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Ideal Medical Savings Accounts For Everyone: Encourage Patient Responsibility!

Stanley Feld M.D.,FACP,MACE

The third spoke in the future states wheel is Patient Responsibilty for their health and Healthcare dollars.

The Ideal Medical Saving Account would decrease the cost of the Healthcare System because it would dis-intermediate the Healthcare System’s complex and convoluted business model.

The Ideal Medical Savings Account should be an option for all consumers who have all types of insurance coverage. The Ideal Medical Savings Accounts would create competition for patients among physicians. It would create competition among healthcare insurers.

Medicare, Medicaid, corporate self-insurance plans, association healthcare plans, individual healthcare plans and ordinary healthcare insurance plans provided by employers could all offer the Ideal Medical Savings Account.

If MSAs were structured as my Ideal Medical Savings Account is structured the result would be a decrease in the cost of healthcare, a decrease in premium costs and an increase in healthcare quality.

The Ideal MSA must be paid for by pretax dollars as all other healthcare plans are.

If the government, individual or employer puts the first $6,000 of insurance in individual trusts for the consumer the entire healthcare and medical care supply chain would be disrupted by consumers.

An immediate argument is Medicaid patients are not smart enough to determine their own healthcare needs if they were responsible for the first $6000 of healthcare insurance coverage.

This is rubbish. It is condescending to patients on Medicaid. If the government is so worried they should provide education to help these Medicaid consumers make wise healthcare choices using available social media.


 The entire goal of the Ideal Medical Savings Account is to provide incentives for consumers to become responsible for their health and healthcare needs rather than be entitled to medical care.

The mechanism for this reversal from a dysfunctional system’s business model to a functional system’s business model is patients’ owning their healthcare dollars and having financial as well as medical incentive to be responsible for their health, maintaining their health, and choosing the most efficient and effective medical care.

Consumers would become Prosumers (Productive consumers) of health care rather than passive consumers of healthcare.

This mechanism has worked in many industries using the Internet as a facilitator.

The Internet can become an extension of the physicians care.

At present there are many web sites offering advice to patients. The defect is they are not an extension of the physician’s care of the patient.

Physicians would be motivated through competition for the patients’ owned healthcare dollars to choose the sites for his patients that would be an extension of their care.

Physicians associations could create web sites for their members.  Social networking between physicians and their patients could direct their patients to that site. This would be the meaning of an extension of the physician’s care.  

Patient responsibility is the third spoke in my formulation of the future state business model of a functional healthcare system.



It must be remembered that the present state’s business model is dysfunctional. It must be repaired.

The future state must not be encumbered by any of the baggage of the dysfunctional present state business model.

If the future state model is made clear to patients, potential future patients and recovered patients (consumers) they will demand for this future state model.  

Using social media consumers can drive the healthcare system to the future state business model.

It is similar to what ITunes did to music publishing, Amazon did to book publishing and Netflix did to the movie industry.

 It turns out everyone is better off and the system is more efficient and costs less for consumers. 

The consumers would own the first $6,000. They would be responsible for the management of there healthcare dollars. They would also be responsible for choosing their physician.

I have found that when physicians and patients sign a patient physician contract the treatment results improve. Both physicians and patients have their responsibilities clearly defined.

The patient physician contract motivates patients to be responsible for their own care. Patients responsible for their care is critical to successful clinical outcomes.

If there were a financial incentive attached to this physician patient contract along with a potential bonus the results would be even better.  

This was especially true in the treatment of Diabetes Mellitus.

In treating chronic diseases such as Diabetes, physicians must be the teachers, prescribers and coach. Patients must become the professor of their disease. Patients live and care for their disease 24/7.

Financial incentives would motivate patients to take an active role in their medical care.  

Obesity is a major problem in America today. Patients and patient education is the only solution to the “The Obesity Epidemic.”

The only way to decrease obesity is by burning more calories than is eaten.  Society must encourage exercise, and reducing intake. It turns out society encourages the opposite.

Mayor Bloomberg is doing the right thing in New York City. He uses simple transit Subway advertisements to increase awareness caloric intake. He has required each restaurant to publish calorie counts.

It is a simple educational message that everyone can understand. It is amazing how intelligent people misjudge their caloric intake.

Constant repetition of calorie counts of various foods along with estimates of calories burned can result is a cultural change for the need to burn more than we eat.  

Companies such as FitBit are building simple products to help us achieve this goal. 

Obesity contributes to the onset of many chronic diseases. The treatment of the complications of chronic disease result in eighty percent of the healthcare dollars spent for direct patient care.

If a consumer abuses his health and ends up spending the initial $6,000 he has no money left to put into his retirement account.

If a patient has a chronic disease and has excellent control of his disease he can avoid the complications of his disease. If the patients take the appropriate medical care avoids hospitalization and the emergency room for the year, the provider of his Ideal Medical Saving Accounts can afford to give that person a bonus for his retirement account.

This would add an additional financial incentive for consumers.

As a society we are smart enough to solve the problem of a dysfunctional healthcare system. The present course is unsustainable.

The future state’s business model with consumers responsible for their healthcare dollars and the patient physician relationship restored can achieve the goal of a sustainable healthcare system. 

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

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Patients’ Responsibility And Hospital Readmissions

Stanley Feld M.D.,FACE,MACE

has rules to penaliz
e hospital systems if a patient was readmitted to the
hospital before 30 days of initial admission.

Prior to October 1,2012 Medicare revised hospitals' readmissions penalties
. On October 1 Medicare started fining hospitals
that have too many patients readmitted within 30 days of discharge due to
complications of their disease.

The formula for determining these penalties is
extremely complicated
. The formula is almost impossible to understand.   

Hospitals whose admission rates are above the
national average will be penalized. The data analytics are supposed to risk
weight patients to see if the hospital should be penalized.

Patients with multiple co-morbidities have a higher
chance of readmission.

