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Chronic Disease Management And Education As An Extension of Physicians’ Care.

Stanley Feld M.D.,FACP,MACE

All the Spokes in my Future State healthcare business model should be attended to simultaneously to be effective.  

My vision ignores the barriers of the journey to implementing the changes in this discussion. There will be many barriers.  Legacy vested interests find it difficult to see a better way when those interests are struggling to survive in the present system.

The healthcare system must be consumer driven. Consumers must be put in control of their healthcare dollars. The other stakeholders will then be forced to cater to the consumer.

When this happens all the stakeholders’ vested interests will become aligned. It will result in a decrease in healthcare costs and an increase in stakeholders’ satisfaction.

Patients will accept responsibility for the management of their health. Physicians will become more efficient in their delivery of care..

The music industry fought Apple after ITunes dis-intermediated its legacy business model only to find its profit increased.

Consumers must have a way to obtain adequate chronic disease management education.  They must have transparent healthcare costs and understand treatment choices. Physicians must be actively involved in their patients’ education.

Chronic disease management education must be an extension of the physicians’ care. It is part of patients’ medical care. Physicians must be motivated to provide this care.

 

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Effective chronic disease management is dependent on patients managing their chronic disease. Patients will take control only after appropriate incentives and educational methods are in place.

The goal is to decrease the onset of complications of a chronic disease. Patients can control their disease and decrease the occurrence of chronic complications. Eighty percent of the cost of medical care is spent on treating these complications.

Physicians must teach patients to become the professor of their chronic disease. The educational vehicle must be available 24/7 for patients to be able to review concepts they did not understand completely.

Physicians must have knowledge of current evidence based medical care to teach patients properly.

Much of the infrastructure is in place. It tends to be provided by secondary stakeholder and undermines the patient physician relationship. The infrastructure is not utilized properly.

Patients need to be responsible for controlling their disease. Chronic disease management is not an entitlement. It is a patient responsibility.

Patients are dependent of the government or the healthcare insurance industry to pay their bills. They have first dollar healthcare coverage

My ideal medical saving account would solve this issue. It would probably cost the government and the healthcare insurance industry less if they provided patients with $7,500 in a trust fund, provided the incentives for keeping money not spent and provided first dollar coverage after the patient spends $7,500 dollars.

Patients will then be converted to Prosumers (Productive consumers) and become intelligent consumers of healthcare.

Consumers would then encourage or force their physicians to provide appropriate chronic disease management education.

The formation of social networking on multiple levels could enable physicians to provide this education inexpensively and effectively.

For example, all of a physician’s diabetics patients can be members of his social network for diabetics. The information to learn about diabetes can be provided by his social network. Testing of patients’ understanding of core principles of diabetes can be done with direct feedback to the physician. This would provide the physician with insight to emphasize topics the patient did not understand.

The core information could also default to a more detailed explanation of the topics misunderstood.

It could be done for many chronic diseases such as asthma, COPD, heart disease, GI diseases, and joint diseases.

This education would promote the physician patient relationship. It would demonstrate than their physicians care about their care.

If there is a contradiction in the education between the physician’s thinking and the core information, a separate social network connected to the core information for physicians only can serve as a platform for debate between physicians. Continuing medical education could even be provided to give physician incentive to participate.

There are many innovative mechanisms to use to promote the patient-physician relationship, educate patients to be professors of their disease, and to be responsible for their own disease management.

The utilization of information technology through social networking will repair the healthcare system. It will enable access to education and affordable care.

 

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

Please send the blog to a friend

 

 

 

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Healthcare Costs Are All About Chronic Disease Management

 

Stanley Feld M.D., FACP,MACE 

The National Institute for Healthcare Management Foundation is a nonprofit, nonpartisan organization focused on healthcare. The foundation just published an excellent report on the distribution of  healthcare costs in the population.

The results indicate that reducing healthcare cost is all about reducing and managing chronic diseases.

U.S. healthcare spending has sharply increased between 2005 and 2009 by 23 percent from $2 trillion to $2.5 trillion per year.

This is a result of a combination of factors. Chief among them is the increasing incidence of obesity. 

Who spends the money?

 Five percent of the population is responsible for 47% of all health care spending in the United States. Ten percent of the population accounted for 63.3% of the expenditures.

Fifty percent (50% percent) of the population accounted for only 3% of the healthcare expenditures.

The low cost person spent $233 in 2008 for healthcare services. Those in the top half of spending cost insurers, the government, or themselves $7,317 a year. The top 1 percent cost $76,476 per year. These are discounted fees not retail fees.

Healthcare expenditures were concentrated among a small group of high-cost patients. These high cost patients were older patients (over 55 years old) with one or more chronic diseases. If they were young and they had one or more chronic diseases healthcare expenditures increased. The more chronic diseases a patient had, the higher the likelihood the patient would be in the top 5% of healthcare dollar utilizers.

Fifty percent of the top 5 percent of healthcare spenders had high blood pressure, a third had high cholesterol, and a quarter had diabetes. The incidence of hypertension, hypercholesterolemia and adult onset type 2 Diabetes Mellitus is directly proportional to the presence of obesity.

