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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, et.al. 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 lbs.so 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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Let’s Get Smart

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Lies About Government Spending

Stanley Feld M.D.,FACP,MACE

President Obama and the mainstream media have been bragging about how well Obamacare is working. They cite that Obamacare is bringing down government health-spending growth.

However they have not been telling the truth. They have taken numbers out of context and have spun a lie.

The evidence presented by federal actuaries is that health growth has been under 4% in the five years prior to 2014.

The Obama administration has made a big deal out of this finding. President Obama has bragged that he is bending the cost curve with Obamacare.

His statements are deceptive. It means government health spending growth has been just under 4%. It is still increasing by 4% year to year and not the usual 6%-10% increase.  

Obamacare spending for direct medical care did not go into effect until 2014. All that went into effect was increases in taxes from 2010 until 2014 and spending on the growth of the bureaucracy resulting in a 4% growth. The math had nothing to do with increased direct medical care.

According to federal actuaries, spending on all health care grew 5.5% in 2014. Actual enrollment was lower than expected enrollment in 2014.

2014 was the first year of spending on direct medical care. Healthcare spending will continue to increase in 2015 to 5.3%. The reason is spending for Obamacare took affect in 2014 and continued in 2015. The reason for the slight predicted percentage decrease for 2015 is at least two fold. Less people signed up for Obamacare in 2015 than predicted and reimbursement for physicians and hospitals decreased.

Other reasons for a government decrease in spending are consumers are paying a greater share of their medical bills and reining in their use of medical care services.

One in three Americans said they or a family member delayed medical care because of costs in 2014, according to a report late last year by survey company Gallup.”

President Obama and his administration are deceiving the American public about the success of Obamacare.

The cost to taxpayers and people who are insured has actually increased. President Obama continually tells us costs are decreasing.

The mainstream media, especially The New York Times and Paul Krugman, continually repeat the lie. If you repeat a lie enough times people begin to believe it is the truth.

A reader asked me where did the New York Times readers leave their thinking apparatus. Someone else pointed out that the New York Times readership is decreasing because the newspaper has lost its credibility.

The New York Times opinions seem to be presented without supporting evidence.

The truth is premiums are increasing, coverage is decreasing and insurance deductibles are increasing for everyone including the middle class. Access to medical treatment is decreasing. Out of pocket expenses are skyrocketing.

The deception continues unchallenged by Republicans. No one is talking about the fact that the Obama administration is lying about what is happening on the ground.

“According to a report from actuaries at the Centers for Medicare and Medicaid Services published in the journal Health Affairs. In the years through 2024, spending growth is expected to average 5.8%, peaking at 6.3% in 2020.”

The cost of healthcare to the government is going to increase further and faster than predicted by federal actuaries as a result of expanded government insurance coverage under the 2010 health law, and the ever expanding Medicare’s baby-boom beneficiaries entering Medicare age.

As technology increases and as the baby boomers enter Medicare and more expensive life-saving drugs are developed costs to the government are going to increase.

The cost of pharmaceuticals is reported to have increased by 12% last year. The deals the government makes with the pharmaceutical companies are pathetic. The prices continue to mount for the government as consumer out of pocket costs for drugs increase.

By 2024 healthcare costs to the government and consumers are projected to be over 20% of our GDP and rising at the present Obamacare rate.

Americans will be older and sicker.

There is little government focus on helping our population become motivated to become  healthier and more responsible for their health and their own healthcare as they age.

Obamacare is forcing Americans to become more dependent on the government for their healthcare needs.

Hopefully, people are noticing that government does not work and more government will be a disaster to our medical and financial health.

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Trust Is An Important Word

Stanley Feld M.D.,FACP, MACE

Trust is confidence in the honesty or integrity of a person or thing. An example of trust is the belief that someone is being truthful.

 The world is complex. As individuals we cannot know and do everything. We must assign surrogates to express and carry out our will.                                                           

We must trust those surrogates. When those surrogate seem to deceive us we distrust them.