The penalties are part of a broader
push under President Barack Obama's
health care law to improve quality while
also trying to save taxpayers money.”

The gigantic perverse incentive is for hospitals to
avoid the initial admission of sick patients with multiple morbidities. Those are
the patients that have a better chance of being readmitted within 30 days.

It is also impossible to evaluate quality of medical
care using claims data. False  conclusions will not be a true reflection on who
is at fault and should be blamed and penalized for the readmission.

 It could be
that patients did not adhere to the discharge instructions.  

two-thirds of the hospitals serving Medicare patients, or some 2,200
facilities, will be hit with penalties averaging around $125,000 per facility
this coming year, according to government estimates.”

The formula for penalty
assessment  is extremely complicated. The
Centers for Medicare & Medicaid Services has discovered errors in its
initial calculations in August 2012.  

one in five Medicare patients return to the hospital within a month of
discharge, costing the government an extra $17.5 billion in 2010.”

A total of 2,217 hospitals are being
punished in the first year of the program, which began Oct. 1. Of those, 307
will be docked the maximum amount: 1 percent of their regular Medicare

Only acute myocardial infarction,
congestive heart failure and pneumonia will be evaluated the first year.


Overall, Medicare has estimated it will recoup about $280 million
from hospitals where it determined too many heart attack, heart failure or
pneumonia patients returned within 30 days

Dartmouth Atlas of Health Care and the Robert Wood Johnson Foundation latest
report "The Revolving Door Syndrome on
hospital readmissions points out highly variable rates.

Ninety two (92) academic
medical centers and 37 hospitals saw readmission rates for their patients
actually increase. 

                                               Double click to see legend

David Goodman, MD, co-principal investigator
for the Dartmouth Atlas Project said
. "Despite
awareness of the problem, progress and improvement has been slow."

report divided readmissions into two types, those affecting patients whose
first admission was for a surgical procedure and those affecting patients whose
first admission was for a medical condition such as congestive heart failure,
pneumonia, or heart attack.

The surgical 30-day readmission
rate dropped from 12.7% in 2008 to 12.4% in 2010, while the medical 30-day
readmission rate went from 16.2% to 15.9%.

The report shows wide
among academic medical

“The highest readmission rates in 2010 were the
Cleveland Clinic, with 21.6%
, and the Hospital of the University of
Pennsylvania, with 21.4% among AMI, congestive heart failure and pneumonia.

The hospital with the lowest rate was NYU Langone Medical Center, with
14.4%. “ 

The University of
Medicine and Dentistry in New Jersey (UMDNJ) had the highest surgical
readmission rate with 20.7%, and the Stony Brook University Medical Center on
Long Island, with 20.6%.

If this data is correct
academic institutions will not be in the mood to be penalized for taking care
of sick patients.

Other studies have shown
that there is only a 50-60% adherence rate by patients to prescribed treatment.
This lack of adherence can be a significant driver to readmission rates. There
is no data evaluating patients’ role and responsibilities in re-admission

What are patients’
responsibility for their care? If patients do not receive enough education to
avoid hospitalization they should demand the education.

If patients are not
interested in self-management of their disease they should tell their

If the patient is too sick
to learn to self-manage a family member should be involved.

Patients have responsibility
for their self management to avoid readmission is high!

Yet the government is quick
to blame hospitals and physicians for high re-admission rates without examining
all the facts.

Another factor not
evaluated in determining readmission rates is the pressure on the hospitals to discharge
patients quickly.

doctors feel they are caught in a squeeze play
," the report says.
"Hospital administrators carefully monitor length of stay—they are eager
to send people home because the longer a patient stays, the less money they
make. Thus providers said that the prevailing pressure is to discharge
patients as early as possible" even if it's too soon.”

is the slippery slope the healthcare system is on. The data management is
faulty. The government is not evaluating all the complex variables resulting in
hospital readmissions. This defect leads to faulty decisions. Those decisions
lead to more complicated unintended consequences.

should be driving the healthcare system not the government. The government
should make the rules to level the playing field for all stakeholders.

government should defend the interests of patients.

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

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What Is Patient-Centered Healthcare?

Stanley Feld M.D.,FACP, MACE

Patient-Centered Healthcare is a new buzz phrase. It has become popular among Republicans in the last few years.

I have a feeling most people do not know what physicians mean by patient-centered healthcare.

The true definition is that patients are in the center of the medical care interaction. Patients determine their needs and their physicians. Patients drive the medical encounter. Neither the government nor the insurance industries drive the medical encounter.

A fatal floor in Obamacare was that President Obama wanted the federal government to control the healthcare system.

President Trump’s goal is to have patients in control of their own health and healthcare dollars. It is not a problem if the government or employers provide those healthcare dollars.

I believe Tom Price M.D. understands that the only system that will work is a system in which the consumers (patients) are responsible for their own health and healthcare dollars.

The government’s job is to provide incentives in the healthcare system for consumers to become responsible for their health and healthcare dollars.

I am not at all sure the Republican congressional leadership understands the definition or value of patient- centered care.

Obamacare provided just the opposite. Obamacare provided incentives for consumers/patients to be dependent of government.

This fundamental tenet of patient-centered care was tested by Stewart, in 2000. 

 Experts studied audio taped doctor-patient interactions while patients also rated these same interactions. 

 Expert opinion could not be correlated with positive results, but patient-perceived patient-centered care correlated with “better recovery from their discomfort and concern, better emotional health.

 A Wikipedia definition of “Patient centered healthcare” does not exist. There are many consumer-driven healthcare definitions.

Most of the Republicans are talking about patient centered healthcare. However, they start and end with Health Savings Accounts and Consumer Driven Healthcare.

The American Association of Clinical Endocrinologist defined patient-centered healthcare in its diabetes guidelines of 1996 and 2002. (on request)

The guidelines were a System of Intensive Self-Management of Type 2 Diabetes Mellitus.

