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I Told You What To Do 8 Years Ago: Part 3

November 4, 2015

inMedicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

I told you about all my ideas necessary to repair the healthcare system 8 years ago. None of the ideas have changed

Politicians and their healthcare policy wonks have not implement or supported any of theses ideas. The adoption of Obamacare has made the healthcare system worse.

“The hardest thing to explain is the glaringly evident, which everybody has decided not to see.”

Any Rand, The Fountainhead

It is a pity that the public votes for people who hold their vested interest and their quest for power above the needs of the people.

It is worse that the traditional media works as a special interest group to support the politicians’ quest for power over the people.

Our government is getting further from the solution to the problems of our healthcare system in order to force consumers to be more dependent on big government and less responsible for themselves.

The end game will be a disaster for Americans, our freedoms and our financial well-being.

My ideas do not support the vested interests of secondary stakeholders. I support consumers’ interest. Many of these secondary stakeholders are abusing the healthcare system. They take advantage of consumers.

The government is one of those secondary stakeholders that cause dysfunction in the healthcare system with its endless regulations.

The government regulations are written to control physicians and patients..

Consumers’ health and their healthcare dollars must be the responsibility of the consumers. A consumer driven healthcare system is the only way to stop the evolving medical care and financial disaster.

This week the progressives in Colorado blew my mind. They want to eliminate Obamacare because it has failed and replace it with a state run single party payer system.

This group has 200,000 signatures to petition that its proposal be put on the 2016 ballot.

In the small print they are proposing a $25 billion dollar tax increase to pay for the proposal.

Obamacare has resulted in increasing the cost and dysfunction of the healthcare care system. The adoption of this single party payer system will make it worse.

I am sure many people in Colorado are unaware of the progressives’ stinking thinking.

However, the petition is the first step in President Obama’s scheme to make thing so bad that the people beg the government to take over the entire healthcare system.

This tactic is right out of Saul Alinsky’s playbook and right up Hillary Clinton’s alley.

Meanwhile, “What Have I Said So Far? Spring 2007 Part 3 is republished below.

Maybe people will start paying attention to what is happening in our healthcare system before it is too late.

For more details on each proposal please click on the links.

“What Have I Said So Far? Spring 2007 Part 3

Stanley Feld M.D.,FACP, MACE

The following are additional solutions necessary for the Repair of the Healthcare System

Develop Centers of Excellence and Focused Factories in both hospital based clinics and physician outpatient clinics to treat chronic diseases by a team of multi disciplinary experts using systems of care based on evidenced based medicine.

Disease management systems can be developed in primary care physicians’ offices because there are not enough specialists to take care of all the patients with chronic disease.

Treating chronic diseases this way should lower the complication rate for chronic diseases. The result should be a reduction in the cost of healthcare by at least 45%.

Emphasis should be place on teaching the patient how to be the “professor of his disease”. Payment should be available to the Center of Excellence for this education.
Promotion of and payment for early evaluation, recognition and treatment of chronic diseases is essential to detect and prevent the complication of these chronic diseases and lower the cost of healthcare.
A sophisticated information system connecting medical care with financial outcomes. An ideal EHR should be made available to physicians on a per use basis so that the investment cost is not a burden to the physician. The information technology should be used as a learning tool for the physician to continually improve the quality of care and not as a weapon to penalize physicians.
Quality of care should be defined aswhom to evaluate, how to evaluate, whom to treat, how to treat, how long to treat, how often the patient should be seen, how often the patient should be retested, and the measurement of adherence to medication.

Measurement of quality should be all of the above. However, the key measurement of quality is the medical outcome as it relates to the financial outcome. If you prevent a $50,000 complication utilizing $1,000 of treatment you have a leveraged financial outcome as well as an excellent medical outcome.

The main question is, “was the complication of the chronic disease avoided?” We are misguided when we start believing that measuring the percentage of our patients we measure cholesterol on, or the percentage of patients on whom we do colonoscopies or bone densities is a measure of quality of care.

It is simply one element of quality medical care and it should not be rewarded as the Pay 4 Performance advocates are suggesting. This thinking makes us vulnerable to another false hope of reducing complications of chronic diseases.