In the past six years Americans’ trust in their leaders has been eroded.

It seems that our government surrogates have tried to deceive us over and over again. I have discussed almost all the instances the Obama administration has deceived the American people with respect to Obamacare i.e If you like your doctor you can keep you doctor” to name one.

The State Department has deceived us about Benghasi and with the outlines of the nuclear agreement. The Clintons have deceived us with their Clinton Foundation donations and the perception of undu pedaling of influence.

The result is public distrust of our institutions and each other. They have promoted distrust and  media is the message.

Atul Gawande M.D., a surgeon and public-health researcher, became a New Yorker staff writer in 1998. He contributed greatly in the public healthcare arena in 2007 making surgery safer by creating a pre-op, inter-op and post-op surgical checklist.

He has also created a checklist for delivery of babies in under-developed countries. These checklists have decreased morbidity and mortality.

I am a Gawande fan. He is a good thinker. However, in my view, he has a few blind spots. These blind spots showed up in his most recent article “Overkill.”  

Dr. Gawande’s problem is that even if his observations are somewhat correct they are not universally valid. He proves that his observations are not totally correct as he describes his approach to clinical practice.

His approach to clinical practice is to do less, not more. However, he does not consider the potential unintended consequences of doing less.

Most of his writings in the New Yorker criticize physicians and their practice of medicine.

 The articles could be interpreted as an attack of practicing physicians’ care. It could erode consumers’ confidence in their physicians causing them to mistrust all physicians and their clinical judgment and advice.

 Dr. Gawande should reexamine some of his premises. He should focus on educating both consumers and physicians as he did with his surgical checklist.

 Yellow journalism does not solve the healthcare system’s problems. It creates greater problems.

 In this New Yorker article his blind spot is well illustrated. He initially quotes Kenneth Arrow an economist who in 1963 won a Noble Prize in Economics for describing a vital problem economic call information asymmetry.”

“There is a severe disadvantages that buyers have when they know less about a good than the seller does.”

Kenneth Arrow pointed out that the prime example was health care. Doctors generally know more about the value of a given medical treatment than patients, who have little ability to determine the quality of the advice they are getting.”

Kenneth Arrow is absolutely right. Since 1963 many industries have worked to solve this problem of information asymmetry using the Internet to make consumers Prosumers.

Physician leaders knew Arrow was absolutely correct. Some have tried to correct the situation through patient education and the developed System of Care through the use of Chronic Disease Treatment Teams.

To me this represents a constructive approach to information asymmetry in the healthcare system rather than the approach of stimulating consumers to mistrust their physicians.

There is a simple solution. Patients must be empowered to understand their disease and the options they have for treatment. They must also take responsibility for their care.

The American Association of Clinical Endocrinologists initiated the team approach for the treatment of Diabetes Mellitus in the 1990’s. It was called “A System of Intensive Self-Management of Type II Diabetes Mellitus.”

Teaching patients to intensively control their own blood sugars and helping patients become the “professor of their disease” can decrease the complication rate by at least 50%.

The complications of diabetes result in 80% of the cost of diabetes to the healthcare system. Managing Diabetes Mellitus correctly also decreases the pain and suffering resulting from this devastating disease.

It took twenty years for the government and the healthcare insurance industry to support this notion of chronic disease management.

AACE wrote guidelines outlining the development of Diabetes Education Centers wherein patients with diabetes were the center of the Diabetes team with physicians being the coach of the team and nurse educators, dieticians, exercise therapists, psychiatrists or psychologists being the assistant coaches and an extension of the physician’s care. 

“A System of Intensive Self-Management of Type II Diabetes Mellitus.”

It is critical patients take responsibility for their diabetes care.  They must not be passive about their treatment. They must judge the quality of their treatment. If it is not excellent they need to move on. The problem might be that the patients’ healthcare plan will not permit the patient to choose those physicians and care provders in Obamacare.