The Type 2 Diabetic was taught to become a “professor of his/her diabetes.”

The goal was to get the diabetic blood sugar as close to normal as possible. It was shown that normalizing the blood sugar helped avoided the vascular complication of diabetes. The treatment of the vascular complications of diabetes absorbed 80% of the money spent on diabetes.

Patients live with their disease 24/7. Blood sugars are very variable. Patients need to learn how to adjust to these variables by managing their medications and lifestyle.

Patients taking a pill or a shot will not control their blood sugar unless they understand the medication and how to adjust it to have the greatest affect on the blood sugar.

The only way a patient can understand how to control their blood sugar is for them to understand how their blood sugar affects the effectiveness of the medication and how their medications and lifestyle affects their blood sugar.

This same phenomenon applies to most chronic diseases.

The only way to decrease the complications of chronic diseases is for patient to drive the treatment of their disease.

This in turn will be the only way to control healthcare costs. This is what I mean when I say patients should be in control of their health.

As an added incentive to control costs, patients should be in control of their healthcare dollars so they figure out how to use medication most affectively.

In the February 2017 Endocrine News published by the Endocrine Society there was an article interviewing four endocrinologists for their definition of patient centered care.

“In 2001, The Institute of Medicine published a book called Crossing the Quality Chasm: A New Health System for the 21st Century.”

“In it, the institute identified six aims for improvement of healthcare delivery, one of which was “patient-centered care,” defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”

The Institute of Medicine’s definition moves patients’ needs and attitudes toward patients being in the center of care. It does not place them as responsible for the management of their care. It does not include patients’ responsibility for their care.

All four of the endocrinologists got close to the definition of patient centered care. Only Carol Greenlee, MD, FACE, FACP, of Western Slope Endocrinology in Grand Junction, Colorado nailed the definition. Dr. Greenlee is the only physician in private practice.

She said:

“One of the most important things is partnership with the patient and what is called “contextualized” care, which means taking into account a patient’s needs and circumstances, goals and values.

It is also called developing a physician/patient relationship.

Another aspect is moving from the physician being at the center of the care model, with staff working to help the physician (doing tasks for the physician or other clinician such as “rooming” the patient or “scheduling” the patient for the clinician) to the staff also “taking care of the patient” as their job, with different roles on the patient-centered care team (getting the patient in for a needed appointment).

It is doing what is best for the patient (not giving the patient what they want, e.g. pain meds, MRI, antibiotics) or ask for (those things are not often best for the patient, but takes time to discuss through).

It’s taking our best science and knowledge and technology and then adapting it to meet the patient’s unique needs, circumstances, values, and goals.

It requires clearing up misconceptions (such as asking what the patient currently understands about a condition or a test or treatment), helping discuss risks and benefits in the context of that individual patient.

It requires asking not just telling, but it is not dumping everything back on to the patient.

It is taking into account the “work” (the job) of care (self-care that the patient or family need to do) on top of the illness and the rest of life that the patient and their family have to deal with and do (i.e. consideration)

Most clinicians think that they are already patient-centered because they care about their patients.

But that does not mean they provide patient-centered care or practice in a patient-centered approach.

I thought I was patient-centered because I cared but then I had to uproot my mental model to really become patient-centered.”

Republicans and their advisors do not understand the meaning of the concept of patient centered care.

Tom Price M.D. understands the concept of patient centered care.

Without the patient being in the center of the management of his/her care, the healthcare system can never be repaired and will never be financially sustainable.

I hope President Trump gets the concept in spite of the advice from congressional Republican and Democrats. Congress is trying to satisfy all the secondary vested interests. Healthcare is a big business with many secondary stakeholders. They do not want to lose this important profit center.

These stakeholders are better organized than patients or physicians to influence healthcare policy makers.

The primary stakeholders are patients with their head coaches and assistant coaches being physicians and their healthcare team.

Patients must be in the center of the healthcare team because they are the only ones that can influences the cost of medical care.

The opinions expressed in the blog “Repairing The Healthcare System” is, mine and mine alone.
All Rights Reserved © 2006 – 2017 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE
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Listen Up: It Is All About Personal Responsibility

Stanley Feld M.D.,FACP,MACE

In my last blog I continued my War on Obesity. I started this war in 2007.

There has been little progress in this war because of cultural conditioning and a lack of emphasis on personal responsibility.

Every New Year’s Day millions of Americans make New Year resolutions to lose weight. They are initially successful. They then regain the weight they have lost.

If America is going to solve the healthcare systems unsustainable cost, it is going to have to solve the increasing Obesity problem.

The National Institute of Diabetes (niddk.nih} recently published Overweight and Obesity statistics:

  “More than two-thirds (68.8 percent) of adults are considered to be overweight or obese.”

 “ More than one-third (35.7 percent) of adults are considered to be obese.”

 “ More than 1 in 20 (6.3 percent) have extreme obesity.”

 “ Almost 3 in 4 men (74 percent) are considered to be overweight or obese.”

Each year the obesity problem gets worse. Companies have sprung up selling weight loss formulas. These companies advertise their great success.

However, most of the iconic personalities used in their advertising have regained their weight after experiencing mild or significant weight loss.

This study was conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention.

NHANES III was designed to provide nationally representative data to estimate the prevalence of major diseases, nutritional disorders, and potential risk factors.

  • Sixty-three percent of men and 55% of women had a body mass index of 25 kg/m2 or greater.


  • A graded increase in the prevalence ratio (PR) was observed with increasing severity of overweight and obesity for all of the health outcomes except for coronary heart disease in men and high blood cholesterol level in both men and women.