It is logical to conclude that as the incidence of obesity and its severity increases the complications of obesity (hypertension, hypercholesterolemia, and Type 2 Diabetes) will increase.

It follows that healthcare costs will increase as a result of the increasing incidence of obesity. America must control the obesity epidemic.

Little progress is being made to decrease the increasing incidence of  obesity or Type 2 Diabetes.

In a perfect world, if obesity could be decreased, the incidence of chronic disease would be decreased.

In a perfect world, if the patients with chronic diseases could be taught to self-manage their disease, healthcare costs would decrease because the incidence of complications of chronic disease would be decreased by at least 50%.

 The treatment of the complications of chronic diseases is the most costly healthcare expenditure.  

President Obama’s Healthcare Reform Act mentions prevention and chronic disease management. There are no concrete incentives for patients to learn how to manage their chronic diseases. There are no specific financial incentives for physicians to develop facilities to teach patients to mange chronic diseases.

Americans are in for a long and costly dysfunctional healthcare system to the disadvantage of consumers and physicians.

President Obama’s Healthcare Reform Act puts consumers in a passive dependent position. Consumers need to be put in a proactive position to care for and be responsible for their health and healthcare needs.

Physicians have to have incentives to teach consumers to be self-reliant.

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

 

 

 

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A Medicare Contradiction! Osteoporosis and Chronic Disease Management

Stanley Feld M.D.,FACP,MACE

I have stressed the need for encouraging and developing systems of care for chronic diseases since the treatment of the complications of chronic disease consumes 90% of the healthcare dollar. Physicians are working very hard to teach other physicians systems of care for the prevention and treatment of osteoporosis.

We are in an era where medical care lives and dies by evidence based medicine. We are in the process of eliminating clinical judgment and the patient physician relationship, both of which are important to the therapeutic effect. I have point out the defects in reporting statistical significance for evidence based medicine studies. The two studies have been referenced. The Women’s Health Initiative and the recent rosiglitizone meta-analysis of the incidence of heart disease by Nissen.

The government has decreased the funding of clinical research. Therefore, most clinical research is driven by pharmaceutical interests. This has the potential to distort the integrity of evidence based medicine studies even further. Recently the FDA was criticized for not monitoring clinical studies more effectively.

The government has realized that 90% of the cost of medical care is due to the complications of chronic disease. In order to decrease the complications of chronic disease physicians have to recognize and treat all people with the chronic disease. Most studies show physicians can decrease the complication rate of osteoporosis by 50% if it is recognized and treated effectively.

NCQA is the National Committee for Quality Assurance. The organization tries to define quality medical care. In its 2007 report on osteoporosis, it found that osteoporosis was only evaluated in 21.7% of patients at risk using the NCQA accepted guidelines for the evaluation and treatment of osteoporosis.

The National Osteoporosis Association, the American Association of Clinical Endocrinologists and the International Society for Clinical Bone Densitometry have all published guidelines for the evaluation and treatment of osteoporosis which are more inclusive and I feel more accurate than the NCQA accepted guidelines.

Medicare, despite its recognition that preventing the complications of osteoporosis is important to lower the cost of care has acted to discourage physician from evaluating patients at risk.

The general physician performance for evaluation and treatment of osteoporosis was reported by NCQA to be only 21.7%. Physician performance in evaluating and treating osteoporosis should be increased to 100% in the patients at risk. Osteoporosis does not occur overnight. It takes at least thirty years to develop significant bone loss. During those 30 years the patient is losing bone mass. It would seem logical to detect significant decreases in bone mass early, before the patient suffered a fracture. Fracture that could be prevented is patients at risk are evaluated and treated appropriately.

Many healthcare insurance companies will not pay for bone density studies in women under sixty years old with risk factors for fracture because USPHTF said the evidence is not good enough. Unfortunately, they did not review and evaluate all the studies before reaching that conclusion. The private healthcare insurance companies figure a patient 65 years or older is the governments problem and not its problem anymore.

I should think osteoporotic fractures are the patients’ problem. I should think preventing osteoporotic fractures should be the patients’ goal. It should also be the government’s goal.

Medicare spends 21 billion dollars a year to treat the complications of osteoporosis. In an effort to reduce cost of diagnostic testing with CAT scans,MRI scans and Ultrasound scan the government has past the DRA (Deficit Reduction Act). In error DXA testing (bone mineral densitometry) was included on the list in the DRA. Medicare regulators elected to reduce the reimbursement to physicians for bone densitometry from $140 in 2006 to $82 in 2007 and as low as $34 by 2010. This reimbursement is far below the average cost of doing the DEXA scan. A recent study by the Lewin group showed that the average cost of doing a DEXA scan is $134. Many clinics had been forced to discontinue doing DEXA scans. The physicians taking care of osteoporosis can not afford to continue to do scans for less reimbursement that it cost.

There is no motivation on the part of family practitioners to do bone densitometry in his office with the extreme reimbursement cuts and the excessive overhead. It is logical not do anything that will result in a loss of income. There is less desire to subject the patient to the hassle of making an appointment in 3 weeks and going to the radiology department of a hospital for a bone density and then making a return office visit. The new ruling has created a disincentive for primary care physicians to learn systems of care for the prevention of the complications of osteoporosis. The result is just the opposite of Medicare’s goal.

