Stanley Feld M.D., FACP, MACE Menu

All items for April, 2017

Permalink:

I Don’t Get The Republican Leadership

Stanley Feld M.D., FACP, MACE

The media and Democrats in congress are stonewalling every initiative President Trump has presented whether or not it has merit. .

The American people have spoken. Donald Trump is President. Republicans control both the House of Representatives and the Senate.

I should think the Democratic leadership would realize they are not connecting with the people. They should fear for their jobs and the jobs of other party members.

Nancy Pelosi, chair of the House Democrats, said, “We are the opposition party and it is our job to be the opposition.”

She is wrong. The Democrats should be doing what is right for the American people.

Recent elections have proven Americans do not approve of the Democrats’ policies at federal, state or local levels.

President Obama’s Democratic court appointed judges are slapping temporary injunctions on some of President Trump’s executive orders for no logical reasons.

These injunctions are occurring despite the terrorist disruptions that have occurred in American cities.

President Obama and the Democrats did nothing to neither stop this loss of life nor decrease the fear these terrorists generated.

The judges are slowing his initiatives down until they get to higher courts.

Democrats are acting juvenile.

Paul Ryan and the Republican establishment are not helping President Trump fulfill his agenda. They seem to be tripping up President Trump at every turn.

At the same time they are making the Republicans look bad and the Democrats look good.

If some of President Trump’s executive orders need congressional approval the Republican leadership in both houses should start the legislative process to get that congressional approval.

It seems like the Republican establishment is doing everything to make President Trump an ineffectual president.

The Republican establishment is bickering over the fine points of the initiatives. They are not looking at the big picture.

The American public gave the Republicans both houses of congress in order to allow them to be effective. The nuclear option in the senate should guarantee legislative effectiveness.

President Trump has some good ideas to fix the healthcare system and create economic growth.

Paul Ryan is supposed to be a legislative genius.

Paul Ryan seems to be intimidated by the Democrats and the mainstream media. He has not been bold in stepping out and supporting President Trump’s initiatives.

He should realize that the majority of the American public is not paying attention to the mainstream media.

This is reflected in the decrease in readership of the New York Times and the viewership at CNN and MSNBC. The mainstream media should not be influencing Paul Ryan’s actions.

Everything President Obama did during his presidency slowed the economy and polarized the nation. Paul Ryan should be doing the opposite.

Everything President Obama did with Obamacare made the healthcare system less efficient and more dysfunctional. Paul Ryan should have had a Republican consensus plan ready to repeal and replace Obamacare.

It is embarrassing that he did not have a plan ready after seven years.

My advice to the Republican controlled congress is to give President Trump a break and give him some support.

Stop playing politics. You are playing right into the Democrats’ obstructionist hands.

Paul Ryan’s healthcare fiasco is the prime example. He wouldn’t be speaker if it would not for the election of members of the Freedom Caucus.

Paul Ryan should take the bill the house previously passed and send it to the Senate. If there are things in that bill that do not pass the sequestration test for the Senate to pass the bill with 51 votes modify the bill.

Ryan has not made it clear to the public what he thinks is wrong with the old bill. He has also been secretive about the ongoing negotiations to repeal and replace Obamacare.

Now Paul Ryan is delaying President Trump’s wall appropriation request. He seems to be delaying President Trump’s tax cut initiative until 2018 without explanation.

If it is because the healthcare bill is not passed then pass the old healthcare bill.

He and the establishment Republicans confuse me. I think the American people are confused. Maybe the Republican establishment has to be voted out of congress in order to get anything passed.

I believe what President Trump is trying to accomplish is pretty logical. President Obama and the Democrats messed us up over the last eight years.

Many Americans are hurting. Americans who are not hurting do not understand it. Perhaps they refuse to understand it.

It is time government starting working and trying new ideas.