Consumers have abrogated their responsibility for their treatment and the cost of their treatment to a third party. This problem originated when they were able to buy first dollar healthcare insurance coverage. Consumers were not and are still not at financial risk even though their health is at risk.

This system of disease management demands that patients become responsible for the management of their disease.

Our health is our most valuable asset. We must be responsible for our health.

Obamacare’s health insurance exchanges continue promote the same defect in our healthcare system.  It does not encourage patients to be careful about healthcare dollars or the responsibility for their healthcare.

“Doctors, therefore, are in a powerful position. We can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations.”

Please note that Gawande indicts physicians in his second sentence for recommending care of little or no value because it enhances income.

In fact ordering a CAT scan, MRI or lab work does not enhance physicians’ income unless the physicians own the machinery. Hospitals and independent testing centers own the machinery to do these tests and make the profit. Therefore his reason for “Overkill” is not primary.

Dr. Gawande goes on to expand Professor Arrow’s argument about over-testing in a system of information asymmetry.”

“Another powerful force toward unnecessary care emerged years after Arrow’s paper: the phenomenon of overtesting, which is a by-product of all the new technologies we have for peering into the human body.”

“The United States is a country of three hundred million people who annually undergo around fifteen million nuclear medicine scans, a hundred million CT and MRI scans, and almost ten billion laboratory tests.”

New technologies have ben a boom to the practice of good medical care. It could be argued that someone getting hit in the head and developing a long lasting headache should get a CAT scan or MRI of the brain rather than pre MRI, CAT scan era, a skull x-ray that would tell us almost nothing.

Perhaps the unnecessary care is not so unnecessary. Perhaps it is important to know the baseline study results of tests to understand the progression of an illness and controlthrough blood testing.  

There does seem to be too much testing. What might be the cause?

Dr. Gawande overlooks a very important cause of over-testing.

It is defensive medicine. Physicians are afraid of getting sued in our litigious society if they miss something. The Massachusetts Medical Society study brought out this very important point. Physicians by their own admission over-test to avoid missing an underlying disease.

A rough estimate of the cost of over-testing in America is between $200 billion to $750 billion dollars a year as a result of defensive medicine.

Dr. Ezekiel Emanual, an advisor to President Obama, has stated that the healthcare system does not need malpractice reform because defensive medicine only cost the system $25 billion dollars a year. The cost is insignificant. He is dead wrong. He is also immune to law suits because of institutional protection. He does not appreciate the wear and tear on the physicians being sued.

As Obamacare makes the healthcare system more dysfunctional consumers have less responsibility for their healthcare. A system of socialized medicine is evolving as a result of Obamacare. The government takes care of us. We all know that Medicare is unsustainable. Intelligent well-respected folks like Antul Gawade use questionable logic to unintentionally erode peoples’ trust in physicians and their judgment.

Meanwhile taxes continue to rise and America is digging itself into a deeper financial hole.

The question should be how do we do things in a constructive  rather than a destructive way.

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

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Simple, Viable Republican Alternatives To Obamacare

Stanley Feld M.D., FACP, MACE

There are many simple and viable alternatives to Obamacare which Republicans should start considering.

Republicans should seriously consider My Ideal Medical Savings Account as an alterative to Obamacare. It is logical, simple, does not require a large complicated infrastructure and aligns all the stakeholders’ incentives.

It is easy for consumers to understand.

Consumers want to have choices. The dysfunction of our healthcare system has gotten to the point where most consumers don’t have a choice. Consumers simply do not know they lost their freedom of choice and access to care until they get sick.

Consumers think they have adequate healthcare coverage until they get sick. Only 20% of the population gets sick.

The other 80% of the population refuses to think about the problem.

When they do experience illness, the dysfunction in the healthcare system makes them furious. They want to blame someone. Physicians are usually the targets of their frustration.  

Most physicians are trapped in a situation that causes them to fight for their own survival for all the reasons I have previously enumerated. This creates a more dysfunctional healthcare system.

