to basically transform this country?

Last January he said Obamacare would not be an issue in the midterm elections. He keeps on misleading the public about Obamacare.

 He and his henchman keep saying Obamacare is working. Obamacare is a success. The evidence that it is not working is abundant. The people who voted for him are feeling its failure.

All these people are feeling the pain of President Obama’s policies. They also recognize that their wishes are being ignored.  

People do not know what they need.  Voters now know President Obama is ignoring them.

Yet he and Michelle have the audacity to travel around the country telling people “to vote for Democrats for congress to give Barack a chance to finish his work.”

A series of articles have appeared that express voters’s concerns about Obamacare’s failures.  

Radius Global Market Research (Radius GMR did a survey that showed two-thirds of those insured via Obamacare will change healthcare plans in 2015.

 “The survey stimulated competition among healthcare insurance companies to capture this two-thirds of Americans that are dissatisfied with their healthcare insurance policies for 2014.”

The two thirds of the people surveyed wanted,

  • Lower premium and deductible costs
  • Improved access to doctors
  • Improved quality of care by doctors and hospital systems
  • More than half of respondents expect their healthcare premiums to increase
  • More than one-third of those who switched primary doctors after joining ACA plans did so because their doctor was not on the new plan.
  • Twenty five percent of households are visiting their doctor less frequently and/or experiencing longer office wait times.
  • Only 44% of Americans feel they are adequately about the benefits provided by Obamacare.

At present, eighty percent of people who get healthcare insurance through Obamacare receive government subsidies. These subsidies help with the healthcare insurance premiums for people earning up to $50,000 a year.

However, those people are responsible for the deductible under Obamacare. The least expensive coverage is for a bronze plan.  

The average deductible from the Health Insurance Exchange is $5,081 for an individual and $10,386 for a family, according to HealthPocket.

A Silver plan (the next higher plan) had average deductibles of $2,907 for an individual and $6,078 for a family. The initial premiums are higher.

An average family making less than $50,000 cannot afford either deductible. A family making more that $50,000 per year without subsidy cannot afford the premium or the deductible.

People having a pre-existing illness will eat into the deductible that they cannot afford. Therefore they will avoid medical care.

The impact of the deductible is a surprise to people with preexisting illness. They do not have coverage until the deductible is met.

This creates stress on these individuals. It also represents a form of deception for these people. They thought they had good insurance coverage. President Obama promised them good healthcare coverage. He lied to them. They will remember the lie at the voting booth.

Insurers must cover certain preventive services, like immunizations, cholesterol checks and screening for breast and colon cancer, at no cost to the consumer if the provider is in their network.

 But for other services and items, like prescription drugs, marketplace customers often have to meet their deductible before insurance starts to help.”

Physicians have been deceived as well.

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 number of doctors complained about the vast amount of bureaucracy that has been added to the medical profession.

"Get government OUT of healthcare," one doctor wrote.

Another physician wrote in the survey

"The system is broken and I am out of here as soon as I can. I am tired of being used, abused and lied to. Has anyone here woken up to the fact that we are always the last ones to be considered in the equation of change?"

It is clear the primary stakeholders in the healthcare system (patients and physicians) feel deceived by President Obama.

I do not think they are going to let him finish his work. They will stop him at the voting booth in November.

It will be difficult for the country to survive another two years of Harry Reid’s obstruction if the Democrats hold the senate.

Obamacare remains a big issue among many people despite President Obama’s promise that everyone will like Obamacare by the November election.

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

Please have a friend subscribe





  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Caving In

Stanley Feld M.D.,FACP,MACE

As time goes by the implementation of Obamacare (ACA) becomes more bizarre.

The start of the 2015 enrollment period in Obamacare’s health insurance exchange program was delayed from October 1, 2014 until November 15, 2014.

The reason for the delay is obvious. The Obama administration fears another disastrous enrollment rollout just before the midterm elections.

President Obama is protectingDemocratic candidates who voted for Obamacare from the political fallout.

The enrollment period is supposed to end December 31, 2014 in order for insurance coverage to start January 1, 2015.

This enrollment period is very short. The Thanksgiving and Christmas holidays will make it even shorter.

President Obama will probably delay the end of the enrollment period once again by executive order.

The Obama administration must also deal with people who lied about their enrollment qualification. Hundreds of thousands could not show proof of income or eligibility for government subsidies for their insurance for 2014.

The government has not published any data about the number of people who have been disqualified for providing false information.

