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Consumer Driven Healthcare As A Result Of Social Networks

Stanley Feld M.D.,FACP,MACE

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Social networks can express the feelings and preferences of various groups. They have given people an individual voice. If there is universal agreement on a social network, the social network can change the supply chain of any organization, government policy or even government.

We have seen it this week in the rapid reversal of policy by Nancy Brinker and the board of directors of the Susan Komen Foundation toward the funding of Planned Parenthood of America.

 Ms. Brinker and the board were not very transparent for the reasons of its policy change in the first place. The original defunding policy was probably the result of the Foundation’s own funding pressures by pro-life contributors.

The rapid reaction of the Susan Komen Foundation social network, which was so skillfully developed by Ms. Brinker, was the probable reason for the switch back to the original policy.

 The new policy was to withdraw funding for Planned Parenthood’s providing mammograms for needing women. The new policy contradicted the mission of the Susan Komen Foundation. The social network reacted and the new policy was rescinded.

It took only a week to change the policy back to the old policy.

Social networking caused congress to abandon SOPA and PIPA in two weeks.

Both examples prove the power of the people.

The real question is how do you mobilize the power of the people to fix the healthcare system?

Everybody of all age groups knows the sound bite,“the healthcare system is broken.” 

Not many people understand the reasons it is broken. Nor are many people interested in creating the bandwidth to know those reasons until they become sick.

People who are not sick really do not care as long as they perceive they have adequate healthcare insurance coverage.   

Many President Obama fans think he is doing a great job reforming the healthcare system because of his use of well-known sound bite that the healthcare system is broken. He has promised to fix it.

He has promised to decrease healthcare costs and provide adequate access to healthcare for all people.

I have shown that President Obama’s healthcare reform act will increase healthcare costs, increase the budget deficit, decrease access to care and ration care.

Even before his healthcare plan is fully implemented it has resulted in an increase in cost of care, decrease access to care and rationed care.

Below is a comment from a neurosurgeon who was returning from a CMS seminar about restriction of access to healthcare.

It is a worthwhile to listen to his comment on new HHS regulations limiting access to care.

A way to mobilize “the people power” is get people 20 to 50 years old to understand what is being done to destroy the healthcare system. Everyone is going to need the healthcare system eventually.

These younger people understand how to develop social networks and get them to have a desired effect.

In order to reduce the cost of healthcare and increase the quality, the system must be converted from a government and healthcare insurance industry driven system to a consumer driven system.

I was “called out” by a reader because I called the new system a consumer driven system. He wants to call it a patient driven system. He defines all consumers as patients.

 “ In my opinion, everybody is a patient, and a member of one of three groups: The first group is composed of

"Patients in waiting" (the well, who require periodic screening and health information to stay well, and the worried well, who are coping with issues of some sort for which they have yet to seek professional advice); 

The ailing, composed of people who are actually coping with conditions of one sort or another that make them less than well; and 

The recovered, those who have regained an adequate measure of good health and functional capabilities after having experienced and recovered from a spell of illness. 

What we need to do is to work to make all three publics (to use a marketing term) aware of the fact that regardless of which group they may currently occupy, they are all stakeholders in the mess we currently call the healthcare system.”

This is a great point. It might inspire the “patients in waiting” to get involved now before it is too late.

In my 2020 business plan for the future state, patients are in charge not the government or the healthcare insurance industry.

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Patients would own their healthcare dollars. They have incentive to be wise consumers of healthcare and take responsibility for their health and healthcare. They would also have the incentive to make prudent healthcare and medical care choices.

The consequences of this ownership would change the behavior of the government and the healthcare insurance industry.

Both would become facilitators at the edges of the healthcare system and not the gigantic hairball in the middle of the system obstructing the patient physician relationship.

Social networking could force the government to relinquish its quest to control everybody’s choices and access to care.

 A consumer driven system would decrease the demands for expensive excessive care by the patients because they have “skin in the game.” The result would be to decrease the cost of healthcare.

These results would occur if all the other spokes of my 2020 business plan on the wheel were accomplished at the same time.

Many of you may remember the hope of a physician in Brooklyn.

“I cannot finish my career in Medicine without finding a way to integrate experienced people with great ideas and insight with young people who know how to create the tools to bring innovative approaches to actually create a functional healthcare system.”

It is my hope also.

Innovative software can be built for the future state that empowers patients in waiting, the ailing patients and the recovered patients (consumers) with the tools to express their needs.

Patients in all three groups can accept and take responsibility for their care.

In order to transform the healthcare system you do not need all the consumers in the country to be in the social network. It simply has to be compelling enough for people to join as the goals get the attention of others.

Consumer (Patient) Driven Healthcare along with the Ideal Medical Savings Account will be the foundation of this transformative healthcare system.


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

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Who Said Consumer Driven Healthcare Cannot Be A Market Force?


Stanley Feld M.D.,FACP,MACE

I love Costco. Its prices are great and its selection is abundant. Last week I was dazzled by the display of megavitamins as soon as I walked into the store.

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Americans want to be healthy. Few have a death wish but many (60%) are obese. Megavitamins have been touted as the instant route to healthy living. The megavitamin business has grown into a $30 billion dollar a year business.

Megavitamins have been successfully oversold.

There is no evidence that megavitamins are the route to health and healthy living.

“A national survey by the US Food and Drug Administration found that 73% of US adults were found to use dietary supplements in 2002.”

There is little good evidence to support the widespread use of dietary supplements.

The US Preventative Health Services Task Forces reviewed some of the literature on megavitamins and dietary supplements. The group stated there was insufficient evidence for or against the use of multivitamins with folic acid or antioxidants. It also stated that the use of Vitamin A, C or E did not have sufficient evidence for or against its use.

 I think these supplements could be helpful if the requisite dosage was known. There is no evidence that these dietary supplements are helpful at the present dosage. There are no scientific studies about which doses would work. There are only testimonials attesting to usefulness.