If we did DXA on all women over 65 years old, 50% would have either vertebral fractures or bone densities low enough to treat by the guidelines of the major medical organizations involved in the treatment of osteoporosis. If all patients over 65 years old were evaluated and treated if necessary the Lewin group calculated that it would create a net saving to Medicare of $1.14 billion dollars a year. Women would also be healthier also.

There are no studies or guidelines for men. However, 1 in 5 men over 70 years old have significant reduction in bone density or a vertebral fracture. Where is the regulators common sense and empathy in their effort to reduce the deficit? They should be concentrating of fixing the broken healthcare system and saving the patients’ health as well as the governments money.

If you go to any Wal-Mart at 10 am on any week day you would see many retired people. Of those over 65 years old you could diagnose osteoporosis in at least 50% of the women and 35% of the men just by asking them their height at age 20 and then accurately measuring them. They all know how tall they where at age 20. If they lost one and one half inches in height they have had a painless vertebrae fracture. Only 35% of vertebral fractures are painful.

There are no large evidence based medicine studies in men. Therefore neither private insurance nor the Medicare pays for bone densitometry in men.

My question is again, who should buy your shoes, clothing, or food? The answer is obvious. We should. Who should buy our medical care? To me the answer is equally obvious. We should. The only way we are going to be able to do it is if the system is changed to a consumer driven model where we own our healthcare dollar. The Ideal Medical Savings Account provides the correct incentives for all the stakeholders.

P.S. If you are as bothered and concerned about this issue as I am please go to www.nof.org/advocacy put in your zip code and send a letter to your congressperson urging him/her to co-sponsor Congresswoman Shelley Berkley’s bill “Fracture Prevention and Osteoporosis Testing Act of 2007”.

Thank you
Stanley Feld M.D.,FACP,MACE

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Chronic Disease Management Part 4

Stanley Feld M.D.,FACP,MACE

Now that you understand the Type 2 Diabetes Mellitus disease process and what you have to learn about your imaginary disease, the strategy for treatment should be simple to understand.

The goal is to decrease the increasing resistance to insulin as you age, gain weight, do less exercise or increase your stress. The blood sugar increases cause a further increase in insulin resistance. By decreasing insulin resistance the result is to decrease the burden on the pancreas to produce insulin. We have to eliminate the causes of insulin resistance, namely, weight gain, stress and the increasing blood sugar. Additionally, exercise increases the effective number of insulin receptors and decreases insulin resistance. If this strategy was simple to execute there would be much less need for the powerful medications developed over the last few years to decrease insulin resistance. A survey done by the American Association of Clinical Endocrinologists (AACE) of its members a few years ago showed that most Type 2 Diabetics were on at least 3 oral medications. The average cost per year of each medication is about $1700.00. If the patient was spending his own money and understood that weight loss, decrease in stress and increase in exercise could help restore insulin sensitivity and decrease blood sugars. The result would be that much of the medication costs could be decreased markedly in most patients. Patient motivation with the appropriate coordinated education about Type 2 Diabetes and the appropriate follow-up by the Diabetic Education Team (DET) would be high.

Another critical self management tool is home glucose monitoring. Patients can now monitor the effect exercise, weight loss, and stress reduction has on their blood sugar. They can also monitor the effect of the various medications on their blood sugars at various times of day. If patients understood how the various medications worked and learned how to spot problems they could make adjustment between visit to normalize the blood glucose level after email consultation with the physicians and their diabetes education center. However, this consultation time spent between visits should be compensated in order to motivate the physicians to expend the time and energy to set up and execute such a system. The new system has to be driven by the patient and his control over his healthcare dollar (Consumer Driven Healthcare).

I have outlined a system of care for Type 2 Diabetes Mellitus. I will review the power of chronic disease management in other chronic diseases.

If our society really wants to fix the healthcare system these various systems of care must be developed, promoted, and funded. The government, insurance industry, and health policy makers are starting to develop an interest in doing the right thing. However, this potentially means their losing power over the consumer and his ability to drive the system in a real market healthcare economy.

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Chronic Disease Management Part 3

Stanley Feld M.D.,FACP,MACE

This blog is dedicated to Joan Colgin R.N., MSN the best Diabetes educator I have ever met. Joan Colgin R.N. is dedicated to the nursing tradition that the patient is first. She is dedicated to helping the physician help the patient.

You recall I asked you to image you have discovered you have Type 2 diabetes. I have provided you with an understanding of the pathophysiology of Type 2 Diabetes Mellitus. You understand why you have an elevated blood glucose level. I reviewed the devastating effects an elevated blood glucose level can have on your eyes, kidneys, nerves and heart.

Now I need to tell you what must be done to enable you to control your blood glucose level to prevent the chronic complications of Diabetes. I understand some people learn faster than others. Some people have so much fear and anxiety about diabetes that they have a very difficult time understanding what has to be done.

