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President Obama; If You Really Want To Reduce Healthcare Costs, Effectively Reform The Medical Malpractice Tort System: Part 4


Stanley Feld M.D.,FACP,MACE


President Obama, there are other consequences of the present malpractice liability system that cannot measured in dollars or impact. In order to avoid potential law suits physicians are avoiding high risk patients and high risk patient procedures. The result is a decrease in patient access to necessary care.

The measured costs of defensive medicine can be calculated from the Massachusetts Medical Society survey.

“Physicians practice defensive medicine because they don’t trust the medical liability system. This survey should provide a strong impetus for legislative, business, and health care industry initiatives promoting fundamental liability reform.”

It is essential to introduce effective and fundamental liability reform to reduce the practice of defensive medicine, decrease costs and improve access to care.

The Massachusetts Medical Society’s survey of physician concerning defensive medicine also point out the restriction of access to care as a result of the malpractice environment.

“The survey found that 38 percent of responding physicians reported they reduced the number of high-risk services they performed, with orthopedic surgeons (55%), obstetrician/ gynecologists (54%), and general surgeons (48%) reporting the highest frequencies.”

These actions by physicians’ specialties are a natural reaction to the malpractice environment. It also reduces the healthcare system’s capacity to care for sick patients.

“28 percent of physicians in the sample reported reducing the number of high-risk patients they saw, with obstetrician/gynecologists (44%) and the surgical specialties (37–42%) much more likely to reduce their number of high-risk patients.”

In many small or medium sized communities there is little or no access to medical or surgical specialists to take care of high risk patients. President Obama, rather than increase the quality of care, as you have promised, the quality of care in some communities will decrease.

Other surveys by the Massachusetts Medical Society confirm their survey.

“In its annual Physician Workforce Study over the last five years, the Society has found that an average of 44%-48% of physicians in the state reported that they are altering or limiting their practices because of the fear of being sued.”

The 2008 workforce study’s results were worse than the Massachusetts Defensive Medicine survey. More than half of physicians in seven specialties said they have progressively limited their practices, the fear of a frivolous malpractice suit being the primary reason. It is natural for people to adjust to their environment.

“Neurosurgery practices (76%), urology (75%), emergency medicine (66%), obstetrics/gynecology (57%), family medicine (53%), general surgery (51%), and orthopedics (51%).”

President Obama, what should you do to neutralize the negative impact of defensive medicine?

First, do not believe the arguments of the trial lawyers. The claim that malpractice reform will harm patients "by limiting their ability to seek compensation through the courts" is a smoke screen to protect their profitability in law suits.

The medical liability system is inefficient. It does not compensate patients experiencing medical errors very fairly. In fact more than 50 cents on every compensated dollar goes to pay lawyers and the courts. Patients may wait year to receive a single penny. The wear and tear of a malpractice suit on patients experiencing medical errors and physicians being sued is enormous.

The answer is not to leave it up to congress to work it out. Congress has a 30% approval rating. Congress is also composed mostly of lawyers. You are our leader. You are the one who must outline the change that is fair to patients, the government, and physicians.

The fundamentals of change should include the following:

  1. Decrease the profitability of malpractice suits for attorneys.
  2. Invest in a culture of patients’ safety at every healthcare enterprise.
  3. Promote full disclosure to patients about adverse events quickly without legal consequences.
  4. Promote apology to patients without legal consequences.
  5. Provide fair compensation to patients for medical errors.
  6. Professional mediation and arbitration to resolve disputes quickly and dismiss frivolous claims abruptly.
  7. Create a body of judges immune from liability to adjudicate malpractice suits. The body should be composed of physicians and lay leaders. The best judge of physicians medical errors are other physicians if they were freed of adverse countersuit
  8. Create a system of no fault malpractice insurance.
  9. Place limits on patient compensation and expedient rate of compensation.
  10. Eliminate the adversarial nature of the claims.
  11. Build trust between patients and physicians.

Defense attorneys will hate most elements of this proposal because it threatens their vested interest and profitability. I suspect they will fight them with tooth and nail.

President Obama, if you implement these proposals to fundamentally change the medical liability system you would go a long way to reduce the practice of defensive medicine and a yearly wasted cost of $700 billion dollars to the healthcare system.

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



President Obama; If You Really Want To Reduce Healthcare Costs, Effectively Reform The Medical Malpractice Tort System: Part 3


Stanley Feld M.D.,FACP,MACE

President Obama, the details of the Massachusetts Medical Society Defensive Medicine survey have profound importance in explaining trends in the delivery of medical care. Unfortunately, only meaningless sound bites have been given by the media. The survey’s significance has not had the impact on policy it should.

The authors state that the dollar estimates do not include the diagnostic procedures, hospital admissions, specialty referrals and consultations or unnecessary prescription by physicians in specialties not included in the study.

The eight specialties surveyed represent only 46% of the physicians in the Massachusetts. The real costs to the healthcare system from the practice defensive medicine in the state of Massachusetts are much higher. The authors estimate the real costs could be twice the $1.4 billion dollars per year they estimated.

I believe the costs of defensive medicine in many other states are much higher because the cost of litigation in many states is lower and the malpractice awards are higher encouraging litigation.

“This survey clearly shows that the fear of medical liability is a serious burden on health care,” said Dr. Sethi. “The fear of being sued is driving physicians to defensive medicine and dramatically increasing health care costs. This poses a critical issue, as soaring costs are the biggest threat to the success of Massachusetts health reform efforts.”