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

All Rights Reserved © 2006 – 2017 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

Please have a friend subscribe

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

Permalink:

Those Indecipherable Medical Bills? Part 2 CPT Coding Is One Reason Health Care Costs So Much

Stanley Feld M.D.,FACP,MACE

After Ms. Wanda Wickizer was discharged from the University of Virginia Healthcare System (Part 1) the catastrophe caused by the healthcare system’s coding process began.

“The acronym HCPCS originally stood for HCFA Common Procedure Coding System, a medical billing process used by the Centers for Medicare and Medicaid Services (CMS).”

“Prior to 2001, CMS was known as the Health Care Financing Administration (HCFA).”

HCPCS was established in 1978 to provide a standardized coding system for describing the specific items and services provided in the delivery of health care.

The cost of Medicare and Medicaid became so high that the government decided to start knowing what it was paying for and standardizing the payments.

Such coding is necessary for Medicare, Medicaid, and other health insurance programs to ensure that insurance claims are processed in an orderly and consistent manner.”

This coding system has been dysfunctional since the government developed it for Medicare and Medicaid in 1978.

The unspoken goal was to decrease reimbursement for services provided for Medicare and Medicaid patients.

The government wanted to commoditize can reduce reimbursement by the evaluation of physician and hospital usage of procedure and services.

Initially, use of the codes was voluntary, but with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) use of the HCPCS for transactions involving health care information became mandatory.[2]

Ms. Rosenthal’s story is about how this poor woman, Wanda Wickizer, got trapped in the dysfunction of the healthcare system’s coding system.

Wanda Wickizer should have been insured through Obamacare. However, through the inefficiencies of the government or Ms. Wickizer lack of understanding of Obamacare she did not have insurance.

The healthcare system makes no provisions for billing the uninsured.

There are multiple prices charged for treatments and procedures. Hospital systems and physician groups have their own individual retail prices for services and procedures.

These providers negotiate prices with the government and the healthcare insurance industry.

There are many different prices negotiated by many different providers with the healthcare insurance industry. A healthcare insurance company negotiates many of the government’s final prices. The healthcare insurance company acts as the surrogate for the government.

None of these prices are transparent.

There is no one that negotiates price for the uninsured. The uninsured are responsible for the retail price of the services rendered unless they can negotiate a better price.

“And so in early 2014, without an insurer or employer or government agency to run interference between her and the hospital, she began receiving bills:

  • $16,000 from Sentara Norfolk (not including the scan or the E.R. doctor), $50,000 for the air ambulance.
  • Her local hospital
  • By the end of January, there was also one for $24,000 from the University of Virginia Physicians’ Group: charges for some of the doctors at the medical center. “I thought, O.K., that’s not so bad,” Wickizer recalls.
  • A month later, a bill for $54,000 arrived from the same physicians’ group, which included further charges and late fees.
  • Then a separate bill came just for the hospital’s charges, containing a demand for $356,884.42 but little in the way of comprehensible explanation.”

The uninsured are the only people who are responsible for the original retail prices. All the rest of the payment providers, namely the government and various members of the healthcare insurance industry pay their negotiated fees.

Shouldn’t the government pass a law requiring hospitals and doctors to charge only Medicare prices to the uninsured? It would eliminate Ms. Wickizer bill, a bill that reflects retail prices for services rendered.

The big mistake the University of Virginia made was that it did not provide her with a line item bill identifying the price of each service and procedure.

The University of Virginia subsequently refused to provide a line item bill to the patient. It was as if the university was hiding something.

Any thoughtful hospital administrator would have solved the problem in a minute.

It must be remembered that each provider has a different retail price per procedure and service. The reasoning is that they are trying to collect the highest amount they can.

There is something called a “chargemaster price.” It could help the uninsured figure out the wholesale price for services and procedures if they knew what the line item services and procedures they were charged for were.

The patient could then figure out what Medicare pays for those services and procedures.

However none of these line item charges are in the patients (EOB) Explanation Of Benefits. The EOB is impossible to interpret.

A simple rule should be passed by congress or issued by CMS saying a clear explanation of charges is required for payment of the bill.