Increasing obesity in our population is a huge health risk.The government should declare war on obesity. It should strive to eliminate the many stimuli we are exposed to. It should institute a gigantic public media campaign to explain the health risks and the stimuli in society to overeat.
The most important need is to put the patient in charge of his disease management. The patient must be responsible for his care and in control of his health care dollar. We do not need more schemes destined to fail such as;

the California and Massachusetts mandates. We do not need the Pay 4 Performance scheme that will distort the healthcare system even further.

We need some common sense infused into the development of a healthcare system that is driven by the patients and not the facilitator stakeholder for the purpose of the facilitator stakeholders’ bottom line.

If patients do not want to take care of themselves they will suffer medically and financially.

These are some of the solutions I have proposed. We need the political will and leadership to institute and execute these solutions.

Responsibility for follow up care and compliance must be the patient. The physicians are the teachers educating patients to be experts in their disease self- management.

In the present system the penalty to the patient is bad health. The new system should have a clear message of good health and financial reward. It is much cheaper for all the stakeholders in the long run.

The patient has to;
• Be responsible for the purchase of care.
• Have ready access to care.
• Be responsible for the appropriate adherence to care and medication regime given by the physicians.
• Be rewarded for excellent lifestyle changes and avoidance of complications of disease.

If this is accomplished, and it can be with appropriate leadership and the demand by the consumer, we can repair the healthcare system.”

It is almost past time to start listening and demanding a “consumer driven healthcare system.”

Consumers have Patient Power and do not even know it.

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

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A Big Idea For President Obama

April 17, 2011

inMedicine: Healthcare System, Patients Problems, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

President Obama has been disingenuous during his entire time in office. He has publicly asked for ideas on Repairing The Healthcare System before and after he took office. I will repeat the advice that he has ignored in the next few blog post.

He has been influenced by the ideas of Tom Daschle and Don Berwick to the exclusions of ideas that might actually be effective. Both men are convinced that the healthcare system would be repaired if there were a complete government take over.

President Obama has been extremely cunning in working his way toward a complete government takeover of medicine. Some of Mr. Daschle and Dr. Berwick’s ideas are good. Most of their ideas will not fix the defects in the healthcare system. There is a total disregard of citizens in their program.

President Obama is expanding the bureaucracy and creating a wasteful morass of new agencies. Those agencies are generating incomprehensible and non-enforceable regulations. The regulations are trying to commoditize medical care in America.

Our healthcare system is a mess. Medicare and social security in its present form will result in a 100 trillion dollar a year deficit in 75 years. The solution to Repairing the Healthcare System is relatively simple. The key to the solution is social responsibility by all stakeholders involved in the healthcare system and individual responsibility by the consumers and potential consumers of healthcare.

Neither political party is getting behind a big idea that’s bold enough to actually solve major problems.

Unfortunately, secondary stakeholders (the healthcare insurance industry, hospital systems and government) have not become socially responsible toward the best interests of consumers. Consumers will assume responsibility with significant incentives and appropriate education.

One big idea is to reform the food industry. The food industry’s products and advertising undermine Americans eating healthy. The food industry’s advertising has to be redirected to consumer education and not consumer self-destruction. President Obama’s approach to healthy eating has been tokenism.

He has ignored appropriate input on how to fix the food industry in an effort to decrease obesity in America.

No one has asked for the opinion of practicing physicians. The focus of all healthcare policy “experts” is economics.

Here is a big idea.

Obesity leads to chronic diseases such as Type 2 Diabetes Mellitus. Walk into any Coronary Care Unit in the nation and 80% of the patients with myocardial infarctions are obese and have Diabetes Mellitus. The complications of Diabetes Mellitus cost the healthcare system $160 billion dollars a year. Eliminating obesity will reduce the incidence of Diabetes Mellitus by at least 50%.

Cheap manufactured food subsided by the government results in 19% of America’s fossil fuel use. It also results in more than 75% of the obesity in this country.

Eighty per cent of the healthcare dollars are spent on the complications of chronic diseases. The eighty percent cost to the healthcare system is one trillion six hundred million dollars a year.