  • With normal-weight individuals as the reference, for individuals with BMIs of at least 40 kg/m2 and who were younger than 55 years, PRs were highest for type 2 diabetes for men (PR, 18.1; 95% confidence interval [CI], 6.7-46.8)


  • Women (PR, 12.9; 95% CI, 5.7-28.1]


  •  Gallbladder disease for men (PR, 21.1; 95% CI, 4.1-84.2) and women (PR, 5.2; 95% CI, 2.9-8.9).


  • Prevalence ratios generally were greater in younger than in older adults.


  • The prevalence of having 2 or more health conditions increased with weight status category across all racial and ethnic subgroups.


The Prevalence Ratio of Obesity and Type 2 Diabetes is 18.1 for men and 12.9 for women.

Therefore Type 2 Diabetes is very prevalent in both Obese and Overweight men and women.


  • Up to 75% of adults with diabetes also have hypertension, and patients with hypertension alone often show evidence of insulin resistance.
  • Hypertension and diabetes are common, intertwined conditions that share a significant overlap in underlying risk factors (including ethnicity, familial, dyslipidemia, and lifestyle determinants) and complications.
  • These complications include microvascular and macrovascular disorders. The macrovascular complications, which are well recognized in patients with longstanding diabetes or hypertension, include coronary artery disease, myocardial infarction, stroke, congestive heart failure, and peripheral vascular disease.
  • Although microvascular complications (retinopathy, nephropathy, and neuropathy) are conventionally linked to hyperglycemia, studies have shown that hypertension constitutes an important risk factor, especially for nephropathy.

Eighty percent of the treatment costs for diabetes and hypertension to the healthcare system is the result of the treatment of the complications of hypertension and diabetes.

In order for a healthcare system to be sustainable diabetes and hypertension must be cured. It is essential that each must be recognized early and treated aggressively.

Patients must be taught to be “the professor of their disease” so they can self-manage the control of their disease. Blood pressures and blood sugar are changing continuously. Patients live with their disease 24/7.

This takes a lot of personal responsibility and personal discipline.

Equally important is the morbidity resulting from the complications of diabetes and hypertension, two diseases that result from obesity.

Complications from the onset of both hypertension and diabetes take about eight years to develop. This is the reason to diagnose and discover Pre-Diabetes at the onset.

  • The shared lifestyle factors in the etiology of hypertension and diabetes provide ample opportunity for non-pharmacological intervention.
  • Thus, the initial approach to the management of both diabetes and hypertension must emphasize weight control, physical activity, and dietary modification.

Lifestyle intervention is remarkably effective in the primary prevention of diabetes and hypertension. These principles also are pertinent to the prevention of downstream macrovascular complications of the two disorders.

This is the where my story of the importance of personal responsibility comes in.

A restaurateur, in his early 50’s, who runs a large restaurant in Dallas, that I frequent, was slowly gaining weight. At 269 lbs. he had difficulty standing on his feet all day long. He was being treated for hypertension and hyperlipidemia (high cholesterol).

His physician told him he must lose weight. He informed him of his risk factors for the complications of these diseases.

This was all he needed hear. The thought of having to quit the job he loved and the possibility of dying from the complications of his diseases was enough to make him decide to loss the weight.

He was told he would be fine if he lost the weight.

He has lost 70 far without assistence. He has decided to be personally responsible for his weight loss.

He now gets up at 5 am each morning and exercises for one hour each day before work.

He has stopped eating his wonderful pasta dishes. He eats nothing that is white.

Every time I meet a friend at the restaurant, the restaurateur sits down at our table for a chat. We usually talk about how great he is doing in the weight loss department.

I had initiated an obesity program at Endocrine Associates of Dallas P.A. in the mid 1980s. A California clinical endocrinologist, with whom I did my endocrine fellowship with, had a very successful obesity program. He convinced me to start one at EAD.

Patients on large doses of insulin were totally off insulin after two weeks. It was successful until the patients graduated from the program.

Unfortunately the recidivism rate (regaining weight) was around 80%. This rate was not dissimilar to the national overage at the time.

EAD stopped the program.

In my view there were not enough patients who turned the corner and stuck to the program.

I believe the restaurateur has turned the corner. This fellow has turned the personal responsibility corner to control his food intake and exercise output. I do not believe he will regain his weight.

He has exhibited personal responsibility for his health and well-being.

If only physicians could solve the obesity problem so easily, the cost of healthcare would plummet to sustainable levels.

The development of Type 2 Diabetes Mellitus would also plummet and the cost of the treatment of its complications would vanish.

Social change is necessary in restaurants and fast food chains.

People have to be taught to eat wisely in restaurants and at home.

People have to be provided with education about the perils of obesity.

People have to understand the natural history of obesity.

People have to be motivated to not only maintain their health. They have to be given financial incentives to control their health.

This can only be achieved with a consumer driven healthcare system in which people are provided with incentives to control their healthcare dollars.

My ideal medical savings account will provide all the appropriate incentives for all people of all economic levels.

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

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

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More Magic Of The Patient/Physicians Relationship

Stanley Feld M.D.,FACP,MACE

The complications of chronic diseases account for 80% of the costs of those diseases for the healthcare system.

The role of patients with chronic diseases and their physicians must be clear to both patients and physicians.

President Obama wants to make physicians responsible for the outcome of their care for patients. Physicians have control of making the diagnosis and prescribing treatment.

Physicians do not have control of patients’ adherence to therapy and control of patients’ behavior.

Only patients can be responsible for their behavior. Physicians are managers of a healthcare team. The healthcare team is composed of physician extenders (assistant coaches).

Patients are in the center of the team. Patients live with their disease 24 hours a day. Patients have to learn how to manage the day-to-day fluctuations in the control of their chronic disease.

If the disease is managed well both the acute complications (emergency room visits) and chronic complications (in Diabetes Mellitus heart attacks, blindness, kidney failure and strokes from hypertension) can be avoided.

The cost of care would be markedly reduced if these complications were avoided.

Patients with diabetes need to understand the disease use methods to control their blood sugar, blood pressure and lipid levels.