Defensive medicine is definitely a threat to the success of the Massachusetts healthcare reform efforts. President Obama, defensive medicine is a big burden nationally to the healthcare system. Its costs will undermine any attempt at healthcare reform unless you take medical malpractice liability reform seriously. There has to be a fundamental change in the structure of adjudication.

The survey’s findings must be studied carefully. The physicians surveyed estimated their percentages for defensive medicine testing to avoid law suit. I think their estimates are low. The real percentages must be studied objectively using data mining techniques. Nonetheless the current estimates reveal unsustainable waste in our dysfunctional healthcare system.

Radiological imaging is one tool overused by physicians defensively to avoid litigation. Physicians feel they must test everything even if the probability of a positive result is insignificant.

“Plain Film X-Rays: An average of 22% of X-rays were ordered for defensive reasons.”

“CT Scans: An average of 28% of CT scans were motivated by liability concerns, with major differences among specialties.”

About 33% of scans ordered by obstetricians/ gynecologists, emergency physicians, and family practitioners were done for defensive reasons.

The total number of unnecessary CT scans needs to be calculated along with its costs in order to understand the significance of the percentage presented. The health policy solution should not be to lower the reimbursement for CT scans. The solution is to fix the medical malpractice liability system.

MRI Studies: An average of 27% of MRIs were ordered for defensive reasons, with significant differences by specialty.

The highest rates were reported by obstetricians/ gynecologists, general surgeons, and family practitioners, with the lowest rates by neurosurgeons and emergency physicians.

Ultrasound Studies: An average of 24% of Ultrasounds were ordered for defensive reasons. Orthopedic surgeons (33%) and obstetricians/gynecologists (28%) reported the highest rates, with neurosurgeons (6%) and anesthesiologists (9%) the lowest.

I believe neurosurgeons are underestimating their use of radiologic procedures in order to look good. Neurosurgery is one of the specialties with the highest malpractice rates. Please note that obstetricians/gynecologists take no chances and order the most procedures for defensive purposes.

Laboratory Testing:

An average of 18% of laboratory tests were ordered for defensive reasons, with emergency physicians (25%) reporting the highest rates and neurosurgeons (7%) the lowest.

Specialty referrals, consultations and hospitalizations are overused the most for defensive reasons. No one wants to take a chance and send the patient home even if the indication for hospitalization is small. Hospitalization is also the most costly overused element in defensive medicine.

Specialty Referrals and Consultations:

“An average of 28% of specialty referrals and consultations were motivated by liability concerns, with significant differences by specialty. Obstetricians/gynecologists reported that 40% of their referrals and consultations were done for defensive reasons, and anesthesiologists and family practitioners said that 33% of their referrals and consultations were done for the same reasons.”

Hospital Admissions:

An average of 13% of hospital admissions were motivated by liability concerns, with surgical specialties reporting lower rates than the other specialties.

The percentages of defensive procedures are admitted by practicing physicians. The cost of defensive medicine is high and wasteful. President Obama, defensive medicine is not the minor problem that the malpractice attorneys want you to believe it is. It is time for definitive action now.


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


President Obama; If You Really Want To Reduce Healthcare Costs, Effectively Reform The Medical Malpractice Tort System: Part 2

Stanley Feld M.D.,FACP,MACE


President Obama, as you know the real truth is elusive. Every vested interest has an agenda to protect. My agenda as a long time practicing Clinical Endocrinologist, now retired from active practice, has been to preserve the value of the profession of medicine and permit the delivery of the best clinical care possible to patients. Society has strayed from these goals. There are multiple problems with the healthcare system. They are interrelated and must be solved simultaneously.

The present malpractice liability problem leading to the practice of defensive medicine is a huge problem for the healthcare system. It is essential that this problem be solved before meaningful cost savings and increased quality of care are realized

Malpractice attorneys dismiss the system of adjudicating malpractice liability as the cause of significant defensive medicine costs. They claim that they are the protectors of mistreated patients. You will soon receive a 29 page document defending their claim and dismissing the significance of defensive medicine.

“Trial lawyers are preparing for a fight, starting with a 29-page research document they will send to Capitol Hill in an attempt to convince lawmakers that lawsuits have very little to do with healthcare costs.”

The malpractice attorneys will attempt to make a compelling argument. I suspect they will have little real scientific evidence to prove their point in the 29 page document.

Donald Berwick Professor in the Department of Health Policy and Management Department of Health Policy and Management has never been a friend of practicing physicians. He has frequently pointed out the defects in the practice of medicine. Recently Don Berwick made the following off the cuff comment in response to a question after he addressed the American Medical Association (AMA) meeting.

"What about malpractice reform?" the first questioner asked when Berwick opened up the discussion to attendees. He was a physician, and murmurs of approval rippled through the crowd.”

Berwick’s answer didn’t please the questioner and many of his colleagues. “The data just doesn’t back up the claim that malpractice lawsuits are one of the top drivers of healthcare costs, he replied.”

No one was brave enough to ask Dr. Berwick to show them the data for this conclusion. I have read Fooled By Randomness twice. I am starting to understand that all expert opinions are noise unless they are confirmed scientifically. Even then conclusions can change as the knowledge base changes.