The Obama administration knew about this uninsured billing problem. It did nothing about it because it wanted to force patients into buying Obamacare insurance even if they couldn’t afford it or didn’t need it.

I believe Tom Price M.D. (President Trump’s head of CMS) is aware of the problem. He also understands this simple way of solving it.

The healthcare insurance industry and the government get a detailed EOB for services rendered through the CPT coding system first established in 1978.

The Obama administration added 74,000 new codes to the CPT coding system. The government and the insurance companies wanted to know what they were paying for in detail.

This led to the requirement for Electronic Medical Records (EMR) and then meaningful use EMRs. Physicians and hospital systems will not get paid if they do not have a meaningful use EMR this year.

This led to a very expensive EMR development industry. EMRs were expensive. They did not function as meaningful use EMRs. They had to undergo extensive upgrades.

An EMR function should really be a teaching tool, teaching physicians how to upgrade their services to the best evidence based medicine practices.

Instead it has become a tool for the government and the healthcare insurance industry to punish patients.

The EMRs are unaffordable to many physicians. It has force them to sign up to become hospital system employees.

The government should have built a universal EMR in the cloud and charged physicians by the click.

The increase in codes led to an expensive coding industry. People are trained to teach physicians and hospital systems how to use the new 88,00 codes correctly.

The industry essentially teaches those providers how to how to game the healthcare system so that they can collect the most money for their services from the government and the healthcare insurance industry.

The goal of the government is to reduce reimbursement to providers.

Where is the consideration for patients in all of these maneuvers?

Where is the consideration for the uninsured patients?

Ms. Rosenthal’s main point is that CPT gaming by the medical professions and hospital systems are driving up healthcare costs.

However, missing from her argument is who developed the dysfunction CPT system.

Why was it developed?

Why was coding made so complex that it drives users of the coding system to game the system?

Ms. Rosenthat gives a few examples of coding driving the costs up.

  1. The diagnosis code for “heart failure” (ICD-9-CM Code 428) instead of the one for “acute systolic heart failure” (Code 428.21), the difference could mean thousands of dollars.

“In order to code for the more lucrative code, you have to know how it is defined and make sure the care described in the chart meets the criterion, the definition, for that higher number.”

In order to code for “acute systolic heart failure,” the patient’s chart (EMR) ought to include supporting documentation, for example, that the heart was pumping out less than 25 percent of its blood with each beat and that he was given an echocardiogram and a diuretic to lower blood pressure. Submitting a bill using the higher code without meeting criteria could constitute fraud.”

“Each billing, then, can be seen as a battle of provider coder versus payor coder.

The coders who work for hospitals and doctors strive to bring in as much revenue as possible from each service, while coders employed by insurers try to deny claims as overreaching.”

Hospital based physicians are taught how to up-code to generate the most income. They have little say in the coding process. Patients have no way of knowing if a procedure or service is coded.

  1. In a doctor’s office, a Level 3 visit (paid, say, at $175) might be legally transformed into a Level 4 (say, $225) by performing one extra maneuver, like weighing the patient or listening to the lungs, whether the patient’s illness required that or not.
  2. E.R. doctors have been taught that insurers might accept a higher-reimbursed code for the examination and treatment of a patient with a finger fracture (usually 99282) if — in addition to needed interventions — a narcotic painkiller was also prescribed (a plausible bump up to 99283), indicating a more serious condition.

The actual cost and expertize that might go into these services are never discussed or considered by bureaucrats decision and policy makers.

Price transparency for the patients would make a world of difference to costs. It would drive the cost of care and healthcare premiums down.

It might even result in the development of competitive pricing and a free market system.

I am sure the Trump administration is aware of this defect in the dysfunctional healthcare system.

President Obama ignored the problem as he tried to control hospital systems and physicians. He simply down coded services.

He probably figured that a single payer system would make everything much easier.

All I can say is look at the government run Veteran Administration Healthcare System.

Why most politicians ignore the coding defect in coding is beyond me?