The basic educational process initiated by the physician must be reinforced by the Diabetes Education Team (DET). The DET must be an extension of the physician’s care in order for them and the educational process to be effective. It is very important that there are no contradictions in the educational process.

In 1995 the American Association of Clinical Endocrinologists (AACE) published Diabetes Guidelines: Medical Guidelines for the Management of Diabetes Mellitus: The AACE System of Intensive Diabetes Self-Management.

These guidelines were updated in 2002. This system of care was developed by Endocrine Associates of Dallas P.A. We developed a Diabetes Education Center within the practice. Joan Colgin R.N.,MSN. was the chief nurse educator. The physicians, the nurses and the dieticians worked together as an integrated team. We learned a great deal from patients and from each other. We figured out how to teach patients with various learning skills how to become the professor of their diabetes.

We learned that the patient must make a commitment to become as knowledgeable as possible. The patients had to learn how to self-manage their disease and understand the meaning of the results of home glucose monitoring. You will see in the AACE guidelines a Patient Physician contract. (p78)

Patients have to commit themselves to become the professor of their disease and the physician and his team commit themselves to teach the patients how to control their disease.

The AACE guidelines also contain as series of test questions of the patients’ knowledge. (p71-77). The correct answers are starred. Patients are tested at the onset of the education process and at the end of the course. The recommendation is that the education should be given on an individual basis so teaching can be customized to the patient’s learning skill. The test is repeated at 6 months to determine how much the patient has retained. If there are areas of weakness in understanding they can be addressed.

In the process of follow up with the physician the patients are taught to question their reaction to medication and make suggestions to the physician about changes in therapy.

If the physician discovers areas of patient misunderstanding that will hinder the patient’s self-management, the DET can reinforce the education in that specific area. The goal is to normalize the HbA1c in order to avoid complications of Diabetes Mellitus.

This is a very powerful process of care. The difference between the 2002 AACE Diabetes guidelines and other chronic disease guidelines are they are patient centric. Most guidelines are physician centric. Empowering the patient can improve control of blood glucose levels and thus prevent the complications of diabetes.

It introduces the process of rapid cycle improvement into the care of chronic disease management. The care of the patient is led by the patient’s input and participation in the treatment decision making process. The adjustments to therapy are not led by periodic static testing in the physician’s office. Periodic testing is simply a snapshot of the disease process. It tells us the results of the previous care. It is not proactive and tells us little about the changing disease process.

It has been stated most patients are not smart enough to learn about their disease and participate in the care of their disease. I recently received a comment from Dino Ramzi’s expressing this.

“I also know patients who do not have the intellectual capacity to understand the information they are being presented, despite our use of video, comic books and printed material to explain the principles of self-care. Some are too financially constrained or socially overwhelmed to do the right thing. Sometimes paying the rent and putting some food on the table is more important than exercising or taking your pills. Other patients are too depressed to motivate themselves to proper self-care. Others seem to have had some unpleasant interactions with the healthcare system or perhaps a personality disorder (this is a somewhat charitable way of describing the peculiar dysfunctional manipulations of a sorry minority).

The grand fallacy of relying on personal responsibility is that people have at their disposal all the choices to be made. The worst can’t do better.”

I agree with Dino Ramzi’s comment to some extent. However, many people who fit into his categories have not been given the opportunity or financial incentive to learn about their disease. Some patients cannot be motivated to self manage their disease because of their social circumstance. However, with focused training and financial incentive a great number of these people will respond.

However, these patients represent a very small minority of the patients with Type 2 Diabetes Mellitus. Our present system is not effective in decreasing their complications of diabetes. These patients will have complications in any system.

I am talking about the patients that want to learn and self manage their disease. The goal is to educate and motivate the great majority of people who are capable of learning and taking responsibility for their care.

Michelle Sobel, chief creative officer for Emmi Solutions, Inc, a Chicago-based company that produces interactive patient education videos expressed the concept beautifully, “The engaged patient is more than an informed patient. The engaged patient is activated. She understands information critical to her health, communicates effectively and confidently with her clinical team, complies with instructions related to her treatment, and is positively transformed by her experience with care.”
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You will recall the adherence/compliance rate for the treatment of most chronic disease has been studied to be only 40-50%. By engaging patients to be proactive in the care of their disease the adherence/compliance rate increases to up to 90%. Only with the appropriate treatment and the appropriate patient adherence to treatment will we decrease the costly complication rates of chronic diseases.

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What Does Chronic Disease Management Mean? Part 2

Stanley Feld M.D.,FACP,MACE

The responsibility for the control of the onset of the complications of chronic disease is the responsibility of the patient. Patients live with their disease 24 hours a day and need to learn how to manage it.

There are 20 million patients with Type 2 Diabetes Mellitus in America. This number is growing every day because we are experiencing an obesity epidemic. As I have previously discussed, this epidemic is the fault of our cultural conditioning.

The physician’s responsibility is to teach the patient how to manage his chronic disease.

Imagine you were told you have Type 2 Diabetes Mellitus. Think about your potential emotional responses. Think of all the bad things you have heard about diabetes mellitus. Think about the fantasies you would have about your future morbidity and mortality. These fantasies are the result of the media information and free public service campaigns various organizations have to heighten awareness about Diabetes Mellitus.