In November 2008, the Massachusetts Medical Society published a survey of practicing physicians. The purpose of the survey was to get a sense of what practicing physicians (the generators of defensive medicine) thought the incidence of defensive medicine was in their practice. I was surprised it was not published in the New England Journal of Medicine.

“A first-of-its-kind survey of physicians by the Massachusetts Medical Society on the practice of “defensive medicine” – tests, procedures, referrals, hospitalizations, or prescriptions ordered by physicians out of the fear of being sued – has shown that the practice is widespread and adds billions of dollars to the cost of health care in the Commonwealth.”

The devil is usually in the details. The details found were the details at ground level. It was not speculations by experts or secondary measurement. The defect in the survey was the fact that was a survey (surveys have its scientific defects) even though 900 practicing physicians in eight specialties in Massachusetts completed the survey. Its strength is the survey links practice to costs.

“The Investigation of Defensive Medicine in Massachusetts” is the first study of its kind to specifically quantify defensive practices across a wide spectrum and among a number of specialties. The study is also the first of its kind to link such data directly with Medicare cost data.”

Physicians self reported on seven tests that might be used in defensive medicine. They were plain film X-rays, CT Scans, Magnetic Resonance Imaging (MRIs), ultrasounds, laboratory testing, specialty referrals and consultations.

Based on Medicare reimbursements rates in Massachusetts for 2005-2006 the eight specialties surveyed generated 281 million dollars in defensive medicine costs in outpatient clinics. Their practice of defensive medicine also generated $1.1 billion in unnecessary costs for hospital admissions. The big winner here was the hospitals. Hospitals might not be motivated to fight as hard as physicians to eliminate defensive medicine because defensive medicine serves its revenue generating agenda well.

The estimate of a total of $1.4 billion only includes 7 tests and 8 specialties in a 900 physician sample. Massachusetts is a small state. If we assume all the states are the same size and multiple by 50 states we are talking about $70 billion dollars wasted on defensive medicine.

If the survey included all specialties, all physicians, and all costs including the cost of malpractice premiums and physician practice time lost in litigation in all states, my guess would be the cost of defensive medicine would be ten times the 70 billion dollars. A $700 billion dollar cost for defensive medicine is an unnecessary cost to the healthcare system. This cost can be dismissed lightly or yield to unscientific expert opinion. The result does not include the emotional toll on physicians being sued and the lawsuits effect on their ability to practice medicine.

The legal system for handling malpractice claim is very costly. A more logical and cost effective system for adjudicating patients harmed by medical error needs to be instituted.

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


President Obama; If You Really Want To Reduce Healthcare Costs, Effectively Reform The Medical Malpractice Tort System ?: Part 1

Stanley Feld M.D.,FACP,MACE

President Obama, you have not discussed the need for medical malpractice reform. Without medical malpractice reform you will not be able to reduce the cost of healthcare and increase the quality of medical care. It will be difficult because malpractice reform goes against the vested interest of some of your major supporters, plaintiffs’ malpractice attorneys.

There is at least one trillion dollars of waste in our $2.3 trillion dollar healthcare system. One hundred fifty million dollars ($150 million dollars) is wasted on excessive administrative costs by the healthcare insurance industry. The remainder is generated by the practice of defensive medicine and cost of malpractice insurance.

“Much of this waste is generated or justified by the fear of legal consequences that infects almost every health care encounter. The legal system terrorizes doctors. Fear of possible claims leads medical professionals to squander billions in unnecessary tests and procedures.

Physicians and nurses are afraid to speak candidly to patients about errors. They try to explain the risk reward ratio of treatments for fear of assuming legal liability. The result is the practice of defensive medicine and over testing to cover every possible contingency. This legal anxiety is also corrosive to the therapeutic magic of the physician patient relationship.

It would be relatively easy to create new rules that would provide a reliable system of justice for patients harmed by medical treatments and procedures without encouraging costly litigation. If a new system was in place it would decrease the costs of defensive medicine significantly. It would encourage physicians use of clinical judgment rather than expensive tests and improve the physician patient relationship.

“ The good news is that it would be relatively easy to create a new system of reliable justice, one that could support broader reforms to contain costs.”

Everyone makes mistakes in every walk of life. The legal liability threat could generate further unnecessary errors. Physicians, nurses and hospitals are advised not to offer explanations about a mistake. Sometimes errors are concealed to avoid a legal ordeal. The hidden error could be compounded by additional mistakes.

“Even in ordinary daily encounters, an invisible wall separates doctors from their patients. As one pediatrician told me, “You wouldn’t want to say something off the cuff that might be used against you.”

There are cost multipliers created as mistrust accelerates between the patients and physicians. You would like physicians to adopt electronic medical records. Some physicians avoid using EMRs because the information could be misinterpreted and used against them. There is an increasing use of second opinions. Every examination requires an observer for the examination to avoid legal liability. Every problem requires multiple laboratory tests to rule out something that might have been missed. An example is a CAT in the Emergency Room for even the slightest head trauma.

“Medical cases are now decided jury by jury, without consistent application of medical standards. According to a 2006 study in the New England Journal of Medicine, around 25 percent of cases where there was no identifiable error resulted in malpractice payments.

“Nor is the system effective for injured patients — according to the same study, 54 cents of every dollar paid in malpractice cases goes to administrative expenses like lawyers, experts and courts.”