The obesity epidemic is interconnected with our energy policy and energy subsidies, farm policies and subsidies, environmental policy and conditioned attitudes toward fast food.

Michael Pollan points out the problem with our entire food supply system and the impact it has on healthcare, the environment and energy.

“Which brings me to the deeper reason you will need not simply to address food prices but to make the reform of the entire food system one of the highest priorities of your administration: unless you do, you will not be able to make significant progress on the health care crisis, energy independence or climate change

The three problems are tightly connected. The repair of each problem has to must be done in a creative way that aligns all the stakeholders’ incentives with consumers’ health and wellness.

Michael Pollen goes on to tell President Obama “Unlike food, these are issues you did campaign on — but as you try to address them you will quickly discover that the way we currently grow, process and eat food in America goes to the heart of all three problems and will have to change if we hope to solve them.

Mr. Pollan’s point is the way we grow food and manufacture food stuff is a major reason for obesity and pollution leading to the complications of chronic diseases (Type 2 Diabetes Mellitus and chronic lung disease). This results in a 1.6 trillion dollar cost to the healthcare system. All American’s needs is the will to change.

It is going to require a lot of public and congressional education. It will be harder to educate congress than the public. Vested interest lobbying drives Congress. President Obama must help the public create a greater voice than the special interests. The public will then lobby the congress.

Michael Pollan says “the 20th-century industrialization of agriculture has increased the amount of greenhouse gases emitted by the food system by an order of magnitude; chemical fertilizers (made from natural gas), pesticides (made from petroleum), farm machinery, modern food processing and packaging and transportation have together transformed a system that in 1940 produced 2.3 calories of food energy for every calorie of fossil-fuel energy it used into one that now takes 10 calories of fossil-fuel energy to produce a single calorie of modern supermarket food. Put another way, when we eat from the industrial-food system, we are eating oil and spewing greenhouse gases.

The reformatting of the payment system for physicians with the theoretical effectiveness of Accountable Care Organizations (ACO’s) will not work. It will only waste money. It will only dispirit the medical profession and diminish the effectiveness of a necessary workforce. Physicians are not the villains.

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

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President Obama’s Trick Plays Are Blind-sided By Healthcare Insurance Industry

October 25, 2009

inMedicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

President Obama’s healthcare reform plan will not repair the healthcare system. It will not provide universal coverage. It will not provide affordable coverage and it will not increase the quality of care.

The main reasons are:

1. It does not deal with malpractice reform.

2. It does not deal with the administrative services fees charged by the healthcare insurance industry to the private sector and Medicare and Medicaid.

George Stephanopoulos spoke with David Axelrod on the This Week program on October 18,2009. The interview revealed an administration blind spot as President Obama pulls tricks to sneak through a healthcare reform bill that the public does not want and the government cannot afford.

STEPHANOPOULOS: So — so you reject this argument that he has to draw more lines in the sand, twist the arms of his opponents, now tell people what he wants and expect it to get it done?

AXELROD: Let’s take the issue of health care, because that’s, obviously, one of the things that people are referring to. We are farther along than we’ve ever been in passing a comprehensive health insurance reform in this country. It’s something we’ve discussed for 100 years. We are on the doorstep of getting that done, and that’s because of the approach this president has taken.

President Obama has been ramming a healthcare bill through congress. Rahm Emanuel has been having meetings behind closed doors without Republican participation. He is even trying to sneak in the Public Option in the Senate bill the Democrats plan to bring to the floor.

This is not the definition of bipartisan agreement on legislation. David Axelrod’s remarks to prove his point is incomprehensible.

STEPHANOPOULOS: And yesterday, the president in his radio address suggested that he might be willing to take away their antitrust exemption.

Why would the healthcare insurance industry have an antitrust exemption to start with? The healthcare insurance industry’s pricing is non transparent to both the government and the private sector. Actuary calculations are a mystery, an inaccurate estimate and an easy way to cook the books.

STEPHANOPOULOS: Was he saying that he would sign a bill that would take that away and open the door to premium caps by the Congress?

David Axelrod avoided the question because it was a threat to the healthcare insurance industry. I think he knows the healthcare insurance industry wins no matter what kind of healthcare reform bill passes and the public loses.