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

All Rights Reserved © 2006 – 2017 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

Please have a friend subscribe

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

Permalink:

Those Indecipherable Medical Bills? CPT Coding Is One Reason Health Care Costs So Much: Part 1

Stanley Feld M.D.,FACP,MACE

Elisabeth Rosenthal is editor in chief of Kaiser Health News and a former senior writer at The New York Times.

She wrote an extensive article in the New York Times Sunday Magazine Section on the abuse of a hospital system on a patient without healthcare insurance.

Ms. Rosenthal usually points out defects in the healthcare system in great detail. She usually ignores the primary causes of those defects which leads to stakeholders’ adjustments.

Those adjustments lead to abuses of both the healthcare system and consumers utilizing the healthcare system.

It is important for all consumers and politicians (designated surrogates of consumers) to understand these abuses in detail.

It is doubly important that consumers and politicians understand the primary causes for these abuses.

The ideal goal would be to fix the primary causes so that stakeholders cannot abuse the system. In Ms. Rosenthal’s case study the University of Virginia’s bureaucrats are the decision makers who are far removed from the primarily medical care of patients.

They are far removed from the development of a physician/patient relationship. The patient/physician relationship is so vital to the success of a healthcare system.

These bureaucrats are immune to the tragedy that had befallen Ms. Rosenthal’s example, Ms. Wanda Wickizer. They are stuck in the rules its organization made or their interpretation of these rules.

There does not seem to be any flexibility built into the University of Virginia’s Medical School billing system.

The patient in Ms. Rosenthal story is not entirely immune to the disaster that occurred subsequently.

Her husband died in 2006. He had great city of Norfolk Virginia health insurance. The city of Norfolk continued providing her and her kids with insurance for the next three years.

“Her husband, who died in 2006, worked for the city of Norfolk, which insured their family while he was alive and for three years beyond.”

“After his death, Wanda Wickizer worked in a series of low-wage jobs, but none provided health insurance. A minor pre-existing condition — she was taking Lexapro, a common medicine for depression — meant that her only insurance option was to obtain Obamacare insurance through a health insurance exchange in 2010.

In 2009 only ineffective and costly state administered “high-risk pools” were available. High risk pools disappeared in 2010 with the passage of Obamacare.

She said she could not afford her Obamacare option. However, she did not consider the Obamacare option in her economic condition. Obamacare would have subsidized her insurance coverage up to 100%.

“She thought she would need to pay more than $800 per month for a policy with a $5,000 deductible, and her medical procedures would then be reimbursed at 80 percent. She felt she couldn’t afford that.”

She made a decision that did not take into account a potential medical catastrophe.

“In 2011, she decided to temporarily stop working to tend to her children, which qualified them for Medicaid; with trepidation, she left herself uninsured.”

At this point she probably would, also, have qualified for Medicaid or gotten insurance through the health insurance exchanges that would have been subsidized up to 100% by Obamacare.

Additionally, after she was sick she could have applied for Obamacare insurance. She would have supposedly received full insurance coverage at no cost to her. The application for Obamacare after the onset of an illness is one of the major objections to Obamacare.

This is a defect in Ms. Rosenthal’s story. It could have easily been avoided if Ms. Wickizer applied for insurance available to her at minimal charge.

The casual reader of the Sunday NYT magazine section could easily overlook this defect.

The rest of the story is about the billing catastrophe. Ms. Rosenthal exposes all the defects in the healthcare billing system structure.

A catastrophic illness struck Wanda Wickizer on Christmas Day 2013. It was a subarachnoid hemorrhage that can strike at any time.

“The catastrophe struck Wanda Wickizer on Christmas Day 2013.”

It occurred four years after Obamacare was enacted. She had a debilitating headache. The ambulance paramedics missed the diagnosis. They thought she had food poisoning and did not take her to the hospital.

Later, she, at 3 a.m. became confused and groggy. Her boyfriend raced her to Sentara Norfolk General Hospital. A CAT scan revealed a subarachnoid hemorrhage.