These are the major tort reform issues. They must be addressed to decrease wasteful expenditures in the healthcare system. Malpractice lawsuits are a growth industry for defense attorneys, a burden to physicians having to defend themselves and a significant cost to the healthcare system. Malpractice reform is essential to any meaningful healthcare reform. President Obama, I think you know it. The question again is will to take the correct route to reform the malpractice tort system.

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


President Obama Ignores The Issue Of Malpractice Reform

Stanley Feld M.D., FACP,MACE

President Obama, in his signature legislation Obamacare ignores the issue of the need for malpractice reform (tort reform).

The need for tort reform is vital if President Obama really wants to reduce the cost of healthcare due to over testing.

The influence of the disinformation by the administration and the traditional media is terrifying. Inaccurate opinions by influential people will never lead to a functional, affordable healthcare system. It will only lead to increased stakeholders’ distrust and greater dysfunction in the healthcare system.

An excellent example of this disinformation is Senate Majority Leader Harry Reid, a Nevada Democrat, claiming: "The whole premise of a medical malpractice 'crisis' is unfounded."

Harry Reed, as usual, offers no data or proof for his statement. It is his opinion based on no facts.

Dr. Ezekiel Emanuel expressed his opinion in 2011.

“Everyone — conservative and liberal — agrees that $2.6 trillion a year is too much to spend on health care, and that we have to cut costs. But they don’t agree on who is to blame or what is to be done.”

I agree with this opinion. Everyone reaches the conclusion they want to reach using whatever facts they want to use.

He proposes an artificial threshold of significant cost savings in order to form a policy.

 “ A useful threshold for savings is 1 percent of costs of healthcare, which comes to $26 billion a year. Anything less is simply not meaningful.”

One percent is arbitrary. It permits Dr. Emanuel to dismiss problems that cost the healthcare system less than $26 billion a year.

The validity of the data collection is of no concern to Dr. Emanuel. He says only $1.3 billion results in malpractice costs. He ignores over testing, and lawsuit costs.

He says,

“Health care spending in the United States typically increases by about $100 billion per year. Cutting a billion here or there from something that large is undetectable is meaningless. In health care, you have to be talking about tens of billions of dollars before you are talking about real money.

A study, closer to truth than just an opinion, disclosed:

The truth is a full accounting reveals that more than 10 percent of America's health expenditures per year are spend on tort liability and defensive medicine.

This study concludes that $242 billion a year extra spent because of the lack of tort reform.

The $242 billion is well above Dr. Emanuel’s fictitious threshold.

Physicians have admitted to over testing in the Massachusetts Medical Society survey for fear of having to defend themselves against frivolous malpractice suits for potentially missing a diagnosis.

Most physicians love practicing medicine but cannot understand the unbelievably wrong direction President Obama is taking to reform the healthcare system.

In fact, in a recent study by the Physicians Foundation, six out of ten physicians said they would quit medicine. Many physicians are looking for viable exit strategies to avoid quitting.

The Physicians Foundation commissioned an extensive survey of nearly 13,575 physicians. Meritt Hawkins, the physician search and consulting firm, conducted the survey. 

“The survey found that 60% of physicians would retire today, if given the opportunity—an increase from 45% in 2008. And it's not just disgruntled and tired Baby Boomers who want to abandon their healing work. At least 47% of physicians under 40 also said they would retire today, if given the opportunity.”

The survey pointed out many major problem areas.

Two specific issues consistently agreed on by physicians were malpractice concerns and the need for tort reform as well as the lack of cohesive leadership among all physician groups to represent the vested interests of physicians and their patients.

This survey is an excellent. It is a detailed survey that has heightened the awareness of physicians’ practice problems.

The percentage of healthcare costs is even greater when the Massachusetts Medical Society survey is taken into account. The amount spent for defensive medicine can be extrapolated to actual costs from this survey.  

I have written a series of blogs analyzing the impact of the Massachusetts Medical Society’s survey. The extrapolated costs turn out to be about $700 billion a year. The real cost of defensive medicine is somewhere between $242 and $700 billion dollars a year.

In 2003, Texas Governor Rick Perry and the Texas legislature unenthusiastically changed tort reform laws in Texas.

Rick Perry and the Texas legislature rewrote the medical malpractice laws, ending plaintiff attorneys’ practice of venue shopping for friendly judges. They also put a cap of $250,000 on noneconomic damages like pain and suffering.

These reforms have changed the malpractice legal climate in Texas. The reforms limited plaintiff’s attorneys’ profitability on frivolous liability claims.

Texans believe that because of these reforms and the lack of a state income tax, Texas is the country's best state for economic growth and job creation.

A Perryman group report concluded,

Perhaps the most visible economic impact of lawsuit reforms is the benefits experienced by Texans who have better access to high-quality healthcare.

Doctors and hospitals are using their liability insurance savings to expand services and initiate innovative programs; those savings have allowed Texas hospitals to expand charity care by 24%.

The medical malpractice business for plaintiff’s attorneys has dried up in Texas. They are moving to other states. Physicians are applying for licenses to move to Texas from high medical malpractice states. 

“In 2001, according to the American Medical Association, Texas’ ranking in physicians per capita was a dismal 48th out of 50.”

“Beginning in 2003, physicians started returning to Texas. The Texas Medical Board reports licensing 10,878 new physicians since 2003, up from 8,391 in the prior four years.”

 “Dr. Perryman, subsequent to the issuance of his Report, informed TLR Foundation that at least 1,887 of those physicians are specifically the result of lawsuit reform.”