AXELROD: Let’s talk about the insurance industry for a second, because most of the stakeholders in this health care debate are at the table, they’re trying to produce real reform, because everyone knows the current system is unsustainable.

Everyone is at the table because they want their pet dog to be included in the enormous injection of money into the healthcare system.

David Axelrod is also perpetuating the myth that Health Insurance = Health Care. Health Care really is medical care. We have excellent medical care in our country when you are sick. We have few systems at all levels of society to deal with prevention of disease.

Two prominent examples are the food industry and obesity and air pollution and chronic lung disease.

Health Care (Medical Care) is what your Doctor does for you.
Health Insurance is a third party’s promise to pay Doctors out of that third party’s own funds.

The healthcare market is unsustainable because of the pricing in the healthcare insurance industry. This is very different than medical care.

AXELROD: “The insurance industry has decided now at the 11th hour that they don’t want to go along with this. One of the problems we have is we have a health care system now that functions very well for the insurance industry but not well for the customers. In the last 10 years, healthcare premiums have doubled.”

David Axelrod is correct here. He fails to say that Medicare and Medicaid is outsourced to the healthcare insurance industry.

STEPHANOPOULOS: President Obama is saying, if they don’t play ball, they’re going to lose their antitrust exemption?

AXELROD: 10 years ago, 15 years ago, the healthcare insurance industry spent 95 percent of their premiums on health care. Now it spends 80 percent with a 20% profit. More of the money is going to bonuses, salaries, administrative costs.

George Axelrod got the numbers wrong. The healthcare insurance industry keeps more than 20% of every healthcare dollar. It buries its fees in the Medical Loss Ratio calculations.

AXELROD: One thing we ought to do, the House bill has in it provisions that — that says that if they fall below a certain level of return of these medical loss ratios — in other words, the amount of money that they spend on actual health care, that they — they need to rebate some of that money to consumers. That seems like a good idea.

If anyone believes that the healthcare insurance industry will refund premiums I have a bridge to sell you.

Medical Loss Ratio = Incurred Claims / Earned Premiums

The Medical Loss Ratio reflects what Insurers spend on Doctors and Hospitals, ignoring the accounting standards that direct inclusion of all claims against the entire insurance company ( including its shopping centers, blimps, skating rinks, billboards, management salaries "and so on") in the category called "Incurred Claims" – not just medical claims.
This is accounting slight of hand – including non-medical expenditures in a calculated value called "Medical Loss Ratio". President Obama is not fixing the accounting standards that generate enormous profits for the healthcare insurance industry at consumers’ expense.

The greater the incurred expenses, the less money there is available to cover medical expenses. The result is greater than the Medical Loss ratio. The artificial Medical Loss Ratio justifies increases in premiums by the healthcare insurance industry even as physician and hospital reimbursement decrease.

http://www.state.mn.us/mn/externalDocs/Commerce/Hospital_Medical_Dental__Indemnity_Corp_Non_Profit__111403105213_HMDI.pdf

President Obama should be focused on the Medical Loss Ratio accounting standard. If he did the fair thing there would be no need for this disastrous healthcare reform legislation.

President Obama’s hea
lthcare reform plan is not for the people by the people. It is for special interests. The special interests are government and its control as well as the profit of the healthcare insurance industry. If is not for patients and affordable costs and improvement in the quality of medical care.

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

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Dear President-elect Obama

November 9, 2008

inSummary Blogs

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Stanley Feld M.D.,FACP,MACE

Unfortunately, stakeholders will not voluntarily be socially responsible and the consumer will assume responsibility only with significant education and incentives. The goal of remaining healthy is subverted advertising of the food industry. The food industry’s advertising has to be redirected to consumer education and not consumer self destruction.

Over the past 2^1/2 years I have analyzed the problems in the healthcare system and presented the solutions to the problems in my blog “Repairing the Healthcare System”. I will review highlights of the problems and the solutions. I have provided links for you to study.

You have promised you will govern for the benefit of people with input from the people and not special interests. I hope this is true.

You will not be able to make the appropriate decisions without appropriate input. I hope my review will come before you. I am asking my readers to help get it before you.