”Beware of the man with one case.”

 A friend of mine worked for thirty years proving the existence of Vitamin D deficiencies in 50% of the elderly population. It took him half that time to convince the medical population that he proved something.


The dosage necessary ended up being 6 times the dosage in multivitamins. Therefore USPHTF conclusions are correct with the present data. However they might have drawn their conclusions from the wrong data.

This is not an unusual occurrence in clinical medicine as I have pointed out previously. 

The American Medical Association hedged its bet by stating,

It recommends supplements specifically for seniors who have generalized decreased food intake.”

Chances are people who are starving or dying from cancer will have a multivitamin and mineral deficiency.

The American Dietetic Association advises,

“low-dose multivitamin and mineral supplements depending on individualized dietary assessment.”

The ADA’s statement is obviously self-serving.

The American Heart Association made the only logical statement in the whole bunch.

“The AHA emphasized healthy eating patterns rather than supplementation with specific nutrients.

The recommendations against the routine use of supplements are grounded in fairly good evidence if one believes in a methodology used by the Cochrane intervention review.

A Cochrane intervention review of 77 randomized controlled trials with 232,550 participants found no evidence to recommend antioxidant supplementation for primary or secondary prevention of mortality.[7]. 

There is shabby evidence that cannot be generalized regarding possible harm related to the use of some supplements.

 “For example, the Alpha-Tocopherol Beta-Carotene Cancer Prevention Trial demonstrated that beta-carotene supplements increased the risk for lung cancer among male smokers.[8] 

At this point there is no good scientific evidence for the use of megavitamins. “People believe what they want to believe.”  The placebo phenomenon is extremely important.

The media is the message. Somehow the power of advertising has convinced the public that it is good to take megavitamins.

Costco is trying to take advantage of the hype. Consumers are driving this healthcare choice. The result is a $30 billion dollar a year business. The money is coming directly out of the consumer’s pocket. It is not included in healthcare costs.

Consumers are trying to be responsible for their health on the basis of hype. It is much easier in the mind of most to stay healthy taking a pill than do the heavy lifting required for healthy living.

Why can’t someone create an anti-obesity hype that works as well as the megavitamin hype?

Increases in obesity lead to increased Type 2 Diabetes, hypertension, hyperlipidemia and the resulting Diabetic complications of stroke, heart attack, blindness, amputations, chronic renal disease and cancer.

Many schemes have been devised to decrease the increasing obesity rate. None have worked except eating less and doing more.

With the increasing obesity in children there is an increased incidence of Type 2 Diabetes in kids, teenagers and young adults.

Gastric bypass has become the rage for these young super obese people. To my dismay more and more insurance plans are paying for gastric bypass procedures. Even Medicaid is paying for the procedures.

Is the world going nuts?  I guess Medicaid’s logic is if the people become thinner it will decrease the incidence of Diabetes, decrease the complications of Diabetes and therefore decrease the cost of healthcare for these people.

To me it is like painting over rust. The rust will bleed through and the money for the paint will be spent already.

Americans do not get any help from society norms. We are flooded by manufactured foods with tons of calories and tons of salt. Mayor Bloomberg passed an educational law that fast food stores must publish calorie counts on foods.

This is helpful is the calorie count is accurate and people pay attention. 

Home cooking served in small portions is essential. The fat, calories and salt can be controlled. There is no need to have a home cooked meal anymore.

All you have to do is go to Costco or Sam’s and buy any precooked meal you want. Dinner is a 3 to 10 minute microwave pop away. Why would any busy person bother to prepare a home cooked meal? The harmful consequences prepared meals are in the distant future.

If you have dinner at a restaurant an average meal contains more calories than the average person burns in a day. My wife and I have been sharing for years.

Consumers want to be responsible but it is very difficult in the cultural milieu of our society. 

Ken Cooper M.D. created an exercise craze in the 1970’s. It has lasted until the present. He did not figure out how to get people to sustain their exercise program. He also did not figure out how to get people to decrease their intake in our sea of manufactured food and pre-cooked food.

The incidence of obesity is growing.

Most consumers are not stupid. They seek to be responsible in the easiest way possible.

Someone will come along and initiate a legitimate health craze.

The Ideal medical savings account (by providing financial incentives along with intense public education through appropriate advertising) can be as successful as the Dietary Supplement industry.

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

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Consumer Driven Healthcare Plans Trickle


Stanley Feld M.D.,FACP,MACE


As the healthcare debate heats up the meaning of consumer driven healthcare (CDHC) needs repeating. The true meaning of CDHC has been bastardized by the healthcare insurance industry as represented by Health Savings Accounts (HSA).

The healthcare insurance industry feared that if Medical Savings Accounts dominated it would lose control of the initial healthcare premium dollars. The result would be a decrease in profit and an increase in price competition and real price transparency.

The reality would be America would have universal healthcare in a more efficient healthcare system. The system would be more efficient because it would be driven by the consumer for their benefit and not a third party payer. A more efficient system will maintain healthcare insurance industry’s profit while permitting a decrease in healthcare system costs.

“A lack of consumer understanding has contributed to the glacial growth of consumer-driven plans. Can better information from health plans help CDHPs take hold?”

HSAs place limits on consumers’ incentives. All of the healthcare premium dollars are eventually paid to the healthcare insurance industry.

Our economic recession along with increasing unemployment have set the stage for consumers to accept any help government will provide. Enter a single party payer and all its problems. Since Medicare and Medicaid have proven to be unsustainable, it is foolish to throw money at a failing system. It is time to revitalize the system.

Just the opposite should be occurring. CDHC should be promoted and not be marginalized. President Obama’s universal healthcare with a single party payer system marginalizes CDHPs. The route he is taking to achieve everyone’s goals and will not repair the healthcare system.