 The Texas Hospital Association reported a 70% reduction in the number of lawsuits filed against the state’s hospitals.

Medical liability insurance rates declined. Many doctors saw average rates drop between 20% to 50%.

The Perryman Group during the course of this study suggests that premiums are declining even further in 2008.”

The American Medical Association removed Texas from its list of states experiencing a liability crisis; marking the first time it has removed any state from the list.

 A survey by the Texas Medical Association also found a dramatic increase in physicians’ willingness to resume certain procedures they had stopped performing, including obstetrics, neurosurgical, radiation and oncological procedures during the Texas malpractice crisis.

 Two simple changes in the tort laws made malpractice suits unprofitable for plaintiff attorneys.

Rick Perry has been so impressed with the results of his tort reforms that he now wants to extend his state's impressive tort reform record.

Mr. Perry is proposing a British-style "loser pays" rule, which would require plaintiffs to pick up the legal costs of their targets if they lose their suits.

Almost all of America's economic competitors in the world follow this standard. “Loser Pays” as a deterrent to law suits decreases the cost of doing business resulting in lower prices and a competitive advantage for business. “Loser Pays” would deter frivolous lawsuits.

If President Obama really wanted to do something sensible about lowering the cost of healthcare, Texas style tort reform should become the law of the land including loser pays all.

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

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Here Come The Fibs, Distortions and Lies

Stanley Feld M.D.,FACP,MACE

As we approach November 6th (election day)
we will be subjected to more fibs, distortions and lies from President Obama
and his administration.

He has had a miserable record during his first term in
office. The only tactic he has left is to make villains out of Mitt Romney and
Paul Ryan while he makes promises he cannot keep. He has not kept most of the
promises he made before he took office.

As soon as Paul Ryan finished his speech at the
Republic convention he was accused of telling lies.

Carl Sandburg said in The Prairie Years “If you tell a lies enough times it becomes
the truth. The problem is a liar must have a good memory.”

Mr. Sandburg left out the fact that your audience has
to have a good memory to recall your first lie. One of the lies President Obama
told was the lies of Jonathan Gruber in 2009.

At the height of the Obamacare debate, Mr. Gruber’s
lie was all over the op-ed pages throughout the nation. Mr. Gruber, an MIT
economist and architect of Obamacare, stated that Obamacare would reduce the
cost of healthcare insurance for everyone.

we know
 for sure “is
that [the bill] will lower the cost of buying non-group health insurance.” 

The law
permits children under 26 years old to stay on their parents’ healthcare
insurance plan.

Immediately, the parents’ healthcare insurance premiums rose


           Jonathan Gruber
is now telling state governments that the law will significantly increase the
cost of insurance for everyon

 The result is the opposite of the promise.

President Obama brags about this achievement. In
reality he gave the healthcare insurance industry an excuse to raise premiums.

 Jonathan Gruber asserted that in 2016, young people would save 13 percent, and older
people 31 percent, on their insurance premiums

 “President Obama, too, touted the
bill’s ability to “bend the cost curve,”
 that the law would “bring down premiums by
$2,500 for the typical family.”

Jonathan Gruber now: “Obamacare will increase premiums by 19-30 percent.”

President Obama now figures he can call Paul
Ryan a liar.

He has a sympathetic audience in the traditional
media. However, President Obama with Obamacare is throwing Grandma over the
cliff. In fact it looks like he is pulling a Thelma and Louise with the United
Sates of America.

President Obama still seems like a nice guy. Everyone
would love to believe in him but they just can’t trust him.

his speech Paul Ryan said,


And the biggest, coldest power play of all in Obamacare came at
the expense of the elderly

You see, even with all the hidden taxes to pay
for the health care takeover, even with new taxes on nearly a million small
businesses, the planners in Washington still didn’t have enough money. 
They needed more.  They needed hundreds of billions more.”

 “So, they just took it all away from
.  Seven hundred and sixteen billion dollars,
funneled out of Medicare by President Obama
.  An obligation we
have to our parents and grandparents is being sacrificed, all to pay for a new entitlement we didn’t even ask for
The greatest threat to Medicare is Obamacare.”

Paul Ryan’s statement is correct.  President Obama accused Paul Ryan of leaving
the $716 billion dollars in Medicare. He did but he does not use it for
Obamacare. Mitt Romney will repeal Obamacare his first day in office.  

$716 billion left in Medicare by Paul Ryan will shore up the solvency of the
Medicare program itself.

is what President Obama was using the $716 billion dollars in Medicare cuts for.
Notice the $1.2 trillion dollars in new taxes and the $716 billion dollars in
Medicare cuts are being used to pay $644 billion dollars for Medicaid expansion
and $1.19 trillion dollars for subsided exchanges. The a deficit would be $141
billion dollars.

Untitled.png obams 716

anyone believe the deficit would be that low? I doubt it.

President Obama was going to cut $542 billion from
Medicare in the original CBO scoring.

turns out that President Obama is the liar. Someone ought to tell President
Obama, “The public is getting tired of
his lies once they understand them.”

Ryan also said,

 “President Obama created a bipartisan
debt commission. They came back with an urgent report.  He thanked them,
sent them on their way, and then did exactly nothing

Paul Ryan is
absolutely correct. Simpson and Bowles are still steaming about their
commission’s treatment by the President. Paul Ryan then went on to say,

“Republicans stepped up with good-faith reforms and solutions
equal to the problems.  How did the president respond?  By doing
nothing – nothing except to dodge and demagogue the issue.”