Unfortunately no one asked for the opinion of practicing physicians. The focus of all healthcare policy “experts” is economics.

The problems with the healthcare system are broader than economics. The problems are problems that results from the interrelationship of other societal problems.

Eighty per cent of the healthcare dollars are spent on the complications of chronic diseases. The eighty percent cost to the healthcare system is one trillion six hundred million dollars a year.

You are correct when you say you want to prevent chronic diseases. This is harder than it sounds because chronic disease management is not done as an extension of a physician’s care.

Several chronic diseases such as diabetes mellitus and heart disease are mostly a direct result of obesity. The obesity epidemic is interconnected with our energy policy and energy subsidies, farm policies and subsidies, environmental policy and conditioned attitudes toward fast food.

Obesity leads to Type 2 Diabetes Mellitus. Walk into any Coronary Care Unit in the nation and 80% of the patients with myocardial infarctions are obese and have diabetes mellitus. The complications of Diabetes Mellitus cost the healthcare system 160 billion dollars a year. Eliminating obesity will reduce that incidence of diabetes mellitus by at least 50%. Cheap manufactured food subsided by the government consumes 19% of the fossil fuel we use and results in more that 75% of the obesity in this country.

Michael Pollan points out the problem with or entire food supply system and the impact it has on healthcare, the environment and energy.

The three problems your presidency has inherited are tightly connected. The repair of each problem has to must be done in a creative way that aligns all the stakeholders incentive with consumers and their health and wellness being the major stakeholder.

Pollen goes on to say “Unlike food, these are issues you did campaign on — but as you try to address them you will quickly discover that the way we currently grow, process and eat food in America goes to the heart of all three problems and will have to change if we hope to solve them.

Mr. Pollan’s point is the way we grow food and manufacture food stuff is a major reason for obesity and pollution leading to the complications of chronic disease. This results in a 1.6 trillion dollar cost to the healthcare system. It is also major reason for our energy dependence and climate change. All America needs is the will to change. The science is available.

It is going to require a lot of public and congressional education. Congress will be harder to educate than the public because congress is driven by vested interest lobbying. You must help the public create a greater voice than the special interests. The public will then lobby the congress.

Michael Pollan's is a brilliant interpreter of farm policy. He should have significant input in your administration. He should perhaps be nominated for Secretary of Agriculture.

Thomas Friedman should be read carefully. He could provide input into determining the resources need to create the paradigm shift necessary to cure the underlying problems of our environment.

America’s coal resource is abundant and cheap. America’s energy companies would love to expand coal burning plants. Beware of the promise of clean coal burning plants. Dirty coal burning plants result in environmental pollution with soot, sulfur dioxide, mercury and nitrous oxides. The carbon dioxide footprint is currently not required to be measured. The Environmental Protection Agency does not have a CO₂ emission restriction policy in place. Without counting the harmful long term effects of CO₂ emissions on climate change, coal burning plants presently result in the chronic disease complications of asthma and chronic obstructive lung disease. These diseases result in a one hundred billion dollar a year cost to the healthcare system. These diseases and their complications can be reduced by at least 50% with an effective clean air policy.

My review letter to you is longer than I anticipated. You have very hard decisions to make but if your intent is to be transformational these decisions will be necessary.

The reformatting of the payment system for physicians is not going to accomplish anything but dispirit the medical profession and diminish the effectiveness of a necessary workforce. Physicians are not the villain. I will review who the real villain/villains are.

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

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War On Obesity: Obesity And The Economy: Part 10

October 22, 2008

inMedicine: Healthcare System, War on Obesity

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Stanley Feld M.D.,FACP,MACE

Our financial crisis can be an instrument of change in a positive direction. America’s obesity epidemic is a weapon of mass destruction destined to cause another financial crisis. An increase in the complications of chronic disease can cause an economic meltdown if the obesity epidemic is not contained. The complications of chronic diseases result in the expenditure of 90% our healthcare dollars.

The average American burns 1200 to 2000 calories per day with normal activities of daily living. 2.2 lbs. of fat store 9000 calories of energy. In order to gain 2.2 lbs. a person needs to eat 9000 calories more than he burns. In order to lose 2.2 lbs a person needs to burn 9000 calories more than he eats.