“The idea behind consumer-driven health plans is to transform members into healthcare consumers through education and place more responsibility on the individual.”

Health Saving Accounts (HSA) do little to encourage patient responsibility or make patients informed consumers. HSA were a political compromise designed by the healthcare insurance industry. The resulting plan gutted the intent and effect of the CDHC movement.

“ Studies show that the percentage of Americans insured in CDHPs is still in the single digits, largely for two reasons: Consumers simply don’t understand the tax-free savings accounts that are connected to CDHPs, and few health plans are providing cost and quality information to allow consumers to compare doctors, hospitals, and treatment options.”


Consumers do not see a financial advantage of the HSA because there are none. The money has to be used to pay present deductibles and future deductibles. There is no reason the future deductable will not be increased reducing the present value of the money in their health savings account. The healthcare insurance industry wants health savings accounts to fail. It feels its margins are presently excellent and does not need a change.

“More than one-quarter those respondents said that HSAs are difficult to open/manage, or too complicated, or they simply didn’t understand the accounts.”

Consumer driven healthcare is the only thing that can repair the healthcare system. It would take control out of the healthcare insurance industry’s hands. The route to take is the ideal medical saving accounts.

Healthcare insurance would convert to real at risk insurance. Consumer would own and control their healthcare dollar. The government could teach the consumer to use the healthcare dollar wisely. The government could provide clear price and quality transparency. It would force all the secondary stakeholders to compete for the consumers’ healthcare dollar. This competition would force an increase in efficiency and decrease in administrative waste.

The government should act as the facilitator for the competition. The time has come for politicians to do something for consumers and not for secondary stakeholders.


Consumer-Driven Healthcare Will Fail Without REAL Price Transparency!

Stanley Feld M.D.,FACP,MACE

If we are going to be able to Repair the Healthcare System REAL Price Transparency is a must. There is a lot of noise about Price Transparency by hospitals and the insurance industry but it is all pretend. I suspect there is going to be little change in policy until the patients, future patients and physicians as well demand REAL Price Transparency.

Augus Deaton an economist at Princeton tried to be a well informed consumer. In his “Letter from America, Trying To Be A Good Hip Op Consumer” he points out the problems he had seeking good value in his health-care and being an informed consumer. It is a worthwhile read if you want to see what the American consumer of healthcare is up against. Consumer driven healthcare is just talk and will fail unless we want to walk the walk. He points out the lack of available appropriate information and the total opacity encountered when information is limited.

President Bush “Bush Seeks Better Health Care Cost Information” and the people at CMS seem to really want to do the right thing. They will not get better information. Their problem is they are up against a powerful vested interest lobbying machine that has been successful at contaminating every good idea that might hurt them. There is a total resistance to change. The fact is the change might help the vested interest stakeholders. The change would certainly help the consumer of healthcare. President Bush’s only chance will be if we create a public opinion outcry. Once again who is responsible? Unfortunately, we are because our surrogates have let us down.

Medicine is big business and the facilitator stakeholders want to keep control of the big business of Medicine. Checking on quality care was impossible for Augus Deaton. Understanding his potential financial liability was an even bigger chore. Surprise billings were ubiquitous. He could not even know what he was covered for until after the service was rendered. This lack of transparency is ubiquitous in Medicine and not getting any better. Aetna claimed a Price Transparency initiative in 2005. It affected a small group in Ohio and covered only 23 services. This sort of Price Transparency is a relatively meaningless gesture and will not help repair the system. The initiative did generate a lot of sound bite publicity for Aetna at a small cost.

Ohio announced that it is going to publish their hospital DRGs. However, they will not be ready for more than a year. Publishing DRGs does not tell you what the insurance company or Medicare is going to pay for or how much. Wisconsin published their DRGs. It is enlightening but meaningless because you as a consumer can not do anything about the price.

Is this right? My answer is no! We, the people are responsible for making the demand, and demanding it now in an election year. If we are going to be purchasers of healthcare with our own dollars we need to know what we are buying.


What Should Be Done to Repair the Healthcare System?

What Should Be Done to Repair the Healthcare System?

Stanley Feld M.D.,FACP, MACE

On March 10, 2020, Obamacare will be ten years old. Obamacare has had many failures. Obamacare’s biggest failure is the resulting distortion of the healthcare delivery system. The distortion is the result of all the stakeholders adjusting to Obamacare’s new rules and regulations.

All of the stakeholders had to adjust the way they delivered or priced healthcare to their individual advantage.

Primary care physicians started moving toward the model of Concierge Medicine. In order to have a primary care physician, consumers must pay primary care physicians between $2,000.00 and $38,000.00 annually to be in their panel.  The movement toward Concierge Medicine is the result of the Obamacare regulations, the healthcare insurance company’s reimbursement cuts, and the increase in malpractice insurance premiums.

Primary care physicians found that in order to make a living and pay their increasing overhead, they must become Concierge Physicians. This is to the disadvantage of consumers since they must continue to buy healthcare insurance.

The insurance industry has adjusted to Obamacare’s regulations by lowering reimbursement to physicians and hospitals while raising premiums. Insurance companies and Medicare Advantage programs have restricted enrollees to only certain physicians in their network and restricted certain treatments and access to certain specialists and groups.

It all goes back to President Obama’s statement, “If you like your doctor you can keep your doctor. If you like your hospital you can keep your hospital.” To my disappointment the AMA accepted President Obama’s obvious lie in 2010.

As the the government and the insurance industry decreased reimbursement physicians have had to increase the number of patients they see in one day in order to make up for their decreased revenue.

Malpractice claims and malpractice payments for claims have increased in most parts of the country. This resulted from a lack of tort reform by congress and the Obama administration. Physicians then increased diagnostic testing in order to cover all possible illnesses.  The increase in testing led to an increase in healthcare cost.