Sentara Norfolk General Hospital felt it could not handle the subarachnoid hemorrhage and air evacuated her by helicopter to University of Virginia Medical Center in Charlottesville 160 miles away.

At UVM the hemorrhage was stopped and the previous accumulation of blood evacuated. She was in the hospital for 3 weeks. When she was home the catastrophe of the healthcare system coding process began.

Ms. Wanda Wickzer’s story will be continued in Part 2 of Those Indecipherable Medical Bills? CPT Coding Is One Reason Health Care Costs So Much

The opinions expressed in the blog “Repairing The Healthcare System” is, mine and mine alone.
All Rights Reserved © 2006 – 2017 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE
Please have a friend subscribe

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

Permalink:

Feld Men’s Weekend

Stanley Feld M.D.,FACP,MACE

Every year I have gone away with each of my sons, Brad and Daniel for a weekend. We just talk about our lives and have a good time being with each other.

I figure it is good for our health. The boys agree.

My readers have had an extremely positive response to past where I have written about these one on one trips.

Readers know my bother and I are very close. He also lives in Dallas. We meet and have a pastrami sandwich together once a month whether we need it or not.

We have also gone away for weekends in the past with all the Feld men, my two sons and my brother’s two sons.

These weekends have been great for all of us. My sons live in Boulder Colorado, Kenny lives in Atlanta and Jon lives in Dallas.

The boys were close as kids. They have not gotten together very much in the last few years.

However, they love the weekends we have had to bond and just have fun.

It has been very difficult to get everyone together the past four years. This year Brad was determined to make it work. He got tickets to the NCAA finals.

The notification said anyone who can come should come. Unfortunately, Daniel could not come. He and his family were going to be in Japan that week.

The Feld Men have officially added a new member to the group. Jon’s son Jack is now 16.

Jack is a very smart kid. He kept up with all of our conversations. He even taught us a bunch of things.

I welcome Jack to the club!

My brother and I took 7.30 am Southwest Airlines flight to Phoenix on Friday March 31.

Kenny, Jon and Jack were not coming in until Saturday at 10.am. Brad was in Scottsdale for the previous month.

Charlie and I decided we wanted to hang out with Steve Hochschuler and his wife Kim all day Friday.

Steve is co-founder of Texas Back Institute. He has been a good friend since 1970. We both graduated from Columbia College.

Steve now lives in Desert Mountain part-time. He and Kim showed us a great time. Desert Mountain is very upscale. There are lots of big houses, and fancy cars.

There are very few trucks in his neighborhood. Steve has been irreverent all of his life. Steve has the biggest truck with the biggest and bad-est tires I have ever seen.

Their house is magnificent. Lunch and diner at local Desert Mountain restaurants were wonderful.

Steve and Kim took us to a neighbor’s house for a wine tasting with food before dinner. Both the wine and the food were out of sight.

They are living the good life.

This was a good start for the weekend. Charlie and I then drove to the Sanctuary in Paradise Valley to meet up with Brad.

The house Brad rented was beautiful. It had a pool and a tennis court with magnificent mountain views.

I was so tired I fell asleep instantly.

On Saturday morning Jon, Kenny and Jack all arrived at 10 am. We went out for breakfast/brunch to a place Brad and Amy found called Scramble.

Scramble looks like a PF Changs with menus on the sidewall as you wait on line to order and choose your food. The have everything from the simple breakfast to the most exotic omelets, waffles and pancakes.

Scramble

We ate enough breakfast for a week but we were not finished.

Our next stop was Dairy Queen. This old Dairy Queen was a standout in a contemporary designed Scottsdale shopping center.

Dq

Neither Jon, Kenny nor Jack ever had a Dairy Queen Blizzard.

Brad and I told them they had to have a Chocolate Extreme Blizzard.

All three were hesitant by finally complied.

On line DQ

They all loved it.
Gang at DQ
DQ icream thick enough not to spill.

Next back to the Sanctuary and Brad’s house. It was time to hang out with each other.

Brad and Kenney

After a while we all took our Feld traditional afternoon nap.