All the stakeholders fight for their own vested interests. These vested interests have become misaligned. The vested interest of the government is to control of the system and decrease its costs.  

Costs cannot be controlled by regulations without consumer involvement.   Consumers of healthcare must understand the effectiveness of their care is dependent on their involvement in their own medical care.

Consumers’ adherence to treatment is a key component in the effectiveness of medical care.

Medical costs cannot be controlled by government price fixing.

Medical costs cannot be controlled by government restrictions to access of care. Consumers will become sicker resulting in a higher cost illness.

Consumers must be empowered to be intelligent, motivated and responsible consumers of medical care. Only then can healthcare costs be controlled.

A functional healthcare system must provide financial incentives to consumers in order for them to want to be empowered to control costs. Consumers should not be dependent on the government to control costs.

The government must repair the actuary and accounting rules of the healthcare insurance industry. Insurance reserves should not be scored as a loss to justify premium increases.

The healthcare insurance industry takes 40 cents off the top of every insurance dollar that is spent. Consumers with both private insurance and government insurance are only getting 60 cents value for every healthcare dollar spent. The healthcare industry is allowed to do some strange accounting with their required reserves.

If this accounting method were repaired, premium costs would decrease.

Effective malpractice reform would result in a significant decrease in healthcare costs. The Obama administration refuses to believe tort reform is needed.  

Many of the rules written into Obamacare, Medicare, and Medicaid are so screwy they defy common sense and penalize consumers. One glaring rule is Medicare permitting hospitals to admit Medicare patients to the hospital for observation for 48 hours.

Medicare does not pay for Observation admissions. Patients have to pay out of pocket for these admissions.

Consumers must become aware of these screwy rules and protest them. These rules have been written by the Obama administration to save the government money. These rules penalize patients the government professes to help.

Consumers are the only stakeholders that can motivate President Obama and congress to fix the significant points of waste in the healthcare system. Consumers have the power to vote.

I do not believe that President Obama has an interest in repairing the healthcare system. All of his actions signify that he wants the healthcare system to fail. After it fails people will beg the government to completely take over and have a single party payer.

Does anyone trust the government to take over our most valuable asset, our healthcare?

The government take over will also fail because dependent consumers will figure out how to game the system just as food stamp recipient have figured out how to game that inefficient system.

The goal of a sincere administration and congress is to figure out how to motivate consumers to be “PROSUMERS” (productive consumer) with an economic interest in the healthcare system.

Airlines, banks, bookstores, entertainment venues have all figured it out. Why can’t the government help consumers figure it out?

My blog entitled “My Ideal Medical Saving Account Is Democratic” presents a consumer driven healthcare formula. It gives every socioeconomic group the opportunity to be an effective “Prosumer”.

It gives all Prosumers the incentive to be responsible for their health and healthcare dollars.

Below is the blog My Ideal Medical Savings Account Is Democratic!

My Ideal Medical Savings Account Is Democratic!

Stanley Feld M.D.,FACP,MACE

A reader sent this comment; “My Ideal Medical Savings Account (MSA) “was not democratic and leads to restriction of medical care for the less fortunate.'

This comment is totally incorrect. I suspect the comment came from a person who has “an entitlements are good mentality.”

I believe that incentives are good. They lead to innovation. Innovation leads to better ideas.

Healthcare entitlement leads to ever increasing costs, stagnation, restrict freedom of choice and decrease in access to care.

The excellent example of increasing costs, decreasing choice, and decreasing access to care is Medicaid.

The fact that someone is covered by healthcare coverage does not mean they have access to medical care.

 I have written extensively about the virtues of My Ideal Medical Savings Accounts (MSAs). They are different than Health Savings Accounts (HSAs).

HSAs put money not spent in a trust for future healthcare expenses. MSAs take the money out of play for healthcare expenses. MSAs provide a trust fund for the consumer’s retirement.