Obamacare has also increased the cost of insurance by requiring payment for additional coverages. The first dollar insurance coverage after deductibles are met has resulted in the overuse of the healthcare system. The government and the insurance industry are trying to decrease the overuse of the system by increasing deductibles.

In fact, some Obamacare insurance plan deductibles are so high that insurance payment never kicks in. People who buy Obamacare insurance plans cannot afford the deductibles and do not use the insurance until they are so sick, they cannot avoid being hospitalized.

It is impossible to figure out how health insurance premiums increases are calculated by the private healthcare insurance sector or the government healthcare insurance sector. It is impossible to figure out how the multimillion-dollar salaries for insurance and hospital executives are calculated. These expenses are part of why insurance premiums are rising.

It is also impossible to determine how hospital systems price their care. The government also pays hospital systems a premium for outpatient hospital care in an outpatient setting. The fees are at least 20% higher than in a free-standing private practice office.  

Hospital systems are figuring out how to manipulate their reimbursement systems to have an advantage over their competitor.  In New York City, Columbia Presbyterian Hospital System has accumulated ownership of many hospitals inside the city and its suburbs. With that ownership, they have acquired many in-patient and out-patient hospital salaried physicians. The hospital system is now demanding increased payment from healthcare insurance companies and the government in order for patients to use their system. The hospital system has hired many of the physicians’ patients desire to see. Columbia Presbyterian has gained control of the reimbursement levels in those markets.

There is an encouraging trend that was started by Keith Smith M.D. in Oklahoma City. Dr. Smith started a cash-only outpatient surgical clinic several years ago. He charges less for procedures than a patient’s deductible from some insurance companies.

This gives us some insight into how much fat is in the healthcare system expenditures.  Dr. Smith and physicians working in his outpatient clinics are happier and are making more money than they were working for local high-cost hospital systems in town. The patients are happier because there are no hidden or surprise costs.


Dr. Smith’s clinic is drawing patients from all over the United States. He has also inspired the formation of many similar clinics in the U.S.

This is not new. Specialists such as gastroenterologists have opened freestanding centers. They charge less for colonoscopy and endoscopy than the hospital systems. Radiology clinics have done this for many years. The hospital systems have, somehow, worked out payment for their higher costs with the insurance industry and the government.

Dermatology is a specialty that does not need a hospital system. Large physician-owned

dermatology clinics have opened. They charge less than the dominant local hospital system.  

Many of these large specialty centers have sold their clinics to venture capital firms.  

How the venture capital firms are going to leverage their investment is unclear to me.   

Emergency rooms all over the country are overcrowded because primary physicians cannot see all of the patients in their offices in a timely manner. Hospital system emergency rooms are inefficient and overpriced. The ER is an unpleasant experience for many patients.

Venture capital firms have opened free-standing Urgent Care and Emergent Care centers all over the country. (Doc-In The Box). Many of these centers are covered by nurses, nurse practitioners, and physician assistants. All physicians have to do is co-sign with the provider to get reimbursement by the government and the healthcare insurance industry.

This is not my idea of developing patient-physician relationships.    

If a patient has to be admitted to a hospital his primary care physician is not permitted take care of him in many hospital systems. Hospital systems have hired hospitalists to care for patients. A patient might see a different hospitalist each day of the admission.

What happened to the therapeutically valuable physician-patient relationship? This relationship is critical for curing much morbidity from chronic illness. 

 I have covered the Repair of the Healthcare System in great detail in the past.

 I have also covered the errors in the structure of Obamacare leading to the distortions in the delivery of healthcare and the increased costs of the healthcare system.

The stakeholders are physicians, patients, hospital systems, insurance companies, pharmaceutical companies, and the government.

All patients want is to get the best medical care when they get sick. The interest in disease prevention is slowing growing events though many millions of dollars have been spent on programs that could help prevent chronic disease.

All hospital systems, insurance companies, pharmaceutical companies are interested in are maximizing profits and minimizing expenses.

All physicians are interested in is delivering the best care possible.

Patients and physicians are the most important stakeholders in the system.

The government wants to spend the least amount of money possible to enable the best care at the lowest price.

There has been little attempt by congress, the bureaucracy or previous administrations to remedy the defects I have pointed out.

 I have not seen any attempt by Congress to lower the price by decreasing the bureaucratic impact on the price of healthcare. Nor have I seen the exposure of the clandestine deals hospital systems make with insurance companies or the government.

I have not seen any movement toward decreasing the malpractice crisis in America. Tort reform has been vitally necessary for the last thirty years. It has been totally ignored by government officials.

These are some of the basic reforms necessary to start repairing the healthcare system. All our politicians do is kick the can down the road to the advantage of the secondary stakeholders and not the consumers.

These are some of the main reasons the system has to convert to a consumer-driven system that I have outlined previously.

Consumers must control their health and their healthcare dollars. They must be provided with an education that will help them control costs. They must be provided with financial incentives to control costs.

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

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Mechanism Design and the Repairing the Healthcare System

Stanley Feld M.D., FACP, MACE.      

On November 11, 2007, I published the following blog: “Incentives and Mechanism Design.” The authors Leoid Hurwicz, Roger Meyerson and Eric Maskin were awarded the Nobel Prize in Economics for the concept in 2007.

 I suspect few politicians know about Mechanism Design in 2019. I am certain Bernie Sanders and the “Medicare for All” crowd do not know anything about Mechanical Design.

In my last blog, I described how politicians and the mainstream media use Confirmation Bias to try to put the government in control of healthcare against the will and welfare of the public.

I think Donald Trump either studied the use of Mechanism Design and its mechanics or he intuitively uses its principles in his thinking.

Mechanism Design is a concept that tries to put science into social science. It mathematically evaluates vested interests of stakeholders in order to eliminate confirmation bias and line up all the stakeholders’ vested interests for the greatest good. It assumes all the stakeholders have expressed their vested interests truthfully.