These people owe the government money. They cannot afford to pay the amount owed. Is the government going to let these underpayments disappear?

The Obama administration also announced that anyone who was enrolled last year does not have to do anything. They will be enrolled automatically in 2015.

At what price?  Premiums will be higher than last year. Enrollees might not be able to pay the higher or unsubsidized premiums.

Insurance premiums in the health insurance exchanges are going to increase at least 10% in 2015 despite the Obama administrations guarantee, through its reinsurance plan, that it will cover any of the healthcare insurance industry’s claimed losses.

Problems were compounded this week by a CMS announcement that they will not publish the health insurance exchange premiums until November 15,2014.

Medicare premiums are also going to increase dramatically in 2015. Many seniors will not be able to afford to pay them. Senior might not notice the increase until they receive their first social security check.

On January 1, 2015 Obamacare’s “employer shared responsibility reporting requirement”  goes into effect.

“Starting in 2015, applicable large employers will need to identify whether eligible employees have been offered employer-sponsored health care coverage and whether that coverage meets the standard for minimum essential coverage, among other requirements.

Employers will also be required to track employee eligibility for health care coverage, including number of hours worked, etc.”

There is no way employers can track this information manually anymore. They will have to hire a benefits manager to keep track of something that is so fluid as to will be impossible to keep track of.

Employers’ overhead will rise. The large employers will decide it is cheaper to pay the Obamacare’s penalty and force their employees to buy insurance on the federal health insurance exchanges.

How can all these people buy insurance wisely between November 15, 2014 and December 31, 2014 to be insured in 2015.

This will create havoc in the healthcare system.

Creating havoc is the goal of President Obama’s plan to transform America. It follows Saul Alinsky’s game plan precisely. It will lead to population fear. Population fear will lead to a government controlled single payer healthcare system.

The public is presently experiencing a great deal of fear with the potential for an Ebola epidemic. The resulting hospitalizations and deaths that might occur from an epidemic will intensify this fear.

This CDC and the Obama administration keep giving us illogical reason for why they refuse to stop flights from West Africa to the U.S.  

The airport screenings’ protocols are illogical. The training protocols have been unsuccessful.

Havoc will intensify if the United States experiences an influenza outbreak this winter. People will not know whether they have the flu or Ebola. People will overrun the nation’s hospital ERs.

Public and private health insurance policies might not cover the care needed to diagnose and treat these patients.

People will be put in isolation in the hospitals. The patient’s contacts will have to be quarantined. The economy will come to a standstill.

The only option remaining is for the people to beg the government to take over the healthcare system.

I do not know if President Obama and his administration are brilliant or incompetent.

I suspect he is brilliant.

 In either case his goal of socializing medicine will be achieved

Are President Obama and his administration competent enough to control and run the healthcare system?

What is your guess?

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

Please have a friend subscribe



  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Fantasy vs. Facts

Stanley Feld M.D.,FACP,MACE

President Obama is continues to mock the critics of Obamacare who predict failure even as Obamacare is obviously failing.

He knows the media is the message even if his message has nothing to do with the facts.


President Obam's first victory lap.

 There had been three failures at the time he declared Obamacare a success this month.

1. The Obama administration announced that accountable care organizations (ACOs) in the Pioneer ACO model and Medicare Shared Savings Program (MSSP) have generated more than $372 million in total program savings for Medicare ACOs over the program’s two-year span.

The details of the Pioneer ACO models’ savings are difficult to follow.

  • An estimated total model savings of over $96 million and at the same time qualified for shared savings payments of $68 million
  • Eleven Pioneer ACOs earned shared savings, 3 generated shared losses, and 3 elected to defer reconciliation until after the completion of performance year three.
  • The organizations showed improvements in 28 of the 33 quality measures and experienced average improvements of 14.8 percent across all quality measures.
  • The mean quality score among Pioneer ACOs increased by 19 percent, from 71.8 percent in 2012 to 85.2 percent in 2013.


Can anyone make any sense out of this word salad?

One week later three of the 22 remaining Pioneer ACOs dropped out of the program. The program originally had 32 members. 

The Franciscan Alliance, Genesys PHO and Renaissance Health Network have exited the Pioneer ACO program, which is now in its third year.

Only 19 of the original 32 ACOs remain.

Sharp Healthcare, a San Diego-based health system, dropped out August 2014, saying that the ACO model was “financially detrimental.”