It is very easy to gain 9,000 calories and very hard to lose 9,000 calories in America’s cultural environment. The average fast food meal is over 1000 calories while thirty minutes of jogging at an eleven minute mile burns 200 calories.

How can our financial crisis impact our obesity epidemic? Americans are being cautious about spending money. Large amounts of their retirement savings are being wiped out.

Exercise is cheap. Couples sharing meals at restaurants result in half the caloric intake and half the cost.

Restaurant entrees are at least 1200 calories. TGI Friday’s tried to develop a competitive advantage by offering smaller portion entrees at lower prices. The plan has not gotten any traction.

America has to be conditioned to a cultural change in eating habits. We have experienced the explosive change in eating habits in the 1950s and 1960s with the introduction of fast food vendors and snack foods. This was the result of Pavlovian conditioning.

However, a person can feel just as satisfied with half a sandwich as a whole sandwich. In hard economic times sharing a meal cost half as much as two meals. If we eat simple meals at home it can cost much less than buying take out meals or eating in a restaurant.

How can we accomplish this cultural change? I believe it can be done through education and subliminal advertising. Everyone wants to be thin. They do not have the information to accomplish their goal.

Wal-Mart is going to have a nutritional consultant on its web site suggesting inexpensive healthy food planning.

New York City’s Mayor Michael Bloomberg is a genius. We need more leaders like him. The New York City Department of health has initiated an educational campaign on the NYC Subway.

“The five ads appearing in subway cars are designed to help people see how quickly fast-food calories add up and drive home the message that some foods can have deceptively high calorie counts.”

The best is a poster of a delicious looking apple raisin muffin. The ad states the muffin is 475 calories. Above the muffin it say the average person burns 2000 calories per day. The observer was left to fill in the rest and make his own choice.

“If you’re eating it as a snack, you may want to split it with a friend,” Nonas, a registered dietitian, said in a statement.

The New York City Department of Health has four additional advertisements. The ads are educational and subliminal.

This is a brilliant public service campaign. However, it only tells half the story. In order to lose weight you have to eat less and burn more. NYC has to follow up with exercise posters and a sustained campaign. Any campaign has to be sustained and remain exciting in order to cause the cultural change in eating necessary to stop the growth of obesity.

The federal government should be doing a similar public service campaign all over the United States. The media is the message and this message should constantly be a reminder to all of us. If we are serious about Repairing The Healthcare System we have to be serious about my War On Obesity.

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The $34 trillion problem: Senators Clinton, Obama, McCain Are You Listening?

March 10, 2008

inMedicine: Healthcare System

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Stanley Feld M.D.,FACP,MACE

It is easy for the presidential candidates to promise healthcare for all during a presidential election year. However this promise is made without testing reality. The reality is America can not afford to deliver healthcare to all. The country is having difficulty keeping its public hospitals open. These public hospitals are centers for last resort care.

“The prospects that Grady Memorial could close, and that Atlanta’s health infrastructure could crumble, have forced a civic re-examination of the region’s commitment to its least fortunate, a reckoning that has revived old antagonisms over race, power and class.”

“Some have suggested that Grady must compete for paying customers in Atlanta’s fierce medical marketplace, while others say that taxpayers should contribute more to continue its mission. Will Grady outsource, or simply downsize? And if it must downsize, which patients should be turned away?”

None of the presidential candidates have suggested viable solutions to the healthcare system’s problems. I think the Democratic Party wants its declared initiatives to fail. After the initiatives fail they will claim there is no other choice but universal healthcare system with the government as the single party payer. The failure of the proposed insurance paradigm is a back door entry to a single party payer system.

A recent Fortune magazine article said: “Medicare is poised to wreak havoc on the economy. And our presidential candidates are avoiding the issue.”

Alan Greenspan has been quoted as saying “the biggest threat to the American economy is Medicare. You’d think that the greatest threat to America’s economy would be Topic A for the presidential candidates. But it’s actually a topic they hate to touch.”

Instead, the great debate between Hillary Clinton and Barach Obama is to mandate universal coverage or not. If you require people to buy healthcare insurance using a defective healthcare insurance model all you will be doing is providing more customers for the healthcare insurance industry.