The Democrats want to hold onto (fix) Obamacare. However, the Democrats understand Obamacare is not viable in its present form. I believe “Medicare for All” with central government control of healthcare will be a disaster as it has been in most single party payer systems.

I do not believe Obamacare is fixable. I believe President Obama and the Democrats believed that Obamacare would fail. Then the nation would beg either his public option or Medicare for All.

I think President Obama believes “Medicare for All” and the total government control of healthcare is the ideological solution to the problems in our healthcare system.

His confirmation bias overrules all of the examples of “Medicare for All” failed examples at home (Vermont California and Colorado), as well as Denmark, Sweden, England, and France.  

In 2017, the Republicans with a slim majority in the Senate refused to repeal Obamacare. Whether the Republican failure to repeal Obamacare was because of intramural revenge or ideology is best to question is which system is best for the common good.

If our politicians understood the principles of Mechanism Design and were diligently working for the people who elected them benefit, America would be on the way to “Repairing the Healthcare System.”

Against this backdrop of a hostile Democratic Party, in control of the House of Representatives, Donald Trump and his administration is slowing working its way to “Repairing the Healthcare System” using the principals of Mechanism Design.

In November 2007, pre the Obama administration, I wrote:

Last month the Nobel Prize in economics was awarded to Leoid Hurwicz, Roger Meyerson and Eric Maskin. They were awarded the Nobel Prize for developing the economic theory of “Mechanism Design.” My first reaction was “what is that?”

After some research, I discovered the power of Mechanism Design. It is a brilliant economic theory that could solve many economic problems. Mechanism Design applied to our healthcare system could solve the healthcare systems problems.

What is it? “In economics, mechanism design is the art and science of designing rules of a game to achieve a specific outcome, even though each participant may be self-interested. This is done by setting up a structure in which each player has an incentive to behave as the designer intends. The game is then said to implement the desired outcome. The strength of such a result depends on the solution concept used in the game. It is related to metagame theory, which is the theory of games the play of which consists of developing the rules of another game.

Mechanism designers commonly try to achieve the following basic outcomes: truthfulness, individual rationality, budget balance, and social welfare. However, it is impossible to guarantee optimal results for all four outcomes simultaneously in many situations, particularly in markets where buyers can also be sellers [1], thus significant research in mechanism design involves making trade-offs between these qualities. Other desirable criteria that may be achieved include fairness (minimizing variance between participants’ utilities), maximizing the auction holder’s revenue, and Pareto efficiency. More advanced mechanisms sometimes attempt to resist harmful coalitions of players.”

Lodi Hurwitz contributed to the idea of incentive compatibility. His point is the way to get as close to the most efficient economic outcomes is to design a mechanism in which everyone does best for themselves. He says this can be achieved by sharing information truthfully (Price Transparency). It is easy to understand that some people can do better than others by not sharing information or lying.

If everyone’s incentives are aligned, you have a much more efficient economic system. An example is defense contracting. If you agree to pay on a cost-plus basis you have created an incentive for the contractor to be inefficient. If you agree to pay a fixed price you can come close to an efficient price if you have all the truthful information. If you do not you have incentives aligned and truthful information you create the incentive to be overcharged. Most people can do better by not sharing truthful information. If the rules of the game require truthful information you can get close to an efficient market-driven solution.

The concept of Pareto efficiency means no one can be made better off without someone becoming worse off. Therefore, the incentive is to maintain your dominance by not being truthful at the expense of others. Hurwicz observed as others had that the dispersion of information was at the heart of the failure of a planned economy. He observed that there was a lack of incentive for people to share their information with the government truthfullyThe free market mechanism was far less afflicted than central planning bureaucracy by such incentive problems. The free market economy was by no means immune to this defect. He observed that the free market economy can get us closer than central planning to incentive compatibility because the end consumer can drive the discovery of truthful information.

The customer creating rules of engagement in a market-driven economy can get you closer to the ideal of Mechanism Design. Since the customer determines success of an enterprise by creating demand in a transparent environment, they can get closer to incentive efficiency. They create the rules of the game for compatible incentive.

Roger Meyerson contributed the revelation principle, a mathematical model that simplifies the calculation to create the most efficient rules of the game. The mathematical model gets people to reveal their truthful private information leading to aligned incentives.

Eric Maskin’s breakthrough was in perfecting Mechanism Design with his “implementation theory.” His theory clarifies how to design mechanisms that heighten incentive alignment and efficiency.

How does Mechanism Design relate to the Repair of The Healthcare System? We have to set the rules of the games so that we align all the stakeholders’ incentives without one stakeholder takes advantage of another. The insurance industry is taking advantage of the patients, doctors and hospital systems. The hospital systems are taking advantage of the patients, doctors and insurance companies. Doctors are taking advantage of the insurance companies, hospital systems, patients and the government. The government is taking advantage of the hospital systems, the doctors and the patients. Employers who pay the insurance bills for their employees are taken advantage of by the insurance companies. The drug companies are taking advantage of patients and unduly influencing physicians.

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

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

I believe consumers can fix the rules of the game so that all the incentives are compatible. Consumers have to have incentives to force politicians to fix the rules of the healthcare game. Consumer-driven healthcare system will achieve the alignment (incentive compatibility) using the ideal medical saving account.

Twelve years have passed since 2007. America has not gotten closer to the solution to Repair the Healthcare System even though the solution is staring us in our eyes.


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

Copywrite 2006-2019

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The Expansion Of Personalized Healthcare Insurance Benefits.  

 Stanley Feld M.D.,FACP, MACE

The Senate rejected the  slimmed-down Obamacare Repeal bill as Senator John McCain was the deciding no vote July 27,2017.

“When Senator John McCain of Arizona returned to Washington with a fresh scar from brain surgery, it was widely seen as a dramatic effort to help Republicans overturn Obamacare.