This is what Erskine Bowles,
President Clinton’s former chief of staff and the leader of President Obama’s
deficit commission, had to say about Paul Ryan in September of 2011;

telling you, this guy is amazing.
I always thought I was okay with arithmetic.
This guy can run circles around me. He is honest, he is
straightforward, he is sincere
. And the budget he came forward with
is just like Paul Ryan. It is a sensible,
straightforward, honest, serious budget and it cut the budget deficit just like
we did by four trillion dollars

Obama attacked Paul Ryan by saying Ryan voted against the Simpson-Bowles

traditional mainstream media has supported President Obama’s attack without
fact checking. The media was satisfied that President Obama’s message
neutralized Mr. Ryan’s attack on the President.

mainstream media never bothered to find out why Paul Ryan voted against the
Simpson-Bowles recommendations.

media figured it, the media, is the message. President Obama figured the
media’s message would take care of Mr. Ryan. Mr. Ryan was clearly a hypocrite
to the mainstream media.

true that Paul Ryan voted against the Simpson-Bowles recommendations because Simpson-Bowles
raised taxes while doing little
to nothing about health-care spending
, the biggest driver of
growing deficits.

rejecting Simpson-Bowles, Ryan decided to put forward his own plan for deficit
reduction the Path
to Prosperity

the other hand this is what Erskine Bowles had to say about President Obama’s

“President Obama, as you remember, came out with a budget.
And I don’t think anybody took that budget very seriously. The
Senate voted against it 97 to nothing.

He therefore, after a lot of pressure from folks like me, he came
out with a new budget framework. And in that budget framework, he cuts the
budget by four trillion dollars over twelve years. And, to be candid, this four trillion dollars cut was very heavily back-end loaded.
So, that if you looked at it on a ten-year basis and compared apples to apples,
it really was about a two and a half trillion dollar cut.”

More tricks to deceive the public. I could go on and on. Americans
have been fibbed and lied to by its purveyor of hope (President Obama).

However, I think President Obama has lost his tall with the
public. He is now calling for sympathy. He wants the public to let him finish
the difficult work he started.

I hope the public does not give him that chance.

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

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Healthcare Reform Should Be About Motivating Self-Responsibility Not Dependence

Stanley Feld M.D,FACP,MACE

Last week I heard a lecture about Accountable Care Organizations by a physician leader working for one of the major hospital systems.

His discussion made me realize that large physician organizations and hospitals are spending lots of time solving problems of quality medical care. In my opinion quality medical care has not been adequately defined.

A working definition right now is to decrease hospital stays, efficient medical care for a disease at lower cost, avoidance of medical errors in the hospital, and avoidance of hospital acquired infections.

These are important goals. They must be attached to monetary incentives. Many of these problems can be solved now. The solution demands the development of processes of care. An important question is how much money will process improvement save? I estimate that this process improvement could save an estimated 7 to 10% of the healthcare dollar.

The real question should be focused on how to repair the healthcare system by decreasing costs while improving the health of Americans.

This problem is not only about hospitals and medical practices reimbursement. It is about problems created by all the stakeholders. It is about aligning all the stakeholders’ incentives. The solutions to the healthcare system’s dysfunction must be initiated at the same time. You cannot try to fix one problem because it will result in a problem getting worse in another area.

The key to the solutions is to incentivize consumers of healthcare to control their health and be in charge of their healthcare dollars. Consumers can force secondary stakeholders to adjust swiftly to their demands and make them compete for consumers’ healthcare dollars.

Consumers must have incentive. They should be able to keep anything they do not spend of the first $7500 dollars of healthcare coverage. In our present healthcare system consumers do not control their healthcare dollars. They get first dollar coverage with variable deductible expenses. If the deductible is too high they will avoid necessary care and medications.

Society should not want that to happen because patients will get sicker and cost more to treat. Third party payers control the healthcare dollar. This control has contributed to increase the cost of healthcare. .

Some claim the only incentive consumers (patients) should need is to maintain their health. This claim has turned out not to be true.

Where do all the healthcare dollars go?

1. 65% of each healthcare dollar goes to the healthcare insurance industry for overhead for administrative services and insurance reserves whether it is private or government insurance.


2. Only 35% of the healthcare dollar is actually spent on medical care.

3. 80% of the healthcare dollars spent for medical care is spent by 20% of the people.

4. Most of those 20% have chronic diseases.

5. 80% of those dollars are spent on the complications of their chronic diseases.

6. Some claim there is 40% waste in the healthcare system due to uncoordinated care and duplication of care.

7. Much of the excess testing is due to the fear of malpractice claims and the practice of defensive medicine.

Let us follow the healthcare dollars with consumers being in control of their healthcare dollar.

If a moderate size company of 67 employees were willing to pay $15,000 dollars per employee for healthcare insurance it would cost $1,000,000 dollars. If the employer did not provide healthcare insurance the government penalty ($2,000 per employee) would be $134,000 dollars. This would represent a savings to this moderate sized company of $866,000 dollars per year. It would be the logical path to take. The formula I propose will work for the individual buying insurance.