Me napping
I learned to nap in a chair as a medical intern in 1963.

The “car” picked us up at 2:15 for a 5:09 starting time for Gonzaga vs. South Carolina. The games were being played at the Arizona Cardinals football field in Glendale Arizona.

It was far from Scottsdale and the traffic on Saturday afternoon was horrible.

Me and kenny in crowd

Brad had Jon pick the seats because Jon was experienced in watching basketball in a football stadium.

He picked great seats on the 50 yard line in row D of the first deck. The people watching on the floor had to strain their necks. They were always looking up. The playing field was raised a couple of feet.

Tip off

The North Carolina vs. Oregon game followed. It thought both games stunk. All four teams had terrible shooting percentages.

The television timeouts were endless. They took up more time than the regular timeouts. It became annoying.

The food was the typical terrible stadium food. Some stadiums and arenas I have been to have pretty good food including Coors Field, Fenway Park, the Yankee Stadium and the American Airlines Arena in Dallas.

After the games we found our driver easily. He was a master of heavy traffic driving and got us home nicely.

All of us were bushed except for Jack. He was hungry. He wanted a hamburger at 10:30 pm. I guess this is what happens when you are a sixteen year old.

On Sunday morning we all met at 9:30 a.m. for a 9:45 a.m. reservation at Rita’s Kitchen at the suggestion of Kim Hochschuler.

She took Cecelia and me to Rita’s once before. The atmosphere was as good as ever. It was a two and a half hour brunch.

After brunch some quiet time at the Sanctuary. At about 2:30 I went to the fitness center to work out and then to the pool.

We had a six o’clock reservation at the Wildfish Sea Food Grille in Scottsdale. Jack picked up the fact that the font on the menu and the description of the dishes were the same as Eddie V’s in Dallas.

Everyone wiped out their cell phones to see if there was a relationship. There is. The Darden Restaurant chain owns both restaurants as well as Olive Garden, Red Lobster, Seasons 52 and the Capital Grille.

Three of us had steak and three had fish. The waiter was upset that the chef undercooked the steaks. He complimented desert for the table.

I was afraid we were all going to miss the hot fudge sundaes at the Sugar Bowl in Downtown Scottsdale.

The desert was fair. They did not have chocolate ice cream in the restaurant.

After diner we went back to Brad’s rental house. We all watched 1941. I thought it was the dumbest movie I ever saw.

It was a 1979 flick for teenage boys. My bother and Kenny baled after 20 minutes. I stay to the end. Brad and Jon were teenagers in 1979. They thought it was great then but lousy now.

Monday was the day of the finals between Gonzaga and North Carolina.

We had lunch at a Sports Bar. Then we finally got to the Sugar Bowl to have their fabulous hot fudge sundae.

Sugar bowl

Sugar Bowl 2

Me and brad at sugar

Brad and me eating at Sugar Bowl

We left for the NCAA Final at 2:30 to beat the traffic for a 6:09 p.m. game.

I will not complain about the traffic in Dallas, Texas anymore. We got to the stadium at 5:30 p.m.

Both teams played a lousy game. Shooting percentage for both was under 40%. Free throw percentage was not much better.

However, the festival of the NCAA final and the excitement of the crowd made the lousy game worth it.

When we arrived at Brad’s house Jack needed a hamburger at 10:30 p.m. again.

I went to sleep immediately because we were leaving for the airport at 5.15 a.m.

I slept on the plane for the entire ride home.

This was another successful “Feld Men’s Trip.” I can’t wait until next year.

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

All Rights Reserved © 2006 – 2017 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

Please have a friend subscribe

  • Kris Mathew

    I read your full article. It is very very nice article. You explained everything very nicely and put so many good pics. I enjoyed through out reading. Maximum weekend we also go for outing and enjoyed so much with my family. I think every people should go for outing, minimum one weekend in a month. How good for health you know but it’s confirmed that very good for our mental relaxation. I want to give you so many thanks from my bottom heart for this fantastic article. Please do more post. I will visit again and again for your post.

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