Patients have to become “professors of their disease” in order to control their disease.

Physician visits are only a snapshot of what is going on in that patient’s disease process. The information brought to physicians by patients can help physicians, using their clinical judgment, help patients control their disease.

Patients must to be inspired to manage their chronic disease. This requires patients having confidence in their physicians and his assistants.

A good patient/physician relationship can encourage patients to control their chronic disease.

It is hard work for patients to monitor their blood sugar, blood pressure and weight. It is also hard to learn the causes of the fluctuations in their blood sugars and blood pressure.

This idea of mutual trust and confidence between the manager and player are illustrated by something that happened between a teacher and me in high school.

This example is an example of a student/teacher relationship.

It is also an excellent example of the power of an effective patient/physician relationship.

It was a rainy day in the spring of 1953 during my junior year in high school. I was on the high school baseball team. The team could not practice that afternoon because of the weather. The team was sent to the Study Hall for the 8th period.

Ms. W. was one of the 8th period Study Hall teachers. She was my geometry teacher. I thought she was the greatest. I never missed a question in class or on a test. She came over to me that rainy spring day to say hello. She asked how I was doing in trigonometry.

I told her I was not doing well. I can not learn a thing from Mr. B. teaching.

Mr. B. was the chairman of the math department. He taught trig in a very dry way. He was detached. Trig had no meaning to me. He did not teach us to understand the logic of trigonometry and its practical use.

No matter how much I tried to derive meaning from the textbook by myself the material covered was not understandable.

 I felt my ability to learn and problem solve was suppressed. Mr. B’s goal was to have us memorize the material.

Mrs. W. asked me which period I had trigonometry and lunch. I told her trig 5th period and lunch 6th period. She said great she taught trig 6th period. She could get me transferred to her class. I could have lunch 5th period.

I was thrilled beyond belief. She also said she hoped I was aware of the departmental quiz being given the next day. I would be required to take the test.

Ms. W said the chances are I would do poorly on the test.  She encouraged me to study for it when I got home.

The most amazing thing happened that night when I started studying for the quiz.

All of a sudden I grasped the concepts I could not grasp in Mr. B’s class. Now that I was in Ms. W. class I solved problems I could not solve previously. A difficult textbook became easy to understand.

The next day I went into Ms. W’s trigonometry class, took the test, and got 100%.

I know this has happened to all of us at some time in our life. I know it was the result of my knowing that someone had respect for and confidence in me.  

The lesson of Mrs. W. is a powerful lesson. Mrs. W. did enable me to have confidence in my learning ability because of her confidence in me.  She empowered me to learn by myself.

If a relationship is positive, with mutual respect and commitment by both physician and patient, patients can learn to control their chronic disease properly.  

 Chronic diseases such as diabetes frighten patients. This fright makes it difficult to learn how to control their disease to avoid its complications.

Physicians must deal with this through a positive patient/physician relationship. A positive patient physician relationship can make it easier for patients to learn to control their disease.

In practicing endocrinology I developed a patient physician contract to define this physician/patient relationship.

My son Daniel wrote a letter to me about my patient-physician contract that brought tears to my eyes.  

Dear Dad;

I love you. I think everyone should know about your patient-physician contract.

I tell people all the time about your patient-physician contract.

The way you use it to have patients take responsibility for their health and healing.

I’ve adopted this myself in my own health and healing and believe it’s critical since we know ourselves better than anyone else.


The Physician Patient contract as it appeared in Endocrine Practice 2002:8 (Supp 1)

  1. a.    Sample Patient-Physician Contract


I understand that if I agree to participate in the System of Intensive Diabetes Self-Management, I will be expected to do 
the following:

1. Dedicate myself to getting my blood glucose level as close to normal as possible by following the instructions of the 
diabetes self-management team.

2. Regularly visit the clinic for a physical examination, laboratory tests, and nutrition counseling; follow-up visits will 
be scheduled every 3 months or more frequently if deemed necessary by my physician or other members of my 
health-care team.

3. Bring a detailed 1-day food record to each follow-up visit, provide necessary nutrition information for me and my 
dietitian, and adjust my eating habits to meet the nutrition goals established by my dietitian.

4. Use medications as prescribed by my health-care team

5. Monitor my blood glucose levels at home as instructed and brings the results to each follow-up visit.

6. Follow my prescribed exercise plan.

7. Obtain identification as a patient with diabetes, for prompt assistance in case of an emergency.

8. Ask my physician and other members of my health-care team to explain any aspect of my care that I do not entirely 

I understand that if I do not monitor myself carefully, there is a risk of hypoglycemia.

I also understand that if I do not strive to normalize my blood glucose, I am at increased risk of developing the 
complications of diabetes mellitus.

My signature indicates that I have read and understand the above agreement.



I agree to provide the leadership for the diabetes self-management team. Team members will be available to answer 
your questions and help you self-manage your diabetes. I will continue to encourage you to maintain the best possible 
control of your diabetes.



Obamacare in its attempt to standardize medical care is converting healthcare into a commodity and in the process destroying patient/physician relationships.

The healthcare system cannot be repaired without effective chronic disease management. Chronic disease management will not be effective without effective patient-physician relationships.

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

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What Happened to the “Physician/ Patient Relationship?”

Stanley Feld M.D.,FACP,MACE

The only way America’s healthcare system will be repaired is by
revitalizing the Physician/ Patient Relationship.

Veterans complaining about the VA Hospital System in my last
blog brought
on a flurry of negative comments about practicing physicians not
connecting with their  Medicare and
commercial insurance patients in the private sector.

The chief complaint is that physicians are not connecting to
their patients or their patients’ illness. I have heard enough stories to
believe it is true.

A 44-year-old male with
private healthcare insurance sent one such complaint to me.

His acute illnesses history was compatible with acute prostatitis.