The Mayo Clinic and Cleveland Clinic were invited to be in the Pioneer ACO program but rejected the offer. It was clear to them that ACO’s meant taking on too much uncontrollable financial risk.

The ACOs were supposed to deliver a higher quality of care through their integrated hospital systems. The hospital system would also experience greater profits.

At the onset of the program some hospital systems and integrated medical practices recognized they would lose money and possibly be penalized.

The thirteen integrated systems that quit the Pioneer ACO model recognized their losses after they started the program.

I predicted ACOs would fail and provided detailed reasons. I predicted that ACOs would fail because of the financial risks to the ACO. The job of risk is an insurance issue. A healthcare provider cannot control the confounding variables influencing risk.

“Genesys PHO received a $2.5 million penalty in the program's first year and a $1.9 million penalty in the program's second year (Evans, Modern Healthcare, 9/25; Leventhal/Hagland, Healthcare Informatics, 9/25; Beck, Wall Street Journal, 9/25).”

One could conclude that Genesys’ ACO was becoming an improved integrated better because it experienced a smaller loss the second year. It was not Genesys’ conclusion. It withdrew from the program.

2. Last week President Obama predicted that enrollment in Obamacare increase this year. The web site is fixed and enrollment will be easier.

At the same time at least 300,000 people in last years group of enrollees lost their subsidies or coverage because they did not offer proof of their eligibility by September 30th.

There has been little media coverage of this event. This is not the definition of success.

3. In addition, the insurance industry announced that thousands will lose health insurance their current insurance policy with their employer by the end of 2014.

They will have to apply for which will probably be more expensive through the health insurance exchanges. Insurers are cancelling the private healthcare insurance policies because they no longer make business sense.

Of course, it makes no business sense when the insurance company can make more money from the federal health insurance exchange plans. The Obama administration is guaranteeing the healthcare insurance company’s profit and eliminating its risks.

All this appeared at the time President Obama called Obamacare a success and mocked his critics who predicted failure.

The media is the message. If President Obama can manipulate the media enough he can help the Democrats maintain a majority in the Senate with two more years of Harry Reid control.

I do not think the American public is going to fall for President Obama’s disinformation campaign once again.

I hope not.

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

Please have a friend subscribe 


  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


A Bureaucratic Thinking Disorder

Stanley Feld M.D.,FACP,MACE

The Hospital Readmissions Reductions Program (HRRP) is an attempt to decrease healthcare costs by curbing hospital readmissions rates. The program was launched in October 2012.

Hospital reimbursement by Medicare could decreased the following year by 1-3% because of hospital readmission   

It is another alphabet soup program that was not well thought out. It cannot work as envisioned because of the many unintended consequences.

Hospital readmissions are very costly. If patients are readmitted within 30 days after discharge the assumption is patients were not treated effectively as an inpatient so that they could stay out of the hospital.  

Therefore hospitals should be penalized until their treatment improves.

There are other reasons for patient readmissions within thirty days of discharge.

  • Patients might be too sick to be completely healed at discharge from the hospital. If a patient remains in the hospital too long for his diagnosis the hospital is also penalized.
  • Patients did not pay attention to the outpatient treatment regime they were given.
  • Patients did not take the medication they were prescribed.
  • Patients were too depressed from their illness to take the medication and comply with follow-up treatment.
  • Patients were not smart enough to understand the instructions given at discharge.

The measurement of all these metrics would be very complicated even though I think patient adherence to treatment regime is the most significant cause of readmission.

The sicker patients are the more likely adherence to outpatient treatment  is a problem.

The Obama administration chose the easiest measurement to make to this complex problem. CMS would withhold 1% of reimbursements in 2012 and 2% in 2013 to hospitals that have too many patient readmissions within 30 days of discharge for three conditions: heart attack, heart failure and pneumonia.

This is foolish thinking.

One cannot measure a outcome using one variable when you have so many confounding variables that are not evaluated.

The results will also yield unintended consequences. One such consequence is the increase in outpatient observational admissions for 48-72 hours.

Medicare will not cover the outpatient observation admission.

In May 2014 I wrote “Seniors Should Be Madder Than Hell About Obamacare And Not Take It Anymore.”

 “It is all about money. It is about the government spending less, the hospital collecting more and the patients getting stuck with the bill.

Government officials realize that Medicare costs are unsustainable. CMS creates rules and regulations to expose Medicare to less liability.

Unfortunately the unintended consequence is that CMS exposes Medicare patients to more liability in the process.”

Once more President Obama lied to seniors.