“An analysis of their speeches shows that last year Senators Hillary Clinton, John McCain, and Barack Obama would occasionally mention the Medicare mess. But recently, with the economy slowing and voters feeling insecure, all three candidates have turned more populist: Their economic talking points are about feel-good reassurances, not about facing hard realities.”

Americans should be suspicious of Sen. Clinton’s promises. I mention her because she has been the most vocal in diverting us from the reality of the government run healthcare systems mess.

“Unfortunately the day of reckoning is imminent. Sometime in the next President’s first term, Medicare Part A (hospital insurance) will go cash-flow-negative, and it’s all downhill from there.”

“Medicare services more than 40 million old and disabled Americans. As the country ages, Medicare and Medicaid will devour growing chunks of U.S. economic output.”

This is especially true if our obesity epidemic continues. Obese people are more prone to chronic diseases such as diabetes mellitus, hypertension and coronary artery disease.

If we institute universal coverage and single party payer the estimate of healthcare costs consuming 18% of our GNP will jump to 40% of our GNP by 2020.

“In 2070, when today’s kids are retiring, Medicare, Medicaid, and Social Security will consume the entire federal budget, with Medicare taking by far the largest share. No Army, no Navy, no Education Department – just those three programs.”

“Those estimates, reported in the latest Financial Report of the U.S. Government, assume that Medicare payments to doctors will be slashed drastically, by some 41% over the next nine years, as required by current law. It won’t happen. Every year for the past five years, Congress has overridden the mandatory cuts.”

It is obvious something has to change. The estimate of healthcare costs is base on a defect financial reporting by the US Government. The financial report admits these defects.

“As for future cuts, the Financial Report says drily, “Reductions of this magnitude are not feasible and are very unlikely to occur fully in practice.” So in reality, Medicare will go into the hole even faster than official projections reflect. And they show that if Medicare had to be accounted for like a company pension fund, it would be underfunded by $34 trillion.”

The Congress has been correct in its override of proposed Medicare cuts yearly. However, they have done it for the wrong reasons. I have been against the Medicare cuts to cognitive physicians. Medicare cuts do not solve the basic structural healthcare problems.

There are many other constructive solutions. These solutions include a War on Obesity, effective malpractice reform, encouragement of effective disease management and incentives for both patients and physicians to practice effective disease prevention and disease management to decrease the onset of complications of chronic diseases. The solution can only be accomplished with real price transparency by all the stakeholders, an ideal medical saving account, an ideal electronic medical record, and the creation of a system of competition so that the patients own their healthcare dollars and all the other stakeholders compete for their healthcare dollar. These elements of the solution can not be done piece meal. They have to be introduced and enacted as a complete package in order to be effective.

The solution proposed will probably never be enacted. The people (“People Power”) have to make the demand for effective change. There are too many powerful stakeholders who will lose and will not let effective change occur.

Physicians do an excellent job of fixing things that are broken. The government, corporate policies, patients, the healthcare insurance industry and physicians do little to prevent our bodies from becoming broken.
If Mr. Greenspan is correct and the healthcare crisis is “ the greatest threat to the U.S. economy and the candidates haven’t told us what they’d do about it, they haven’t told us a thing.”
The candidates should develop an understanding of the problems and viable solutions to the problems. However, they are avoiding them.

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

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Clinton, Obama Clashing On Healthcare – Part 2 Democrats Debate Requiring People To Buy Coverage

January 20, 2008

inMedicaid, Medicare, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Universal Healthcare

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Stanley Feld M.D.,FACP,MACE

None of the candidates are discussing the origins of our dysfunctional healthcare system. If they understood the origin of the dysfunction I believe the cure would be obvious. The problems started with Medicare and mandated price controls.

Instead they fight over relatively insignificant issues.

“ Clinton is not alone among Democrats in calling for all adults to buy insurance. Former Sen. John Edwards of North Carolina, New Mexico Gov. Bill Richardson and Sen. Christopher J. Dodd of Connecticut have included the requirement in their health plans, making Obama the most notable outlier in the party’s presidential field.”