He needed a new physician because his previous primary care physician
had taken a sabbatical leave.

He called for help in finding a physician to his friends on
Facebook, Twitter and Link In. The consensus was the physician he describes

The physician did multiple tests, several of which I did not
think were necessary, along with a cursory physical examination. The physician
thought the patient had prostatitis and prescribed Cipro for one month. A
follow-up examination was not scheduled.

The last paragraph in the patient’s note to me was,.

By the way, my doctor's office called to let me know the
lab results are in and they are mailing them to me. The doctor told the front
desk person to send me a letter, which I'll get in a day or two. According to
the front desk person, in the letter he says that my labs look good, and that I
need to work on getting my lipids up. Apparently he included a link to a
website that I can learn more about lipids. Pretty great patient care, eh…

This is horrifying to me. The patient will probably do well.
However there is no contact or concern about the patient’s outcome in this
interaction. There was no physician patient relationship formed for a patient
who is looking for a primary care physician.

I would be very upset if this interaction happened to me.  I would be more upset if I then receive a bill
for $800 for the visit.

This patient does not know what the bill will be because the
office said it will bill his insurance company.

The evidence of the loss of the Patient-Physician Relationship of delivering medical care did not happen overnight.

A reader Dr. Dale Fuller sent me this commentary. He walks us through the
evolution of the destruction of the Doctor- Patient relationship.

Dr. Fuller’s view is similar to the view I have discussed in this
blog on multiple occasions. I believe it is important to publish his thought in
its entirety.


 "Whatever Happened to
the “Doctor- Patient Relationship?”


Dale Fuller M.D.

Lately, I
find myself thinking about this question more and more.  I think the first time I heard the term,
“doctor-patient relationship” was back during Harry Truman’s administration,
when there was an effort led by the Democrats to create a National Health
Insurance Program.

Medicine” the opposition cried, and “The end of the doctor patient
relationship!   I wasn‘t even a student
in college back then, and in the absence of more information, I saw the
doctor-patient relationship in the context of my experience with the doctor who
looked after me on those rare occasions when I needed to see him,

Dr. T.D.
Jones, who was a very kind man.  He was a
small town doctor, and the only doctor in my hometown as well as a good many
other towns around it during World War II.

I kind of
understood the term “socialized medicine” in the context of the then-new
National Health Service being launched in Great Britain. 

Truman and
company lost the battle for NHI back then.

The next big
“Socialized Medicine initiative arrived in 1960 
“Socialized   during the Republican administration of Dwight

Robert Kerr, of Oklahoma and Rep. Wilbur Mills of Arkansas, both Democrats
introduced the Kerr-Mills act, the “Medical Assistance for Aged Act 1960-1965”
(benefiting primarily the elderly on Old Age and Survivors’ Assistance).

was passed in 1960, again over cries that it would destroy the doctor-patient
relationship.  But this time the cries
were neither so loud, nor as successful. 
By this time I am a newly minted MD, and my awareness of the total
meaning of the term is still mostly intuitive.

During the
administration of Lyndon Johnson, came the Social Security Amendments of 1965,
which brought us Medicare and Medicaid. 

When I
entered practice in 1968, Medicare and Medicaid were just getting under way, so
I never experienced what it was like to practice in the absence of the law.

In March of
2010, President Obama signed into law The Patient Protection and Affordable
Care Act, and we are now living through the incremental steps preceding that
law becoming fully in effect in 2014.

The various
legislative initiatives have, to be sure, impacted the doctor-patient
relationship in many ways, as the opponents predicted, but it appears to me
that we have been hearing less and less about that relationship as the years
have passed. 

I think it
might just be that the relationship we are discussing may be threatened by a
number of other forces other than the laws described above, but before I
attempt to list those forces, I want to spend a little time setting the stage
to describe just what the doctor-patient might and might not mean.

Goold and
, in an article published in 1999 (1) called the doctor-patient
relationship “a keystone of care: the medium in which data are gathered,
diagnoses and plans are made compliance is accomplished, and healing, patient
activation, and support are provided.”

They say that
the medical interview is the major medium of health care, and that more than
82% of diagnoses are made by history alone.

The three
functions of a medical interview are the gathering of information (both through
history and physical examination) developing and maintaining a therapeutic
relationship, and communicating information.

In the eyes
of the law, physicians also have a fiduciary responsibility toward their
patients. Physicians are bound to act in their patients’ interests even when
those interests may conflict with their own.

In that
physicians are often directly involved with events and conditions that are
life-altering for their patients and families, at birth, during severe illness,
healing or death, it can also be said that in being a physician, and providing
health care, doctors are engaging in a moral enterprise.

There was a
time when the unwritten social contract laid out above, simply existed as an
understanding between patients and doctors.

In the early
1940’s the arrival on the scene of what became the Blue Cross and Blue Shield
program, initially serving the employees of the Dallas, Texas Independent
School District began to interpose a third party, the insurance company,
working through the employers, in the social contract that was the Doctor-Patient relationship.

that interposition was pretty innocuous, with the insurance plan simply paying
the bills of the doctor as they were presented. The phrase, “usual and
customary” arose to define the fees involved that the insurance company paid.
Unusual fees or fees exceeding customary levels became subject to challenge,
requiring justification if they were to be paid.

Over time, a
database of fees that really were usual and customary began to become a better
and better tool to define where the usual kind of fee stopped and the unusual
kind of fee was recognized.

when it came along, introduced the federal government as a payer, and
relatively soon thereafter, the health care bureaucracy began to grow and
insert itself between doctors and patients to an increasing degree.

Since this
was in the “Pre-Medicare era” the number of patients involved was relatively
small, and so the impact on the doctor patient relationship was still somewhat

The arrival of Medicare and Medicaid served to
illustrate that the old “camel entering the tent” analogy was beginning to come

while the organizations were formed to administer the programs, “usual and
customary” was still the order of the day where payments were concerned, and
the social contract still functioned much as it had always done.