The complications of Diabetes Mellitus cost the healthcare system at least $150 billion dollars per year. At a July 4th party, I spoke to a diabetic patient who has had diabetes mellitus for thirty years. He became a professor of diabetes mellitus 28 years ago and has had his blood glucose levels under exquisite control. He has not suffered one complication of diabetes mellitus. There are many patients like this patient.

How does one start to teach patients to be the professor of their disease? I believe it is important for readers of this blog to understand what patients need to learn. It is also important for readers to understand how this process of self-management is a continuous learning project for both the patients and the physicians. The patients’ effort and responsibility in controlling this chronic disease is enormous, and can be very difficult.

You have just been told you have Type 2 diabetes mellitus. If I describe what needs to be learned you can start understanding how this empowerment could result in better control of the blood glucose level. You could also understand how the information could extinguish your fantasies and anxieties about diabetes mellitus. The result would be a decrease in the complication rate of Diabetes Mellitus.

The teaching process has to be a coordinated effort between the physician and the Diabetes Care Team, the nurse educator, dietician, and exercise therapist. We start by teaching patients what Type 2 Diabetes Mellitus is,
why they got it, and how they can reverse Type 2 Diabetes or at least control the rising blood sugar. If patients understands the pathophysiology they know the enemy. They are not frightened about the consequences of the disease. Then a plan can be developed for patients to actively self manage their disease.

At least 20% of the population has the genetic tendency to develop Type 2 Diabetes Mellitus. The genetic defect is an underlying resistance to their own insulin. We have insulin receptors on every cell in our body. These receptors attract insulin. The insulin receptor/insulin combination permits our cells to absorb circulating blood glucose. Once in the cells the glucose gets metabolized to carbon dioxide and water. In the process, packets of energy (ATP) are stored in our cells.

Increasing weight, stress, decreasing exercise, and development of infection decrease the insulin receptors affinity to attack circulating insulin. In effect you have an increased resistance to your own insulin. These external factors are additive to the underlying genetic defect. The more weight gained, the less exercise done and the more stress one has the greater the insulin resistance. As the effective insulin receptors decrease (increased insulin resistance) our body produces more insulin to compensate for this increase in insulin resistance. Over time we can not compensate with sufficient output of insulin to overcome the insulin resistance and our blood glucose rises.

Diabetes Mellitus is defined as a fasting blood sugar of greater than 126mg% on two occasions. Patients can have fasting blood glucose of greater than 126 mg% for many years without symptoms. Many people, mostly men, do not have periodic blood glucose measurements.

High blood glucose levels are the cause of the complications of Type 2 Diabetes Mellitus. The complications are eye disease, kidney disease, neurological disease and heart disease. The average time from the onset to the diagnosis of Type 2 Diabetes Mellitus has been calculated as 8 years. The average time of onset of complications of diabetes varies with the height of the elevation in the blood glucose levels. If you do not recognize that your blood glucose is elevated because you are asymptomatic you can not appreciate that you are harming your body. Many patients first discover they have diabetes mellitus when they are in the Cardiac Care Unit after suffering the cardiovascular complication (heart attack) of Type 2 Diabetes Mellitus.

Why does a high blood glucose level cause eye disease, kidney disease, neurological disease and heart disease? I have observed that once people understand the concept they become motivated to control their blood glucose levels.

Understanding causality is simple. A graphic way of understanding the process is to know that sugar helps alter proteins. The process of converting cucumbers to sour pickles comes to mind. You mix water, vinegar, salt, spices and sugar together. Then add cucumbers to the liquid and put the container in the closet for two weeks. The cucumbers have turned to sour pickles because the proteins in the cucumber have been deformed.

One can think of a person with a high blood glucose level deforming all the proteins in their body. They are essentially pickling all the cells and vessels in their body. The blood vessels narrow because the cells lining the blood vessels are deformed. For example, If there is not enough blood supply to the eye, the body tries to compensate by making more vessels. These new blood vessels (neovascularization) float on the surface of the retina and are fragile. If they bleed, patients can become blind. This narrowing applies to the blood vessels around nerves resulting in neuropathy. As blood vessels narrow, nerve endings will fire ineffectively. Many times these nerve ending misfires are painful. Many patients lose feeling in their extremities as a result of misfiring of nerve ending.

The hemoglobin molecule carries oxygen to the cells of the body. Each red blood cell has a 120 day life cycle. If a red blood cell is born in a high glucose environment it gets deformed or pickled and rather than being a simple Hb molecule it is now a HBA1c molecule. The higher your HBA1c level is, the higher your average blood glucose level has been over the three month period of time. A normal HbA1c level is under 6%. The HbA1c is that high in normal people because after a meal a normal blood glucose can go as high as 160mg%. National laboratories have calculated that the average Type 2 diabetic has a HbA1c of 9.2%. This finding means that neither patients nor physicians are doing a very good job in lowering the HbA1c to normal.