“People are shocked when they receive the bill. Nobody is required to tell them they’re outpatients.”  

Those patients who have been outpatient observation admissions do not qualify for the rehabilitation benefits.

Patients can be responsible for many thousands of dollars for the first 20 days of rehab (nursing home) services.

 “I just found myself in the middle of a medical situation that made it very clear that "the affordable care act" is neither affordable, nor do they care.” 

In 2014 CMS has increased the maximum fine to 3% and added chronic lung problems and elective hip and knee surgery to the list of conditions.

Hospitals are not taking any chances. They are putting everyone they can on outpatient observation status.

Hospitals are also having problems collecting these non-Medicare covered bills from seniors.

Most seniors simply cannot afford to pay and the stress created is not good for their medical condition either which could result in re-hospitalization.

Seniors are increasingly distrusting the government and President Obama about Medicare changes.

President Obama promised them that Obamacare would not affect Medicare or harm one single senior.

Despite hospitals gaming the system with outpatient observational admissions 2,610 hospitals are facing readmission penalties in 2015.

The 2015 fines and penalties affected about three-quarters of the hospitals subject to the programs. The number of hospitals receiving penalties has increased each year from 2,217 in 2013, 2,225 in 2014 to 2,610 in 2015.

CMS also exempted 1800 hospitals from these penalties.

As more conditions are added more hospitals will be receiving penalties. Hospitals will adjust or go bankrupt. The result will be increased cost, a shortage of hospital beds and a weakened and less effective healthcare system.

Many of these readmissions are not the hospitals’ fault. They are the patients’ and their diseases fault.

These policies are just a fraction of the policies that are creating chaos and havoc in America’s healthcare system. They will lead to the demise of, not the improvement in, a cost effect healthcare system.

President Obama’s policy makers have a bureaucratic thinking disorder.

Part of the reason for this disorder is they do not understand problems in the healthcare systems. Their policies are also getting the healthcare system further and further away from creating a cost effective solution to the healthcare system’s problems.

A market driven system along with a consumer driven system can drive down costs down and create happiness for all the stakeholders involved in the healthcare system except the healthcare insurance industry.

I have presented the steps necessary in this slide presentation entitled The Ideal Future State of the Healthcare system.

Obamacare is forcing the healthcare system to turn into not out of the skid.

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

Please have a friend subscribe




  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Democrats and Ayn Rand

Stanley Feld M.D.,FACP,MACE

I have never understood why Democrats have always belittled Ayn Rand. Atlas Shrugged is reported to be the best selling book in history aside from the Bible.

I first read it in 1959, two years after it was published. It is a weak love story but a powerful critique of government policy and the effect of expanding government control over society.

I did not think about it much during medical school. I thought about it when the government started to control my medical practice.

In 1984 my son, Brad, insisted I read Atlas Shrugged again. It describes exactly the effect the government was having on the practice of medicine. 

I did not understand why Democrats in congress and the Democratic Party members become were so angry with Ayn Rand and her philosophy. I thought Democrats were problem solvers for the benefit of the people. 

I finally realized that Ayn Rand’s writings are a dangerous threat to the Democrats’ progressive agenda. The agenda is the government’s control over society turning free citizens into clients of big government. 

In this election year the Democrats have decided to combine their anti-Rand rhetoric with a Saul Alinsky tactic.

The Democrats are trying to immobilize Republicans’ replies through a replay of their anti-Rand sound bites. They are using the traditional mainstream media to spread their disinformation.

If a reader wants to know what Ayn Rand’s philosophy is read Atlas Shrugged. I suspect most critics have not read the book.

Democrats attack Ayn Rand by misrepresenting her philosophy as evil.

This year the Democrats’ attack dog is House Minority Leader Steny Hoyer (D-Md.).

He accused Republicans of following author Ayn Rand’s advice that “compromise is always evil,” and warned that letting Republicans take over Congress would only lead to more gridlock and partisanship.” 

In reality comprise is usually evil. If a policy or law is wrong, compromising will not fix the problem that policy or law set out to fix. According to Ayn Rand there are issues in which compromise is evil. If a law or policy does not work compromise can be evil is if is not modified by compromise.

Steny Hoyer’s warning Republicans taking over congress would only lead to more gridlock and partisanship does not  logically follow the first part of his sentence.  

The House of Representatives have passed about 350 bills. A 98% of the House passed bills were with  bipartisan.