MSAs provide added incentives over HSAs to obtain and maintain good health.  Obesity is a major factor in the onset of chronic diseases. Consumers must be motivated to avoid obesity to maintain good health. MSAs can provide that incentive.

The MSA’s can replace every form of health insurance at a reduced cost. It limits the risk to the healthcare insurance industry while providing consumers with choice.

This would result in competition among healthcare providers. Competition would bring down the cost of healthcare.

Some people might not like MSA’s because they are liberating. They provide consumers of healthcare with freedom of choice. They also give consumers the opportunity to be responsible for their healthcare dollars while providing them with incentives to take care of their health.

MSAs could be used for private insurance purchasers, group insurance plans, employer self- insurance plans, State Funded self-insurance plans and Medicare and Medicaid.

In each case the funding source is different. The cost of the high deductible insurance is low because the risk is low. 

If it were a $6,000 deductible MSA, the first $6,000 would be placed in a trust for the consumer. Whatever they did not spend would go into a retirement trust.  If they spent over $6,000 they would receive first dollar healthcare insurance coverage. Their trust would obviously receive no money that year.

The incentive would be for consumers to take care of their health so they do not get sick and end up in an expensive emergency room.

If a person had a chronic illness such as asthma, Diabetes Mellitus, or heart disease with a tendency to congestive heart failure and ended up in the emergency room they would use up their $6,000.

If they took care of themselves by spending $3,000 of their $6,000 trust their funding source could afford to give their trust a $1500 reward. The benefit to the funding source is it saved money by the consumer not being admitted to the hospital. The patient stayed healthy and was more productive.

President Obama does not want to try this out. He wants consumers and businesses to be dependent of the central government for everything.

MSAs would lead to consumer independence from central government control of our healthcare. MSAs would put all consumers at whatever socioeconomic level in charge of their own destiny.

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

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Republicans who really want to repair the healthcare system should take notice of these suggestions. They should stop proposing complicated alternatives to Obamacare that will not work.

Republicans should start trying to understand the real problems in the healthcare system.

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

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A Bogus Attack For A Political End

Stanley Feld M.D., FACP, MACE

The New York Times continues to be a mouthpiece for the Obama administration. I suspect the editorial board thinks the only thing that will save the healthcare system in America is a government controlled single payer system.

This is President Obama’s goal even if he has to destroy the medical care system.

On September 20th, 2014 the front page top right hand column article in the Sunday New York Times was  After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know appeared.

In the past the New York Times reserved this spot for the most important story of the day.

This story was the most important news story on Sunday September 200h 2014. The Times thought it was more important than a story about the economy, ISIS, the mid-term elections, Israel, Hamas or Iran’s nuclear ambitions. 

The story intended to inflame the New York Times’ readers so they would be angry at the medical profession.

The problem is that the story is peppered with misinformation and disinformation.

The New York Times writer used a typical Saul Alinsky tactic. Her goal was to prevent the opponents of the story from responding intelligently. 

Public opinion will be on her side because the New York Times is supposed to be a credible source.

Saul Alinsky’s rules instruct one to lie if necessary. The next step is to frighten consumers into thinking the system under attack cannot work.

Before his three-hour neck surgery for herniated disks in December, Peter Drier, 37, signed a pile of consent forms.”

Peter Drier did not read or modify the consent forms. He should have made the   hospital and his doctor liable for any unauthorized expenses, providers, or events.

Peter Drier is a bank technology manager. Banks have their own small fine print intended to keep consumers liable and uniformed.

Peter Drier should have modified the consent forms before he signed them. He can refuse to authorize treatment or payment to any provider or procedure performed in the hospital that was outside of his insurance network.

In Network providers have to agree to accept the negotiated fee. If they need an additional provider it must be a provider that will accept the negotiated fee of his insurance company.

A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee.

Every consumer should find out if their providers are in their insurance network .  

All of those prices are ridiculous retail prices. The real question is how much did his insurance company pay and how much is he liable for.