The patient I referred to earlier with diabetes for 30 years has a HbA1c level of 5.5%

Next time I will describe how that goal of a normal HbA1c can be achieved by the patients. It is the essence of the principle of chronic disease management. Normalization of the HbA1c levels can reduce the complication rate of Type 2 Diabetes Mellitus by at least 50%. It can theoretically reduce the complication rate of Type 2 Diabetes Mellitus by 100%. Fifty percent of $150 billion dollars is not a shabby dollar amount toward the repair of the healthcare system. However, the necessary education process to empower the patients to control their blood glucose levels and prevent obesity is not supported by society, the insurance industry or the government.

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What Does Chronic Disease Management Mean? Part 1

Stanley Feld M.D.,FACP,MACE

Ninety percent (90%) of the Medicare dollar is spent on the complications of chronic diseases according to CMS. Eighty percent (80%) of the healthcare dollars for all age groups is spent on the complications of chronic diseases.

I have stated that our medical care system is great at fixing things that are broken. Our healthcare system has not been good at preventing things from breaking. The medical care system has not been good at preventing the complications of chronic diseases once the patient is afflicted with the disease.

There are two reasons for our inability to prevent things from breaking. One, is that most of the abuse to the human body is a result of the patient’s behavior and lifestyle. An additional factor is the genetic predisposition patients have for a particular chronic disease. Physicians can do little to control genetic predisposition presently. Genomics represents a great hope for preventing the onset of chronic disease in the future. Inhibiting stem cell research seems foolish in the face of its potential benefit. Prohibiting the use of embryonic material that is going to be destroyed anyway to me is illogical. The controversy is a result of the science wars presently going on between theology and science. It is my belief once the public understands the potential of genomics and the illogical nature of the controversy, public opinion with turn on the foolishness of the argument and the controversy will evaporate. This is for the future and the prevention of the onset of chronic disease.

Once the patient has a chronic disease, there is much that can be done for each disease to slow or halt its progression and slow or halt the onset of devastating complications. If we were effective in preventing the complications of chronic disease after its onset, this would result in an improved quality of life for patients and a marked reduction in cost to the healthcare system. The present costs of the healthcare system are leading to an increasing number of uninsured as well as bankrupting the nation.

Presently, most studies demonstrate that, with adequate treatment, we can reduce the complication rate of most chronic diseases by 50%. The reduction to the cost of the healthcare system would be 800 million dollars. Theoretically, with perfect control of the chronic disease and perfect medical therapy we could reduce the complication rate by 100%. The result would be a 100% reduction of the 90% of the money spent by the healthcare system on the complications of the diseases.

Most healthcare economists, “healthcare policy experts” and politicians are starting to understand the math. What I have discovered is that they do not understand the process of chronic disease management and the importance of the patient physician relationship. They do not understand the pathophysiology of the chronic diseases or the origin of the complication of the diseases.

The chronic diseases we are talking about are cardiovascular disease and hypertension, diabetes mellitus, osteoporosis and muscular skeletal disease (arthritis and collagen vascular diseases, lung disease, AIDs, and cancer. We have a $2 trillion dollar annual healthcare system. The total cost of all chronic disease complications to the healthcare system is $1.6 trillion dollars per year.

A lot of brain power is going into trying to do something to reduce the healthcare system costs because we simply can not go on with ever increasing costs and ever increasing opportunities for facilitator stakeholders to increase there profitability while there are ever increasing number of uninsured persons.

We must have a universal healthcare system. However, universal healthcare does not mean a single party payer. I believe a single party payer system will add bureaucracy and impose rules that will stifle and inhibit innovation. The result will be increased inefficiency and increased cost. We all agree that what has made America is innovation by entrepreneurs and not rules by bureaucrats. I know that the physicians are not the problem. They are part of the problem. There is no reason to create a healthcare system that will methodically inhibit physician innovation. Even worse, drive a skilled labor force (physicians) out of business whose education we as a society subsidized.

Who is responsible for the complications of chronic diseases? It is the patient who lives with his disease and lifestyle 24 hours a day. The patient must learn how to control his disease to avoid the complications of the disease. The physicians can only be the coach or manager of the patients and modify their treatment plan through his experience and clinical judgment. Physicians must teach patients how to adjust to changes in the course of their disease. Physicians have to do this with their healthcare team with the patient being the most important person on the team.

Patients must be provided with education, incentive and financial reward for their successful adherence to treatment regimes. The promise of good health does not seem to be enough of a reward. Once patients understand that they are responsible for their self-management and the management of their health care dollar adherence to treatment will improve and outcomes of chronic diseases will improve. Physicians also have to be compensated for their effort. To help make the patients the professors of their disease is a very hard process. It is much easier for a physician to set a broken arm, fix a hernia, or even do bypass heart surgery. Yet the insurance industry does not value or reward this effort.

If patients owned their healthcare dollar and needed to spend their money wisely, they would become intelligent consumers of healthcare. This would force innovation by physicians and hospitals. They would force and increase the quality of chronic disease management at decrease the cost. This would also create a competitive environment for hospitals to control prices. They would produce a market driven economy as occurs in other areas of commerce. Healthcare is a not marketplace presently. Hospital prices presently have nothing to do with hospital costs. This is why we need the ideal medical saving account owned by patients and not the insurance industry. The Ideal Medical Savings Accounts would align all the stakeholders incentives to enable the best product at the best price in a truly consumer driven healthcare system.