Assume employers were willing to buy healthcare insurance for their employees. They would put $7,500 per year in a trust for each employee. The employee would be responsible for his healthcare dollars. The fees would be pre-negotiated fees by the government as the healthcare insurance industry does presently with physicians and hospitals. Hospitals and physicians might even want to compete among each other for the consumers’ dollars.

If the employee did not spend all the healthcare dollars in a year the remaining dollars would go into his retirement fund. It would not be used for future medical care.

A new equation for driving healthcare costs would be born.

There would not be a 65% overhead for administrative services for the first $7500 dollars because the healthcare insurance industry would not be administering the first $7500 dollars. The savings would be $4875 dollars.

Patients and physicians would have an additional $4875 dollars working toward direct medical care. The 65% overhead for administrative services for the remaining $7,500 of high deductible coverage could remain the same. The high deductible insurance would provide first dollar coverage after $7,500. The risk to the healthcare insurance industry would be less and so its insurance reserves could be less.

The government pays the same amount for administrative services to the healthcare insurance industry. The government could use the same formula for Medicare and Medicaid.

Consumers would have a monetary incentive to decrease their risk of getting sick (preventing obesity and increasing exercise). If consumers drove the healthcare system the consumption of snack foods and fast foods would decrease with proper education. Those fast food companies would be forced to sell healthy food to stay in business. Consumer would be driven by monetary incentives to stay healthy.

The onset of chronic disease would decrease. The complications of chronic disease would also decrease.

If a patient had a chronic disease at the onset of this new system and controlled their disease well in order to avoid acute and chronic complications of the chronic disease the healthcare system could reward them with a bonus at the end of the year. They would avoid costly hospitalizations.

Consumers would demand and pay to be properly educated to avoid complications of their chronic disease

An added benefit is that there would be less doctor visits and hospitalizations. This would increase healthcare capacity. It would enable the country to provide care for the entire population rather that force the healthcare system to abs
orb additional patients and create shortages resulting in rationing and decreasing access to care.

When people are motive by monetary incentives they are innovative. Innovation stimulates efficiency and decreases costs. It is important to have consumers be responsible for themselves and not dependent on the government.

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


What Healthcare Reform Will Mean For You?

Stanley Feld M.D.,FACP,MACE

Democrats are cheerful on this beautiful spring morning. They are happy because congress finally passed this partisan healthcare reform bill. Many are going to try to represent the vote to the traditional media as a great duty to the American people. I also believe they have no idea of the unintended consequence of President Obama’s healthcare reform bill.

The high level goals of the healthcare reform bill are commendable. The bill’s solutions will end in disaster for taxpayers, the government, and patients who need medical care.

I received a comment from a lawyer this morning.

I can’t imagine what is going to happen with this new healthcare bill.  Decrease payment to doctors, increase number of patients… hmmm.

Also, can you imagine how happy you are if you are a plaintiff’s lawyer?  Less time per patient means more chances of mistake. And just more folks in the system filing bogus claims, too. Total win for the lawyers.

It is also a big win for the healthcare insurance industry, and big pharma . I predict their stock prices will increase in the next weeks.

President Obama’s healthcare reform bill is a big loss for taxpayers and people who are ill and people who are not ill.

The details of the bill are a killer of innovation, jobs creation, and freedom of choice. The bill will increase taxes and decrease quality of medical care. Many of the bill’s benefits will not start until 2014. The increase in taxes will start this year,2010.

President Obama has said: Any one making under $200,000 per year will not pay a penny in increased taxes.

The Joint Committee on Taxation analysis contradicts President Obama’s assertion. Either the congress or the President does not believe the Joint Committee on Taxation or has chosen to ignore it.


The healthcare reform bill will increase Medicaid roles. This will increase burdens on State budgets. Most States have budget deficits. They are required to have balanced budgets.

The Medicaid expansion might be meaningless because of the level of income required for coverage.

If you’re low-income: The law significantly expands Medicaid, the federal-state health program for the poor, making it available to an estimated 16 million more people with incomes up to 133% of the federal poverty level.”

The poverty level was defined in 1955. In Texas poverty is defined as earning less than $950 per month or $11,400 per year. The increase will raise the level to $15,162 per year. How can a person making $20,000 dollars a year afford a $15,000 dollar healthcare policy even if the government subsides 50% of it? A tax credit is meaningless because they do not pay taxes.

This is an example of one of the many non starters in the healthcare reform bill. On the increased taxes side I believe the healthcare reform bill will inhibit investment and economic growth.

A new 3.8% Medicare tax will be levied on investment income including interest, dividends and capital gains that exceed those thresholds.

President Obama’s strategy is to increase taxes. Americans might notice the increased tax burden shortly. The increased taxes could be significant to a moderate earner’s lifestyle and standard of living.

  • If you itemize deductions for income tax: Starting in 2013, medical expenses have to reach 10% of your adjusted gross income to qualify for a tax deduction, as opposed to today’s 7.5% standard. But seniors age 65 and older would be able to claim an itemized deduction at 7.5% of income through 2016.

There is much talk about the Cadillac tax. There is little understanding of the rules. If the average healthcare insurance policy for an individual is going to rise as the healthcare insurance industry predicts, how is anyone going to be able to afford the insurance much less the excise tax?

This will precipitate the Public Option. What effect will the Public Option have on the bogus deficit reduction calculations?

Willie Sutton’s advice is to go where the money is. President Obama is not going where the money is.