Harry Reid, chairman of the senate, has created the gridlock by not permitting these bills to be brought to committee or the senate floor for debate.

Harry Reid has been President Obama’s inarticulate creator of gridlock.

“Compromise is not evil,” Hoyer said. “It is the necessary and noble pursuit of those who govern responsibly in a democracy. We listen to one another. We come to an agreement.”

Harry Reid has not compromised on anything. Neither has President Obama.

How does Steny Hoyer have the chutzpah to make such a statement?

Why doesn’t the traditional media react to this ridiculous statement.

Steny Hoyer’s statement is the typical Saul Alinsky lie crafted to immobilize the enemy’s ability to have a strong reply.

If a policy is wrong and is not working or has not been working reasonable men should debate the issue and change the policy so it works to the benefit of the people.

The policy must be changed. It is the responsibility of both parties to change it to something that can work for the benefit of all the people.

Obamacare is a law forced through congress by a Democratic majority that is not working. Compromise can only make it worse.

Who is to blame for congressional gridlock?

Is it the Republicans or Democrats?

If there were a Republican majority in the Senate and bills passed both houses President Obama has threatened to veto the bills. He would then be responsible for his errors not Harry Reid. 

Hoyer accused House Budget Committee Chairman Paul Ryan (R-Wis.) and others as following Rand’s teachings when it comes to operating Congress. 

The implication is Paul Ryan is evil.

The message is President Obama knows what is good for the people. Therefore. elect Democrats to congress this fall.  

Which of President Obama and the Democrat’s policies have worked? All are failing at the expense of the middle class taxpayer.

President Obama’s policy decisions have been proven wrong daily.

  • He has created chaos in the healthcare system with Obamacare.
  • He has increased the costs of unsustainable entitlements programs.
  • Obamacare is another unsustainable entitlement program.
  • He has increased the deficit from $11 trillion dollars to $17 trillion dollars.
  • America’s foreign policy is chaotic.
  • America’s economy is still a mess and getting worse even though the President claims it is better.
  • People are more dependent on government.
  • Individual privacy had been violated.
  • Independence has been discouraged.
  • Individual responsibility has been discouraged.
  • Cronyism has been promoted..

President Obama wants to do away with racism yet makes every issue a racist issue and blames it on Republicans.

I think before Steny Hoyer and the Democrats start attacking Republicans who might have been influenced by Any Rand, he should read Atlas Shrugged or at least watch the three-part movie.

“He should reexamine his premises.”  (A John Galt quote).

President Obama’s own party members are running away from his concepts of big government and central control in order to be elected. 

They are sounding like Republicans.

The people are realizing that “Big Government” has had difficulty in doing anything efficiently.

These days government competence is all too often exposed as a fragile veneer. When an elite corps like the Secret Service can’t remember to lock the White House’s front door and alleged health technocrats can’t build a working Obamacare website for less than $2 billion, a sense of low-level worry about Ebola seems more than reasonable.”

 President Obama is always blaming his failures on President George W. Bush or his advisors.

Many of President Obama’s advisors are now blaming Republicans for their agencys’ shortcomings. Even Dr. Anthony Fauci, head of the National Institute of Health Infectious Disease division, is implying Republicans are to blame for the agencey’s lack of efficient response to the Ebola virus epidemic.   

“Nor does it inspire confidence that the head of infectious diseases for the CDC is resorting to that promiscuous federal excuse—budget cuts.

Anthony Fauci recently told Congress that sequestration “has, both in an acute and in a chronic insidious way, eroded our ability to respond in the way that I and my colleagues would like to see us be able to respond to these emerging threats.”

Is this a joke? There are many other examples of shifting blame such as our foreign policy crisis in the middle east, the crisis with ISIS, nuclear Iran, Israel/Hamas and the Arab spring to name a few.

All these excuses remind me of the excuses that characters in Atlas Shrugged used when the world was falling apart.

As I listened to President Obama’s repeated statements that government was going to somehow fix what Obama calls “income inequality” it brought to mind several of the more depressing chapters of Any Rand’s novel Atlas Shrugged, which you recall envisioned a dystopian world in which government “looters” stripped society’s producers, thinkers and creators of the fruits of their labor in the name of equalizing society.”

“The looting of the fruit of their labor provoked the producers to withdraw from society. Without producers, thinkers and creators there was an economic implosion and society rapidly declined and fell into chaos.” 