In order to understand its complexity I will discuss the disease management concept of several diseases. Obesity is the worse epidemic we are experiencing at the moment. It leads to diabetes, heart disease and hypertension, each of which has devastating and costly complications. In my “War on Obesity” I have discussed some of its problems. I will integrate obesity into the disease management process.

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Patients Own Their Disease.

Stanley Feld M.D.,FACP,MACE

It is important to listen to what physicians are saying. An article appeared in SERMO, a physicians’ social network, which expressed a physician’s frustration.

It is appropriate to publish some of that physician’s thoughts.

“I first heard this statement over twenty years ago, when I was an intern in general surgery, struggling to find my professional self.”

“My chief resident said; “The patient owns the disease,” “You’re not trying to make them suffer, you’re trying to help. They’re sick, you’re not.”

“The human body is unpredictable.  Disease complications happen.”

The author thought his chief resident was heartless and callous. In a way, he was but he was getting at the heart of the matter. What is the patient’s responsibility in the evolution of disease?

This physician took everything that happened to his patients personally.

The patient owns his disease. The physician does not own the patient’s disease. Lifestyle plays a large role in the cost of the healthcare system.

President Obama’s healthcare reform law ignores the central role patients play in the therapeutic equation.

Day after day in the Emergency Department, people who take no responsibility for their health confront me.  They smoke, they drink, they do drugs, they don’t take their medicines, they drive impaired and crash, and yet they expect me to make them well.

They visit at their convenience, complain about the wait, want their medicines for free, and then don’t pay their bills.

The concepts of health insurance, family doctors, and preventive care have been completely lost.  Everybody except the patient owns the disease.

There was a time that patients knew they owned their disease. They knew they were partners with physicians in the treatment of their disease. Patients had to do the best they could under their physicians’ guidance.

“Somewhere, somehow, things got turned around.  The patients no longer own their diseases.  They’ve given them to us – physicians and society at large.

We are held responsible for everything that happens to a person, regardless of how they conduct their lives or follow our instructions.

  The weight on our shoulders is crushingly real, and forcing many good physicians to walk away from the thing they love most – taking care of others.”

He goes on to say;

I’m still shocked when a patient says, “You have to ….”  It’s endless – “refill my blood pressure and diabetes medicines, even though I don’t know their names or the dose. Patients demand I order an MRI for their two years of knee pain.”

“Say no, explain why, try to educate, offer alternatives, and the reply is  “If you don’t do it and something bad happens, it’s your fault.”

“You can’t tell someone that his or her symptoms are due to obesity, smoking or drinking – that’s judgmental.”

The author’s examples are endless. One last example sums up the dilemma facing healthcare in America.

“I once believed that every time I gave in to a patient’s pressure for an antibiotic for a viral illness, I was contributing to the emergence of super-resistant organisms.

“I believed that I could control the run-away cost of health care by judiciously ordering advanced studies only when absolutely necessary.  I tried to convince people that they owned the disease, that they had responsibilities to meet, that they couldn’t just demand everything be given to them.  And now I’m labeled a “disruptive physician”, because I generate too many complaints.

The increasing prevalence of obesity is a concrete example of the need for patients accepting responsibility for their disease.

Obesity is the cause of many disease processes. Obesity is not a random occurrence. It is linked to eating more than you burn. Potential patients are responsible for their obesity.

When obesity leads to the onset of Diabetes Mellitus, patients are responsible for controlling their blood sugar so they do not develop the complication of Diabetes Mellitus. The complications are heart attacks, hypertension, strokes, blindness, or kidney failure.

The government must provide and promote public education about obesity. Somehow, the appeal of overeating must be squashed and the virtues of exercise promoted.

Physicians and their healthcare teams are responsible for teaching patients how to control their blood sugar.

Eighty percent of the healthcare costs are the result of the complications of chronic diseases. Physicians must be encouraged, not forced, to set up systems of care to help patients become responsible for their chronic disease.

Where is the motivation for physicians in President Obama’s healthcare reform law? Where is the motivation for patients to become serious about intensively controlling their blood sugars in President Obama’s healthcare reform bill? New agencies are being set up to penalize physicians for not using resources to set up systems of care, resources which are uncompensated.

President Obama’s healthcare reform law does not promote patients taking responsibility for their diseases. The law contains nothing that measures patients’ performance. The law contains a lot of proposals that will falsely measure physicians’ performance

The law uses the term preventive care. It is meaningless without providing details. Prevention is immediately defined as providing vaccinations. Vaccinations do not define preventive chronic disease management.

If we are going to decrease the acute and chronic complications of chronic diseases, patients must comply with their physician’s recommendations.

Systems of care for chronic disease management have to be taught to patients and physicians. Medical schools have taught physicians how to treat diseases after its onset. President Obama should focus on setting up systems of public education before the onset of chronic disease.

President Obama’s healthcare reform act puts the burden of successful outcomes on physicians. Physicians do not own their patients diseases.