An important question is; what is the definition of the middle class? The Drum Major Institute, a progressive think tank, has a website called www.themiddleclass.org that places the range for middle class at individuals making between $25,000 and $100,000 a year. The middle class comprise 60% of our population. These are the people the presidential candidates are begging to vote for them. However, the candidates from neither party are presenting viable solutions to the voters’ problems.

A middle class male with a family of four earning $40,000 per year will not be able to spend $10,000 a year with after tax dollars for healthcare insurance. He needs to feed and clothe his family. His home could cost $12,000 a year. Fuel, electricity and gasoline could cost at least $8,000, all with after tax dollars. Income tax bill could be at least $6,000 or more. All this without mentioning food and clothing and other essential expenditures to keep a roof over his family’s head.

A male independent contractor with a family of four who has hypertension and high cholesterol earns $50,000 a year. He does not have access to group healthcare insurance. He would not be eligible to purchase healthcare insurance from any healthcare insurance company. He is a poor insurance risk. Even if he was eligible, this middle class family could not afford the present healthcare insurance premiums.

“The idea of making health insurance a requirement has grown in appeal as politicians and health advocates look for ways to cover the estimated 47 million Americans who do not have it.”

On the other hand, insurance executives are earning millions of dollars a year; hospital administrators feel they deserve one million dollar plus salaries. We all recognize the inefficiencies and waste in the system. The presidential candidates are not talking about how to solve these problems.

Pharmaceutical companies sell their drugs directly to the public through advertising. The FDA has recently taken many drugs of the market. How can the public develop trust in medications? Not a single candidate is discussing the patient safety issues of prescription medication.

Neither are any of the candidates discussing ideas to solve our national obesity epidemic. Obesity is the cause of many chronic diseases. Here is an idea for a candidate. Why don’t you make the War on Obesity a national issue. Two issues can be highlighted. First is the excessive calories in fast food and second the perverse incentives in the farm bill. The farm bill incentives can redirect corn and soybean from foodstuffs to fuel. The result would be decreasing our dependence on foreign oil and promoting a cleaner greener environment. Both initiatives would have a significant impact on our health.
Ninety percent of our healthcare dollar is spent on treating the complications of chronic disease. No candidate is advocating funding for teaching patients to prevent these complications.

Compliance/adherence rate for medication prescribed is about 50% for most chronic diseases. No candidate has mentioned developing public service educational programs to emphasize this problem.
These are a few of the problems that should be addressed.

Yet Clinton is attaching Obama with meaningless sound bites. “He’s called his plan ‘universal.’ Then he called it ‘virtually universal.’ But it is not either,” she asserted in a recent Iowa speech. “And when it comes to truth in labeling, it simply flunks the test.”

The debate about healthcare is entertaining but shallow and negative.

“Clinton mailed a letter to Iowa voters, over the signature of former Gov. Tom Vilsack, which says “Mr. Obama threw back talking points worthy of Rudy Giuliani or Mitt Romney” when questioned about “flaws” in his plan.

In response, Obama distributed a piece in New Hampshire that defended his health proposals and urged voters to “remind Hillary Clinton” that the Jan. 8 primary “won’t be won by launching misleading, negative attacks.”

However Americans are tired of political rhetoric. Someone has to tell the candidates that we are smarter than they think.

“But as the concept of a health insurance mandate gains currency within top ranks of the Democratic Party, the feasibility of the idea remains uncertain and its effects are unproven. As the Obama campaign points out, similar requirements in other areas, such as mandatory automobile insurance and motorcycle helmet use, never result in universal compliance.”

I do not believe Hillary Clinton is interested in the feasibility of her ideas. She is more interested in spinning her sound bites so she can become president.

Obama might be the only one that has respect for our intelligence. I hope America’s intelligence shows up in the polls.

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

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What Does Chronic Disease Management Mean? Part 2

July 9, 2007

inChronic Disese Management, Medicine: Healthcare System, Patients Problems, Physician's Problems, Quality medical care measures

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Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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What Does Chronic Disease Management Mean? Part 1

July 5, 2007

inChronic Disese Management, Medicine: Healthcare System, Patients Problems, Physician's Problems, Quality medical care measures

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Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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