Every time President Obama mentions government enforced income equality or government-led opportunity I think of the villains in Atlas Shrugged such as the politician Wesley Mouch (New York Senator Chuck Schumer) or crony capitalist Orren Boyle (various green energy vampires) to name only two.

In the words of Yogi Berra, “It feels like Da Ja Vu all over again.”

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

Please have a friend subscribe





  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.


Government Is The Problem Not The Solution

Stanley Feld M.D.,FACP,MACE


The government has been attempting to take over the healthcare system since 1935 at the time of the Roosevelt administration.

The government took over the healthcare system 30 years later during the Lyndon Johnson administration. LBJ passed Medicare and Medicaid. It turned out that financial projections were faulty and the business model was defective.

Medicare and Medicaid provided medical care for the elderly and the poor at an affordable price at that time. Everyone loved it. At the time it was also affordable for the government.

I do not think anyone contemplated the healthcare inflation that occurred as a result of the government’s business model.

Inflationary pressure increased rapidly.

Finally, President Reagan said the government could not afford the increasing prices any more. He said enough is enough. He decreased provider (hospital, doctors, pharmaceutical company, and insurance company) reimbursement for Medicare and Medicaid services.

The reduction in reimbursement for services resulted in price shifting increases in reimbursement in the private sector.

Both the private sector and the public sector experienced increased inflationary pressure as a result of this maneuver.

It was clear by 1984 that Medicare and Medicaid were unsustainable long term.  

America did not have a free market healthcare system before Obamacare. It was a hybrid system.

The country already had 90 million Americans in a single-payer system. Ninety million Americans get coverage from Medicare, Medicaid, and the Veterans Health Administration systems.

The problem is these government controlled single-payer systems did not work efficiently. They were financially unsustainable.

Obamacare expands the single party payer system to eventually cover all Americans. Obamacare simply adds on to an existing unsustainable healthcare.   Raising taxes is not going to make it more sustainable.

The expanded bureaucracy will only make the system more inefficient and more prone to fraud and abuse.

President Obama is already modifying the law without congressional approval. He is trying to hide elements of this unsustainability from the American public.

The federal government’s Obamacare enrollment system alone has already cost taxpayers about $2.1 billion dollars according to a Bloomberg government analysis of contracts related to the project.”

The website is still not working perfectly at the backend after spending $2.1 billion dollars.

Americans will experience more of the dysfunction after the mid term elections.  

Navigator companies hired to help people enroll cost $48 a session. These companies are increasing their prices for the 2015 enrollees.


These same companies have had their fraud and abuse exposed. Nevertheless they have been rehired at the increased price by the Obama administration.

President Obama announced to Democrats last spring that Obamacare would not be an issue at the time of the midterms.

This week the administration also announced that the cost of healthcare insurance through the health insurance exchanges is decreasing next year.

It was also announced that there is an increase in the choice of insurance carriers in most states resulting in competitive premium pricing and lower premiums.

President Obama announced that Obamacare is working. He said Obamacare is a non issue in the 2014 mid term elections.

Nothing could be further from the truth.

If our elected officials cannot see President Obama’s trick play how can the public expect to understand the deception?

This is another of the manipulations of Obamacare designed to hide its impending failure from the public.  

The Obama administration set up a reinsurance company funded by taxpayers that eliminates any insurance risk the healthcare insurance companies might incur in insuring enrollees.

Healthcare insurance companies are signing up and competing for market share to gain profit from this no risk insurance. They can easily afford to lower the premiums because the government will cover their supposed loses.

None of this has anything to do with patient care or the quality of patient care.

It has little to do with providing low cost insurance. The cost of insurance keeps increasing. The government pays the difference between the cost of insurance and what patients who receive subsidies pay for their premiums.

Obamacare misses the main problems in the healthcare system. Obamacare creates more dysfunction in the healthcare system.

 Obamacare will result in greater unfunded future liabilities.

White House spin pretends otherwise, but the unfunded liabilities may exceed $100 trillion.”

 The Congressional Budget Office said,

 “Looking indefinitely into the future, the unfunded liability, with optimistic assumptions, is $43 trillion—almost three times the size of today's economy.”

Based on more plausible assumptions, such as those reflected in the "alternative" scenario for Medicare produced by the Congressional Budget Office in June 2012, the long-term shortfall is more than $100 trillion.

It is the responsibility of our elected officials control America’s expenditures.

Unfortunately, for American’s, this is not how a government controlled system works.

Voters must decide how long they are going to tolerate this abuse of power.

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

Please have a friend subscribe


  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.