 Little did Mr. Trump know that the Arizona senator would help drive the stake through legislation that sought to realize the Republicans’ seven-year dream of finally dismantling Obamacare.”

 John McCain’s vote was a surprise to everyone. Mitch McConnell then put healthcare reform on hold. Senator McConnell decided to let Obamacare die on its own.

However, the Senate rejection did not deter President Trump from pursuing healthcare reform .

He has already approved the development of purchasing associations through an executive order. The associations will sell health Insurance coverage. The rules will go into effect January 1, 2019.

He has also has attacked the drug industry with his blue print on drugs. The regulations from this will decrease the costs of drugs by decreasing the number of middlemen in the manufacture to sales process.

On October 2017 President Trump issued an executive order to promote healthcare choice and competition in the country.

In the executive order President Trump said his goal was to ‘Expanded Availability and Permitted Use of Health Reimbursement Arrangements.

 The Secretaries of the Treasury, Labor, and Health and Human Services shall consider proposing regulations or revising guidance, to the extent permitted by law and supported by sound policy, to increase the usability of HRAs, to expand employers’ ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with nongroup coverage.

The Departments of Treasury, Labor, and Health and Human Services proposed regulations in October 2018 that would significantly expand personalized health benefits to consumers and would offer increasing price pressure to lower insurance prices tor U.S. businesses. Most U.S. businesses want to continue to provide medical coverage for their employees. However they need affordable prices.

The proposals, issued Tuesday, October 23, 2018 by Treasury ,Labor and HHS were a response to the October 2017  executive order from President Donald Trump.

 “That order instructed the Departments to increase the availability and usability of health reimbursement arrangements (HRAs)—especially those offered in conjunction with non-group insurance.”

The proposal is well thought out. I have a problem with some of the upcoming regulations but they are an excellent step in the right direction.

The regulations do not utilize a most important element in my ideal medical savings accounts. It does not provide financial incentives for consumers to become informed consumers of healthcare or motivated to save healthcare dollars.

Consumers of healthcare have to be incentivized to become savvy purchasers of their own healthcare and healthcare insurance coverage.

“If enacted, the regulations would create two new HRAs: something we’re calling the individual-integrated HRA, and the smaller, excepted benefit HRA.”

HRAs can be viewed as a superstructure for my ideal medical savings accounts. President Obama did everything he could to discourage the purchase of health savings accounts. His goal was to drive everyone into a single party payer system with the individual consumer’s healthcare decision are made by the government.

Despite President Obama’s attempts to discourage health savings accounts, they grew as the fastest and most popular healthcare insurance product. HSAs permitted consumers to have some   control of their healthcare spending and some of their healthcare dollars.

“In 2013, IRS Notice 2013-54 issued guidance on the Affordable Care Act (ACA) that seriously limited businesses’ ability to offer HRAs. The IRS said that while HRAs integrated with group health insurance satisfy key ACA provisions, HRAs integrated with individual health insurance do not.”

This is where Obamacare discouraged consumers to buy HSA as individuals. The insurance was not completely tax free to businesses or individual consumers.

“Congress provided some relief in December 2016 by creating the qualified small employer HRA (QSEHRA). The QSEHRA, a benefit specifically designed for small businesses with fewer than 50 employees, allows businesses to reimburse employees tax-free for their health care costs.”

With his October 2017 executive order, President Trump sought to expand HRAs even further. In the order, he asked the Treasury, the DOL, and the HHS to reexamine past rulings and “increase the usability of HRAs, to expand employers’ ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with non-group coverage.”

The new proposed regulations are a direct response to that executive order. Unfortunately it does not solve the healthcare insurance problem. The proposal keeps the insurance industry in charge of the healthcare dollars and healthcare decisions. It is a step in the right direction. It helps small business more than it helps the individual.

  QSEHRA  “Qualified Small Employer Health Reimbursement Arrangement”  Individual-integrated HRA
Business size restrictions Only available to businesses with fewer than 50 full-time employees. None.
Employee eligibility requirements All full-time employees are automatically eligible. Part-time employees can be included, but the HRA must be offered on the same terms. Employees can participate in the HRA without individual health insurance, but those without MEC must pay income tax on all reimbursements during the time they were uninsured. The business can set eligibility guidelines according to permitted employee classes, but the HRA must be offered on the same terms to all employees in each class. Employees without individual health insurance, including those covered by a spouse’s group policy, cannot participate in the HRA.
Allowance amount restrictions In 2018, annual allowance amounts are capped at $5,050 for self-only employees and $10,250 for employees with a family. The business can vary allowance amounts only by family status, age, and family size, but not based on employee classes. There are no caps on annual allowance amounts. The business can vary allowance amounts according to permitted employee classes, as well as age and family size.
Group policy requirements Businesses offering the HRA cannot offer a group policy. Businesses offering the HRA may offer a group policy, but it cannot offer both the group policy and the HRA to the same employee class.
Premium tax credit coordination Individuals participating in the HRA are still eligible for premium tax credits, but the amount of the credit is reduced dollar-for-dollar by the amount of the HRA allowance. Individuals participating in the HRA aren’t eligible for premium tax credits.


I will explain each category as well as its advantages and disadvantages in the near future. These regulations do much toward Repairing the Healthcare System.

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

Copywrite 2006-2018

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How Jeff Bezos, Warren Buffett and Jamie Diamond Can Disrupt The Healthcare System

Stanley Feld M.D., FACP,MACE

Jeff Bezos, Warren Buffett and Jamie Diamond should try this disruptive approach in their venture into healthcare reform.

All the other approaches that have been tried have not worked or have become unsustainable. Most of the approaches have been unfair to consumers and the majority of taxpaying Americans.

The only way to empower all the consumers in a healthcare system is to encourage them to become responsible for their health and healthcare dollars.

I believe it can only be accomplished by providing easily understandable financial incentives for consumers to save money for themselves.