The money is in:

1. Creating a system that puts consumers in control of their healthcare dollars and their health.

2. Rewarding consumers for good health.

3. Promoting self-responsibility for their health and healthcare dollars.

4. Creating a system that decreases defensive medicine.

5. Instituting effective and significant Tort Reform to decrease the need for defensive medicine

6. Creating a system that decreases the cost of adopting functional electronic medical records. An ideal medical record should be available to all at minimal monthly cost based on utilization.

7. Providing effective patient educational tutorials using the internet that is a physician approved extension of his care. Patients with chronic diseases must become professors of their disease. If they do not the complications of the chronic disease will occur and consume 80% of the healthcare dollars.

8. Creating systems of care that will prevent and reduce complications of chronic disease.

President Obama’s healthcare reform bill does not deal with any of these cost saving ideas effectively.

Americans love their country. We also know our government has done some stupid things in the past. The healthcare reform bill’s mistakes have been driven by politics, by ideology, by the influence of vested interests, and by the desire for power and fame .

President Obama’s healthcare reform bill is a stupid bill. America will suffer economically from the unintended consequences in the years to come.

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


Physician Frustration With President Obama’s Healthcare Reform Plan and the AMA Endorsement : Part 1


Stanley Feld M.D,FACP,MACE


Physicians are not opposed to healthcare reform. The present healthcare system is broken. It has functioned poorly for both insured and uninsured patient as well as physicians. It has hindered physicians’ ability to deliver quality care. Neither President Obama nor congress is asking practicing physicians what the real problem are and what the suggested solutions are.

Finally, practicing physicians are realizing there is a way to express their frustrations. Practicing physicians are expressing their frustration through the social network Sermo and their individual blogs.

Most physicians want to do the best job they can for their patients. President Obama is focusing on the wrong issues and ignoring important issues like decreasing bureaucracy, malpractice reform to reduce defensive medicine, and increasing individuals responsibilities for their health and healthcare.

According to the Sermo survey, physicians consider important issues to be limiting insurance company’s and government’s ability to deny care; tort reform and settlement caps, and changing the law to allow doctors to negotiate collectively with insurers.

President Obama is focused on saving money by spending money and taking total control of the healthcare system. The healthcare insurance industry and hospitals are focused on making money. Physicians, in general, are interested in taking care of patients’ medical needs and maintaining the special quality of the patient physician relationship while making a living commensurate with their training, patient care responsibilities and liability.

The difference in focus of the government and other secondary stakeholders is not necessarily in the best interests of patients care. In evaluating HR3200 a Sermo editorial by Eric Novack M.D. begins:

 “The 1018 page bill was just released on Tuesday morning Arizona time— it is simply impossible that the AMA could have read the full bill and the associated statutes that are amended within the bill, AND do the analysis of the impact on the medical profession in the states.”

Having been able to actually read the first 200 pages of the bill so far, it is clear that physician autonomy and patient freedom are the last items on the minds of the Congressional leaders and their staffers that have written the bill.

Eric Novack M.D.”

In the name of politics, the AMA was quick to endorse HR 3200. Its endorsement is incomprehensible to me.

“There’s a perception that the (American Medical Association) doesn’t represent the general consensus of the physician community,” said Sermo CEO Dr. Daniel Palestrant.

I thought I might have been missing something in HR 3200. I have been a member of the AMA since 1965.

“Today, the American Medical Association sent a letter to House leaders supporting H.R. 3200, "America’s Affordable Health Choices Act of 2009."

I believe President Obama had given the AMA the notion that it could negotiate reform with the Obama administration. It was obvious that the Obama administrations mind was made up a long time ago. President Obama was calling for a bill on his desk by August recess.

"The status quo is unacceptable," Dr. Rohack President of the AMA said.

I agree with this.

"We support passage of H.R. 3200, and we look forward to additional constructive dialogue as the long process of passing a health reform bill continues. This is an important step, but one of many steps in the process.”

This is an unbelievable statement in face of the draconian provisions in HR3200 and President Obama ultimate goal of total government control of the healthcare system. President Obama has stated he is for a single party payer system. These are President Obama’s statements on You Tube that are statements that are made in context.

The government controls Medicare. Medicare premiums have increased annually, Medicare deductibles have increased annually as have non allowed services (rationing). Physician reimbursement has decreased annually. A 20% decrease is scheduled for 2010. This decrease would reduce reimbursement to below a physicians costs to provide the service.

Healthcare administrative services are outsourced to the healthcare insurance industry. The healthcare insurance industry charges the government twenty (20) percent for the administrative services it provides. The government claims an overhead of two percent because the government administrative services for outsourcing the administrative services is 2 %. Scandals of delays in physician reimbursement by government outsourced healthcare insurance vendors have occurred from Hawaii to Maine.

The AMA knows all of this. Physicians know past behavior is the predictor of future behavior. Why would the AMA think the Democratic controlled congress and administration change its past behavior in the face of increasing budget deficits?

Its goal is single party payer. I imagine the AMA thinks it can make a deal with the Obama administration and congress because of President Obama’s generalized rhetoric.

All Americans must WAKE UP before it is too late. Write your congressional representatives and go to Town Hall meetings this month to make your opinion known.

I would suggest the following note.

“We do not want the government to control our lives and increase our taxes. We want affordable, universal healthcare coverage that does not limit access to care. We want control over our healthcare dollars.

You can reach you Congressional Representative with the links below.


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