At the
request of the Department of Defense, organized medicine (AMA) created a set of
relative value scales in an attempt to standardize professional fees. The set
of codes was called “Current Procedural Terminology (CPT codes)” (first
introduced in 1966).

The charges
were to be based upon a blend of time required, professional skill involved,
and liability risk.

The compendium
of procedures have grown over the years, the principles remain essentially the

In a fit of
zeal, the Federal Trade Commission inserted itself and accused professional
societies of “price fixing” via the CPT codes.

eventually ensued, and money passed from the societies that were sued to the
FTC, and life, after the “nolo contendere pleas’ went on as usual.

The reason
for this was that the societies were not well enough funded to defend their
position vs. the FTC, even though they might have won their cases.

though, as might be expected, the government began to insert itself more and
more into the transaction between doctors and patients, generally, drawing upon
the reality that it was paying, directly or indirectly, for more than 50% of
the care given in the US.

and rules have proliferated, respecting what can and cannot be done for
patients who are beneficiaries of federal programs. 

Another force
was also becoming more vocal in making statements and policy regarding what
could and could not be done for patients.

This force
began with the passage of the Health Maintenance Act of 1973.  This act enabled a vast acceleration of the
whole concept of managed care. 

Insurance Companies citing the growing demand for, and cost of medical care to
employers, found a ready market among employers for their “products” to serve
as “benefits” for their employees. 

and hospitals, fearing that they might be left out of the managed care programs,
made haste to “join” this program or that program, seeking access to the
populations of patients enrolled in the programs by the insurance companies
selling coverage to employers. 

The fear was
that exclusive arrangement with insurance companies would eliminate whole
populations of patients from providers who had not “signed up”.

This meant
that the traditional bilateral social contract between doctors and patients
essentially had come to an end of sorts.

Patients’ expectations
were that service and behavior of the doctor they were allowed to see remained
pretty much the same except for a small by important fact.

employees covered by managed care were required to see the doctors who
participated in the program, and to use the hospitals the programs had
agreements with.

penalties awaited those patients who sought their care “out of plan”, for
whatever reason. 

Now patients
and doctors both have someone else “calling the tune” when it comes to the
delivery of healthcare.

Each time the
“plan” purchased by the employer changed, for whatever reason, there could be a
change in the physicians and hospitals available to the patient. 

This brings
us to a key element of the doctor-patient relationship. A key element is
continuity of care.

Continuity of
brings with it an opportunity develop relationships in which doctors and
patients really know and trust one another. This relationship allows physicians
to recognize changes in patients and recognize the early onset of disease.

Neither the physicians’ understanding nor the
patients’ trust cannot be rebuilt immediately between two individuals each year
who are basically strangers to one another.

 Doctor of days past, the trusted counselor, often
friend and confidant, is no longer exists. 
Now, patients are simply seeing another person in an office. Both
parties are at sea when it comes to knowing what they need to know about one
another to allow the encounter to produce the necessary result within the time

Time, like
continuity, is also a vanishing element in the doctor-patient
relationship.  Fewer and fewer
practitioners have the time, amidst the pressures of “patient throughput” to
really engage in patients’ needs.

must gather and record data, establish a diagnosis, and create a treatment plan
of quality.

documentation has to be complete in order to get paid by the government or the
healthcare insurance carrier.

Doctors must also
explain his treatment plan in such a way that they are assured of patients’
compliance with the treatment proposed in the time available to doctors.

As a result
of decreasing reimbursement and increasing overhead the time necessary for
patient education is insufficient. Patients do not understand the significance
of the therapy. The result is a lack of compliance.

problem is that the “third party payers” rather than the patients approves of any
tests and procedures that doctors believe are needed to strengthen the

The result is
a further erosion of patients trust in the doctor.

The time for
a consultation is short. Tests and procedures are now increasingly used to
substitute for the gathering of data to make the diagnosis.

Tests and
procedure escalate the costs of medical care.

gathering by history and physical examination is time consuming. If a history
and physical examination is properly done it can yield the diagnosis of patients’
problems about 80% of the time.

doctor-patient relationship is indeed fading into the past. The third party carriers
and the federal government have, in their zeal to contain cost, pretty much
seen to that.

The reality
is that the destruction of the doctor-patient relationship costs more in the
long run.

The federal government, in its enthusiasm to
make a positive impact on the quality of care patients receive, has mandated
the use of electronic medical records.

The EMR in
its own way have also served to diminish the doctor-patient relationship.

In many
doctors’ offices, the focal point in the room is a computer with data entry.
The keyboard and the screen have almost the full attention of the doctor, who,
without looking at the patient, asks the questions and types the responses.

The patient is lucky if the doctor makes eye
contact with him/her for a brief interval a couple of times during the visit,
thus further diminishing the possibility that trust can be built in the

The quality
of the encounter can, in the opinion of various policy makers and consultants,
be measured and changed in the same way that manufacturing processes can be
impacted by applying the principles taught by Deming and others.

Maybe it can,
but it has yet to be demonstrated. 
Processes peripheral to the interaction of patient and doctor, may be
made better, but there is little evidence that the same approach can bring back
anything like the doctor patient relationship we used to know."

The three basic goals of Obamacare are
to create an affordable healthcare system with access to care of high quality.

A complicated and complex
bureaucracy that is over regulation will be very difficult to enforce.

It will penalize physicians’
judgment as it tries to decrease reimbursement. It will restrict patients’
access to medical care. It will reduce freedom choice.

Obamacare will not enhance the
Patient Physician Relationships that are so vital to a successful therapeutic

A healthcare system that places
consumers in control of their healthcare dollars and provides incentives to
consumers to be responsible for their health and healthcare will encourage
physicians to save money and rejuvenate the Physician Patient Relationship for
improved therapeutic outcome at an affordable cost.