Peter Drier did not do a very good job in researching his insurance company’s coverage. A third party payer would never approve a $56,000 payment to the hospital for the proposed procedure.

Hospitals bill very high retail prices. They will negotiate a price that is 50-90

5 lower than the retail fee.

 

The author, ELISABETH ROSENTHAL, has a list of recent articles criticizing the healthcare system about exorbitant retail pricing. 

  • COLONOSCOPY: Colonoscopies Explain Why U.S. Leads the World in Health Expenditures
  • PREGNANCY: American Way Of Birth, Costliest In The World
  • JOINT REPLACEMENT: In Need Of A New Hip, But Priced Out of the US Market
  • HOSPITAL PRICES SOAR: A Stitch Tops $5000

All of these articles criticize the retail price providers charge. They do not tell the reader what the providers receive as reimbursement by the government or the healthcare insurance company.

Consumers are the victims of the constant effort to try to reduce healthcare costs and stick consumers with the bill.

Obamacare has driven the healthcare insurance industry to raise premiums and decrease coverage in order to cover their supposed actuarial risk.

The decreased reimbursement by the healthcare insurance industry has driven providers to increase their fees for service. The hope is to occasionally catch a consumer who is uninsured and liable for the fee.

The uninsured consumer cannot afford the fee and therefore will not pay the fee. The provider then has to sue the consumer to collect whatever they can. The cost of the suit is not profitable for the provider. He usually writes off a loss.

President Obama and the government control advocates will use the resulting chaos in the marketplace to prove that a free market for healthcare system does not work. Therefore the country needs a government controlled single party payer system.

The problem with these horror articles is they frighten consumers. They do not address the reason that the healthcare industry costs $2.7 trillion dollars a year.  

The chaos in the marketplace is the result of the government (Obamacare) involvement into the free market system.

I am also not sure if the $2.7 trillion dollars is from retail charges or negotiated payments. The answer to the question is totally opaque.

The reasons for the increasing costs are many.

Americans are becoming less healthy because they are not being responsible for their health. It is hard to maintain weight when almost every restaurants main dish is higher than their daily caloric allotment. 

470 cal 9 24 2014

1200 cal 9 24 2014 jpg

The result is an obesity epidemic. Over 50% of Americans are Obese.

Obese individuals have a 40% increased incidence of chronic disease.

Eighty percent of the healthcare dollars spent are spent on treating chronic diseases and the complications of those chronic diseases.  

Controlling a chronic diseases can decrease the complication rate of those diseases by at least 50%.  

If we ran the numbers we could reduce the healthcare costs below one trillion dollars a year.

Everyone complains about the grotesque profits the healthcare insurance companies make. Everyone understands the profits result from the inflated bureaucracies and double payments made to segments of the bureaucracy.

If one insurance company wanted to be competitive it would lower its premiums and overhead. All the other insurance companies would do the same to stay competitive.

One has only to look at the cell phone industry. Not only has the cost of the cell phones been lowered but monthly charges are continually decreasing.

One should also look at what ITunes did to the music industry.

Look at what Dr. Keith Smith’s surgical center model is doing to the local hospitals’ costs for surgery in Oklahoma City. They are falling precipitously.

The government should stop feeding the public disinformation leading to confusion of the facts..

President Obama's goal is to destroy the medical system so that consumers will believe the only thing that will work is a government controlled single party system.

Single payer systems throughout the world have proven to be unsustainable.

The healthcare system is dysfunctional. Medical care has been distorted at the consumers’ expense and for the profit of the profit of the healthcare industry.

America has to become innovative and build a healthcare system to the advantage of the consumer.

The solution 

 Is about consumers becoming aware.

 Is about leadership.

 Is about innovation.

 Is about consumers being responsible for their health and their healthcare dollars.    

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



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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.

 Daniel”

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 
understand.

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.


__________________________________________ 
Patient

 
________________ 
Date


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.