Providing financial incentives to consumers to save money for themselves can be disruptive to the present models used to pay for medical services just as Amazon has been disruptive to retail sales.

The delivery of medical and surgical care has advanced tremendously in the last sixty years.

At the same time medical care has become unaffordable and the cost of healthcare has become unsustainable.

The incidence of obesity has risen every year. Over fifty percent of Americans are obese.

Obesity begets many chronic diseases and subsequently the complications of these diseases.

Physicians can treat these complications fairly well. However the treatment of chronic disease complications are costly.

How do you decrease the incidence of obesity in America?

Physicians must attack the core causes of obesity.

Among those causes are excess food intake, lack of daily exercise, mental depression, cultural milieu and/or a combination of all of the above.

The cure of obesity depends on the ability to eliminate these core drivers. Financial incentives can get patients involved in eliminating the core drivers of obesity.

The responsibility for obese patients’ healthcare depends on patients’ lifestyle, popular cultural milieu, and patient education.

In America, it is almost impossible to buy a meal in any level restaurant without excess calories.

How do you get people to be responsible for their health and healthcare dollars?

The one key element ignored by policy makers to decrease obesity is to give obese consumers of healthcare financial incentives to concentrate on trying to lose weight.

Obamacare went in the wrong direction. It limits personal liability for their obesity. It does not promote personal responsibility

The only incentive Obamacare provided was the incentive to overuse the healthcare system.

This was especially true for patients on Medicaid. They had zero premiums and deductibles. The only deterrent to accessing medical care was physician availability.

Physicians refused to participate in Medicaid because of low professional reimbursement. Low reimbursement by the government was necessary because of the decreases in funding and participant overuse of the system.

Obamacare planned to cure the shortage of “medical providers” by increasing the number of “valid medical providers” who could bill on their own, such as nurse practitioners and certified physician assistants.

However, the defect there is that patients were not under the supervision of physicians engaged in their care. It ignores the patient physician relationship that is so important to effective medical care.

If Jeff Bezo, Warren Buffet and Jamie Diamond (BBD group) are serious about Repairing the Healthcare System for their employees as a nonprofit organization, they should consider my Ideal Medical Savings Account.

The Ideal Medical Savings Accounts (MSA) are tax-sheltered accounts used to pay for non-catastrophic medical expenses. These non catastrophic medical expenses account for the bulk of the cost of medical care.

Money left from the Medical Savings Account at the end of the year is put into a consumer’s retirement account.

The MSA provides the financial incentive to not overuse the healthcare system.

Warren Buffet understands the money making potential of re-insurance. He is heavily invested in re-insurance companies.

If one of the BBD Groups employee’s gets sick and spends of all of his MSA money, reinsurance provides first dollar coverage for the illness.

The BBD Group could teach employees how to shop for price and value. Insurance companies are supposed to shop for value. However the shopping is never to the patient’s advantage. It is to the advantage of the insurance company.

 Critics always claim this is unrealistic:

  1. The claim is that patients are not smart enough to shop for price and value. 2. Are you supposed to shop around from the back of the ambulance?

 The critics’ use the ambulance argument to eliminate the possibility of consumers using their own judgment to make price decisions.

Patients are smart enough to figure out which hospital they want to go to before they get into the ambulance.

Emergency care represents only 6% of health care expenditures.

But emergency care represents only 6% of health expenditures.”

“For privately insured adults under 65, almost 60% of spending is on elective outpatient care. “


The critics argument is that consumers do not know how to shop prices. Consumers are smarter than the critics think. It would be easy to teach consumers to shop prices.”


“My Ideal Medical Saving Account provides that financial incentive to not overuse the healthcare system. All the articles about my ideal medical saving accounts are attached to this link.

 Likewise, nearly 60% of Medicaid money goes to outpatient care.”

 Medicaid patients also overuse the healthcare system.

Most Medicaid patients can understand the MSA’s financial incentive.

“ For the top 1% of spenders—a group responsible for more than a quarter of all health expenditures—a full 45% is outpatient.”

These patients can be identified as outliers and educational vehicles can be created to decrease this overuse of the system. It would save the re-insurance company a great deal of money.

In my opinion Medical Savings Account are better than Health Savings Accounts. Medical Savings Accounts take the money out of the healthcare insurance company’s hands and deliver it to consumers retirement accounts.

Both HSA’s and MSAs have the unique advantage of providing the financial incentive to for consumers to save money for themselves.

When people have savings to protect in HSAs, the cost of care drops without harmful effects on health. 

 The financial incentives decrease the overuse of the healthcare system.

According to a 2012 study in Health Affairs if even half of Americans with employer-sponsored insurance enrolled in this kind of coverage, U.S. health expenditures would fall by an estimated $57 billion a year.”

 My ideal Medical Savings Accounts provide an even a greater financial incentive and should decrease costs even further.

“ MSAs should be available to all Americans, including seniors on Medicare. Given that seniors use the most health care, motivating them to seek value is crucial to driving prices lower.”

MSAs should also apply to Medicaid recipients. The details for Medicaid recipients can be found in my article “My Ideal Medical Savings Accounts Is Democratic. “

The maximum contribution to MSAs should be raised to $6000 or $7000 dollars. If a consumer gets sick and experiences a cost of more that $6000 he should receive 100% (first dollar) coverage through the BBD group’s provided reinsurance policy. A reinsurance policy would cost the BBD Group less than $6000 a year.

The total insurance package to BBG Group employees should cost the BBD Group $12,000 rather than the present cost of $18,000.

BBD is a self insured association. The association has elimated the multiple middlemen in the present healthcare system.

 When a person with an MSA dies, the funds should be allowed to roll over tax-free to surviving family members.

This financial incentive should be included in My Ideal Medical Savings Account.

“The information that patients require to assess value must be made more transparent. 

2014 study on magnetic resonance imaging showed that price-transparency programs reduced costs by 18.7%.”