He should focusing on where money is wasted not building an infrastructure that will waste more money.

“Somewhere between the past paternalistic model of the physician-patient relationship and today’s give-them-what-they-want system, there has to exist a better paradigm.

As doctors, we need to resist the external pressures to make every one happy.  We must legitimize our expectations and have the backing of hospital administration when appropriate.

We should be empowered to refuse unnecessary, expensive, and often harmful demands. We cannot continue to abdicate the responsibility of our education and profession to political correctness.”

The Sermo physician’s statement demands physician leadership for constructive change. He says just say no.

It is difficult for most physicians to say no when they will be penalized by their hospital administrator or get sued under present malpractice laws.

Patients must own their disease!

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

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President Obama’s Cure Is Worse Than The Disease

Stanley Feld M.D.,FACP,MACE

I am a big fan of Peter Senge’s “The Fifth Disciple”. President Obama’s healthcare reform bill is not solving the underlying systemic problems in the healthcare system. It may bring him fame and glory in the short term. It will be a financial disaster in the long term as many entitlement programs have been.

Peter Senge’s wrote (page 61);

“ The long term, most insidious consequence of applying non-systemic solutions is increase need for more and more of the solution.

This is why ill-conceived government interventions are not just ineffective, they are “addictive” in the sense of fostering increased dependency and lessened abilities of local people to solve their own problems.

The phenomenon of short term improvement leading to long term dependency is so common, it has its own mane among systems thinkers- it’s called “Shifting the Burden to the Intervenor.”

The intervenor may be federal assistance to cities, food relief agencies, or welfare program.

All “help” a host system, only to leave the system fundamentally weaker than before and more in need of further help.

Please consider Peter Senge’s concept as it relates to President Obama’s healthcare reform bill. His bill ignores or proposes the wrong solutions to the five most important systemic dysfunctions in the healthcare system.

The five most important systemic dysfunctions are:

  1. Excessive defensive testing.

Effective malpractice reform would correct this problem

The partial cost of defensive medicine extrapolating the Massachusetts Medical Society survey is at least $75 billion dollars a year. If extrapolated to all medical specialties the cost is in the range of $300 billion dollars a year. The cost excludes time wasted and the stress to both the physicians and patients.

  1. Healthcare insurance industry’s abuse of the system.

Real healthcare insurance reform is needed as described previously. The ideal medical savings accounts, as opposed to health savings accounts or the present healthcare insurance product would eliminate bureaucratic ineffiency and put consumers in control of their healthcare dollars.

Patients must be incentivized to conserve their healthcare dollars and be responsible for maintaining their own health and well being

  1. Administrative services accounting abuse.

The elimination of the abuse and waste by the healthcare insurance industry is necessary. This can be achieved by effective accounting regulation reform for reporting Medical Loss ratios. The Medical Loss ratio accounting abuse adds little value to patient care.

At the same time the regulations for the healthcare insurance industry exemption from antitrust laws should be eliminated.

  1. A lack of efficiency in the physicians’ offices.

The elimination of administrative waste and paper work in physicians’ offices by creating a completely functional and effective electronic medical record in the “cloud” is needed.

The installation, updating and use of the ideal electronic medical record should be simple, customizable and inexpensive. The electronic medical record should t fit the physician’s work flow. Physicians should be charged by the click.

Physicians should not be expected to make large capital expenditures for electronic medical record systems that might not be totally functional and then be financially responsible for upgrading to improve functionality.

President Obama’s proposed system for implementing the electronic medical record will only delay adoption and functionality needed to reduce the cost of healthcare.

  1. A lack of chronic disease self-management tools.

Systematic educational programs for patient self care and management of chronic diseases must be developed for all physicians. These chronic diseases include diabetes mellitus, chronic lung disease, asthma, hypertension, coronary artery disease, certain gastrointestinal diseases, osteoporosis, and arthritis.

Internet information sources can be constructed within physicians’ ideal electronic medical record. The information sources can be customized to the physicians’ office to educate patients. It must be constructed as an extension of a physician’s care. All of the instructional information is presently on the web. The trick is for physicians to pick appropriate sites with information that will be an extension of the physician’s care. Physicians have to have incentive to do this easily.

Along with cancer the complications of these chronic diseases consume 80% of the healthcare dollars paid to hospitals and physicians. The complications of these chronic diseases can be decreased by 50% is systems of self-management are developed. If the costly complications of these chronic diseases decrease healthcare spending can decrease by at least 50%.

If healthcare reform concentrated on these five areas, with a minimum increase in governmental bureaucratic agencies, America would be well on the way to placing control of the healthcare system in consumers’ hands. Consumers would have the incentives and freedom to choose. Consumer driven healthcare would force hospitals and physicians to either shape up or perish.

Government should make the rules, then get out of the way. Consumers must be empowered choose and be responsible for their own care. Consumers will drive the medical costs down.

Consumers have shown, in many areas of our economy, that they have the power to make efficient and wise decisions. We have only to look at the auto industry, the supermarket industry, the telecommunication industry, and the airline industry to realize that consumers are not dumb.

The government can make effective rules for the healthcare industry and let the consumer drive the healthcare system.

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