__________________________________________ 
Physician 
________________ 
Date

 

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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The Wrong View Of The Right Problem

Stanley Feld M.D.,FACP, MACE

Most of the stakeholders in the healthcare industry are not stupid. Most understand the issues very well.

The problem is they all look at the same problem from the prism of their own vested interest. Each government action causes these stakeholders to react in their vested interest.

Each reaction causes a compensatory reaction from the other stakeholders, which in turn causes another chain of reactions.

The healthcare system becomes further twisted into a tighter non-functioning hairball that is more expensive than previously.

Aetna CEO Mark Bertolini was the keynote speaker at HIMSS14. His analysis was correct He said,

“Antiquated systems and out-of-control healthcare costs in the United States are not sustainable.”

He went on to say the healthcare system is plagued by inefficiency and waste.

“ We can’t afford it. It’s unsustainable.”

Employees are now paying 41 percent of their healthcare dollars to the healthcare insurance industry. It includes premium costs, deductibles, and copays.

These costs consume much of employees’ disposable income.  Mark Bertolini predicts that employees will be paying 50% in 5 years as insurance premiums increase.

Mark Bertolini is really saying consumers will stop buying insurance soon. The result will be a decrease in Aetna’s profit.

Who is at fault?

All the stakeholders are at fault. Consumers are at fault for not taking care of themselves. The incidence of the onset of all chronic diseases increases with the incidence of obesity.

When there is an increase in chronic disease there is an increase in the complications of chronic diseases.

Eighty percent of the money spent on treating that chronic disease is spent on treating the complications of that chronic disease.

Patients must manage their chronic diseases under their physicians’ direction. The patient lives with that disease 24/7.

Patients must be taught to be the “Professor of Their Disease” so that they do not get a complication of that disease.

Patients must also be given financial incentives to become the manager of their disease. This incentive can be developed in many ways.

Reimbursement for education is not routine. There is little financial incentive for physicians to set up educational systems.

Hospitals at one time set up educational systems for chronic disease. They found them a financial burden and discontinued them.  The educational systems did not distinguish one hospital from another.

The educational systems were not set up correctly. They should have been set up as an extension of the patient’s physician’s care.

I believe the healthcare insurance industry really wants to lower costs while retaining the profit margins enjoyed in the pre and post Obamacare era.

Aetna’s Bertolini got it right. “We can’t afford it.”

“If we really want to take care of people, we should align incentives around keeping them healthy.”

He is right. His problem is he thinks he controls patients and patient care.

The government thinks it controls patients.

Physicians know they do not control their patients’ behavior.

Neither the healthcare industry and government nor physicians controls patients.

Patients control themselves.

Bertolini said. "Recent data compiled by Aetna found that the top 5 percent of Medicare patients consumed 43 percent of Medicare dollars. They spent on average $108,000 a year per person."

The demographics of these patients disease including past and present lifestyle are not discussed in the data mining survey. This information would be helpful to know the true meaning of this data.

He then concludes, “Let’s not keep sending these people around with 25 different prescription and all these different doctors and hospitals.

Who is the stakeholder sending patients to all the different hospitals and giving all the different prescriptions.

Physicians, of course!

Therefore, let us penalize physicians for spending all this money on our patients.

This is the wrong way to look at the problem.

If there was meaningful Tort Reform, physicians wouldn’t be doing so much unnecessary testing and treating to avoid missing something that could result in a malpractice suit.

If there were meaningful incentives for patients to be responsible for themselves people would stay healthy.

Patients should be responsible for their healthcare dollars not the government or the insurance industry.

People should also be rewarded if they stay healthy just as the auto insurance industry rewards drivers who do not have an accident.

If the government made a meaningful effort to change our eating habits through meaningful education much illness and medical costs would be reduced.

The center of the new healthcare system should be the patients. It should be a consumer driven system.
 

As soon as all the secondary stakeholders focus on that fact and start helping instead of penalizing patients and their physicians, the cost of the healthcare system will come down.

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

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