A consumer driven system would force providers to compete for patients. Information on price could easily be provided to consumers by the government and the healthcare insurance industry.

At present healthcare prices are not transparent. Consumers are not motivated to shop prices. The BBD Groups leverage with its employees would force transparency.

“The most compelling motivation for doctors and hospitals to post rates would be knowing that they are competing for price-conscious patients empowered with control of their own money.”

 In this age of technology and rapid communication telemedicine should be promoted and paid for. One way to do it is to permit physicians to practice telemedicine across state lines. It would supply instant access to expertize at an affordable cost.

Everything possible should be done to encourage consumer responsibility and provider competition.

The present tax code does the opposite. Consumers in-group plans provided by large and small corporations receive their healthcare insurance from the corporation with tax-free dollars.

The larger the corporation the more leverage the corporation has for negotiating the premiums with the healthcare insurance companies.

The BBD Groups volume of consumers would have tremendous leverage with providers.

The younger and healthier the corporate employees are the lower the premiums.

The formation of associations with large memberships of all ages would lower the cost of healthcare. Large associations would have great leverage in negotiating price with providers. They would also spread the risk.

Self- insured associations such as the BBD Group would also spread the risk and lower the cost.

Tax deductibility must be given to these “individual” insurance policy holders and association policy holders so they are, in reality, paying for healthcare insurance with pre-tax dollars the same as the corporate group plan policy holders.

These simple changes in the law would result in an affordable healthcare system that was market driven by consumers. The changes would force providers and the healthcare insurance industry to become competitive.

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

 All Rights Reserved © 2006 – 2018 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE



Consumers Need To Take Back Their Medical Care And Healthcare Dollars

Stanley Feld M.D.,FACP,MACE

A consumer driven healthcare system is the solution to the dysfunctional and unaffordable healthcare system that americans are presently experiencing.

President Trump wants to create the conditions for consumers to take responsibility for their medical care and their healthcare dollars.

The negative noise in the mainstream media should be ignored.

The Obamacare health insurance exchanges have failed. The Democrats and establishment Republicans should realize that the health insurance exchange plan was a defective system that it can not be repaired with patches and more money.

President Trump has signed an executive order to permit private associations to sell insurance. There are many associations that a person could belong too. Consumers could shop for the right association at the right price.

Democrats are behaving as if associations are a foreign enemy.

UnitedHealth has contracted with AARP (an association) to sell Medicare supplemental insurance. UnitedHealth sells this insurance across state lines.

USAA has contracted with Humana to sell Medicare supplemental insurance and Medicare Drug coverage.

There are many supplemental plans that consumers can choose from in these associations. These plans are sold across state lines and are competitive.

The government has to change the tax law to treat individual healthcare insurance plans bought through the associations to be paid for with pre-tax dollars just as the employer sponsored group plans do.

However, associations selling healthcare insurance are only the first step in empowering consumers.

A well-known retired physician (DEF M.D.) sent me his view on what consumers need to be aware of to survive any healthcare system. He calls it

“My Three Rules For Survival”

Remember my three rules for survival:

1) Stay the hell away from doctors.

They always either want to do something or prescribe something, and all too frequently do both.

A large part of this physician reflex is their need to practive defensive medicine. Physicians are afraid they might miss something and get sued.

Major tort reform is necessary in most states. Defensive medicine accounts for $250 billion to $700 billion dollars in unnecessary expenses each year.

I have outlined the steps necessary to remedy the malpractice (tort) crisis and its resulting overuse of testing and medication.

If anyone in President Trump’s administration wants to review the issue in full click on this link.

Nobody confronts the reality you mentioned , people are too fat, they drink too much and smoke, AND they don’t even think about the importance of, and benefits from, exercise.

 I started a war on obesity many years ago. Public officials and poly wonks have ignored my suggestions.

It would be worthwhile to read my post about obesity.

The cost to all of us (including them) of all this denial of personal responsibility is huge!  We need to find ways to get people to focus on taking care of themselves, or to create cost incentives that will encourage them to do so.

While you are in this reading mood you should check out my pleas for the importance of patient responsibility.


We simply cannot continue on the path we are on. I don’t recall ever seeing a patient on a “scooter”, and many in wheelchairs that are obese, and only getting fatter and fatter over time.

     2) Take as little medicine as you can.

Pharmaceutical manufacturers are continuing to drive up the cost of their products and are making enormous profits as a result.  Data is available re: the necessity of people getting medicines that they don’t really need, especially if taken long term on an ongoing basis.

To that, one can add the cost of unnecessary procedures that often leave patients worse off than they were before.  Direct to the public advertising of prescription medications creates demand that is often unaccompanied by benefit.

More and more current information regarding side effects and late effects of medications need to be provided, and not just put into the “fine print” on the package stuffers.

     3) Stay out of hospitals.

 They are dangerous places, with a high prevalence of patient injuries and deaths due to various sorts of medical errors that occur all too frequently, despite a host of quality improvement projects that are well-intended, but would be better in terms of effectiveness if they were made public on a regular basis.

 Scott Atlas makes good arguments for encouraging patients to “price shop” for services they must have.  To that information should be appended information about outcomes of what is proposed, which could, over time, become both hospital-specific and physician-specific.

I have expanded on Scott Atlas’ Wall Street Journal article in my last blog.

Most doctors and most hospitals have not much of a clue as to the outcomes of the services they provide their patients.

And, that is probably plenty for today.  DEF”

Consumers need to be educated to become aware of the many pitfalls involved in their new responsibility.

The educational process can be accomplished with online information and chat sessions. The government could provide the education necessary.

Consumers also need financial incentives to be encouraged to be responsible for their care and their healthcare dollars

This can be accomplished with my ideal medical saving accounts.

Then and only then can we have a consumer driven healthcare system that will lower the cost of healthcare.

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

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

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