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

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Patients and Physicians Must Control Health Care Costs

Stanley Feld M.D.,FACP,MACE

The primary stakeholders in the healthcare system are patients and physicians. The incentives for patients and physicians to save money are non existent. The secondary stakeholders have taken advantage of non existent incentives to create a healthcare system that generates ever increasing costs.

Patients and physicians are the only stakeholders that can control costs. They initiate the use of the healthcare system’s resources. 

Healthcare costs for medical procedures such as an MRI or CT scan have been found to vary by as much as 683% in the same town, depending on which physicians patients choose, according to a study by Change: Healthcare.

The implication is that individual physicians are responsible for the differences. Most physicians do not own MRIs, CAT scanners or PET scanners. Secondary stakeholders own the equipment. They price the procedures and profit from the equipment, not the physicians.

"There's been a barrage of studies that show differences from region to region," said Christopher Parks, founder of Change:healthcare. "That makes sense — California's more expensive than Alabama. But this 683% is within a 20-mile radius in your own town." 

This finding illustrates several dysfunctional issues in the healthcare system.  President Obama’s Healthcare Reform Act is causing these issues to surface as secondary stakeholders are beginning to adjust to the upcoming changes.

For a pelvic CT scan, they found that within one town in the Southwest, a person could pay as little as $230 for the procedure, or as a much as $1,800. For a brain MRI in a town in the Northeast, a person could pay $1,540 — or $3,500. 

The social contract in medicine is between patients and physicians.  Patients should choose physicians and physicians should care for the patients the best they can with integrated healthcare team approaches. Physicians should be the captains of this team approach. 

Patients should be at the center of medical care and be educated to make wise medical decisions.

Physicians should be the coaches and advisors to patients on how to make wise decisions and attain better health.

In the beginning, patients’ employers provided first dollar healthcare insurance coverage. Patients were not at any financial risk. There was no need for patients to care about medical costs. The healthcare costs were their employer’s problem. 

Healthcare insurance companies enjoyed this setup. The more they paid out in benefits the higher they could raise the insurance premiums. Premium increases resulted in higher profits. It worked until employers said stop.

The insurance companies take 40-60 cents out of every healthcare dollar. Medicare and Medicaid outsource administrative services to the healthcare insurance industry. The healthcare insurance industry also takes 40 to 60 cents out of every Medicare and Medicaid dollar.

In anticipation of a reduction in government reimbursement for Medicare and Medicaid, the healthcare insurance industry has raised private insurance premiums, decreased covered illnesses, increased deductibles and increased co-pays.  

The Healthcare insurance industry is also moving toward  "reference-based pricing."

These changes have increased the liability of consumers for out of pocket expenses as opposed to having first dollar coverage. 

Medicare has different allowable fees for procedures in different regions. Medicare pays 80% of the allowable fee after a patient meets his deductible. Providers are only allowed to bill patients 20%.  By law balanced billing is illegal. It does not matter what providers charge for a procedure. Providers cannot bill patients for the balance of beyond the allowable fee. The Medicare fee is the most the provider can receive for a procedure.

“The Medicare Balanced Billing Program works to protect Medicare beneficiaries from being billed by healthcare practitioners for amounts beyond those approved by Medicare. The program investigates and takes action against those practitioner who violate the law.

Many providers are refusing to accept Medicare payment as Medicare reimbursement decreases. These providers can charge patients their fee. It is the patient’s responsibility to know if providers accept Medicare reimbursement. If providers do not accept Medicare, patients should understand their liability for the fee. Patients are liable for the total bill.   

Providers also contract with private healthcare companies. Some providers try to get the highest fee possible for the procedure. Private insurance companies pay different amounts depending on their need to build physician networks. This results in the wide spread in price in the same area. When providers are under contract with private insurers they cannot collect more than the contract price for a procedure. 

"It was eye-opening," said Howard McClure, CEO of Change:healthcare.

McClure said health plans are moving toward "reference-based pricing," in which they look at the average price of a procedure for a region, then say that's all they'll reimburse. But if a patient does not know how much a procedure costs, he or she gets stuck with the remainder of the bill if it goes above that average price.

"It helps the small business," McClure said, "but the consumer's left out in the cold."

Healthcare insurance coverage is changing with “reference-based pricing.”  Consumers are getting stuck with the retail price for procedures. The healthcare industry is using this to keep premiums down for business and compete for employer business.

Only consumers owning their healthcare dollars can stop this. President Obama cannot unless he controls the entire system and dictates prices. It never works because people figure out how to get around restrictions.     

Patients are led to believe that physicians are sending patients to higher priced providers for procedures because physicians will make more money.

Most physicians do not know the prices patients are charged for referred procedures.

Most physicians do not own MRIs, CAT scans or Pet Scanners. It is against the law to receive kickbacks.

It is essential that providers make their fee transparent to all providers and consumers.  Then consumers can choose wisely and create price competition.

Consumers must drive this process to create competitive pricing. Third party payment does not work.

 Consumer driven healthcare using the ideal Medical Saving Account will make it happen. It is the only model that makes economic sense.

 Consumers would start caring about the price of services when making healthcare decisions.

The challenge is to teach consumers to change their mentality toward healthcare costs and force providers through competition to be accountable for these costs.   

This will never happen under President Obama’s administration.  His goal is to empower the government and not consumers. Under President Obama’s administration the healthcare system will become more dysfunctional and further increase the deficit to unsustainable levels.


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






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.


Healthcare Reform Should Be About Motivating Self-Responsibility Not Dependence

Stanley Feld M.D,FACP,MACE

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

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

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

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

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

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

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

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

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

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

Where do all the healthcare dollars go?

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


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

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

4. Most of those 20% have chronic diseases.

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

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

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

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

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

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

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

A new equation for driving healthcare costs would be born.

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

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

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

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

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

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

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

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

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

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