Chronic Disese Management

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A Bogus Attack For A Political End

September 24, 2014

inChronic Disese Management, Disinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Mistrust

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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 20^th, 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 20^0h 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.

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

June 22, 2014

inChronic Disese Management, Medicine: Healthcare System, Patients Problems, Physician's Problems

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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 8^th period.

Ms. W. was one of the 8^th 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 5^th period and lunch 6^th period. She said great she taught trig 6^th period. She could get me transferred to her class. I could have lunch 5^th 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)

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.  Please have a friend subscribe

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The Wrong View Of The Right Problem

April 23, 2014

inChronic Disese Management, Consumer Driven Health Care, Medicine: Healthcare System

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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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I Gave President Obama An Alternative To Obamacare

February 5, 2014

inChronic Disese Management, Consumer Driven Health Care, Disinformation and the healthcare system, Health Savings Accounts vs Medical Savings Accounts, Medicine: Healthcare System

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Stanley Feld M.D.,FACP, MACE

I formulated an alternative to Obamacare in 2006, long before Obamacare existed. President Obama has ignored a plan that will work and align every stakeholder’s incentive.

Obamacare is failing because President Obama does not know who the customer is in the healthcare system. He is blinded by ideology and the belief that government knows what consumers need.

The consumer is the customer. Without consumers of medical care and physicians to provide medical care we would not need a healthcare system.

Consumers and physicians are the primary stakeholders. All the others are secondary stakeholders.

However, physicians receive between 15-20% of the healthcare dollars. Hospitals receive 25% of the healthcare dollars.

Where does the remaining 60% of the healthcare dollars go?

The insurance industry takes at least 40% off the top. The pharmaceutical industry receives 10% and the government wastes 10%.

It is a pity that only 40% of our healthcare dollars is spent on direct medical care. There is much waste and inefficiency built into that direct medical care.

There is also much waste included in the 60% the secondary stakeholder take off the top.

How else would UnitedHealth’s CEO get paid $1.8 billion dollars in cash and stock options from 1998 to 2006?

The excessive insurance industry profits are the direct result of ineffective regulatory agencies controlling insurance pricing.

In 2006 consumer power was demonstrated when UnitedHealth tried to decrease reimbursement to Hospital Corporations of America. HCA protested and threated to quit participation in United Health. Consumer protests followed.

UnitedHealth was the main insurance carrier in the Denver Area. Consumers threated to boycott buying insurance from UnitedHealth. UnitedHealth backed off.

The HCA/United pushback is the first big step. It represents how “Patient Power” should work. Patients should be madder than hell and not want to take it any more.”

In 2006, many of the uninsured were self employed consumers who cannot qualify for insurance because they have a preexisting illness or they are at risk for illness.

The insurance companies refused to sell them insurance. The same consumer in a group insurance plan by law would receive insurance from the same insurance company that turned down the individual.

A self-employed individual can only buy insurance with after tax dollars. A corporate employee receives healthcare insurance coverage with pre-tax dollars.

The same applies for the individual insurance market post Obamacare.

The price of insurance is very high for small businesses. The small business owners do not have the negotiating power of the large corporations.

This results in both the individual and small business not being covered by healthcare insurance. All of the above can be easily fixed.

The problem with Obamacare is the insurance premiums are higher than they were pre- Obamacare. The reasons are obvious.

The only winner is the individual who makes a low enough income to receive a federal subsidy. The loser is the taxpayer.

Obamacare also creates a perverse incentive resulting in people not striving to get ahead.

In 2006 I wrote:

 Patients drive the healthcare system. Patients have tremendous power. They must be taught to use that power in order to Repair the Healthcare System.

Patients must use their “Patient Power” to take control of their healthcare dollars and their health. They should be provided with financial incentives to save the money they spend on medical care.

Neither the healthcare insurance industry nor the government should determine the consumers’ access to care. Patients’ freedom of choice and self- responsibility is the key to Repairing the Healthcare System.

If there are financial incentives consumers will learn to become informed consumers of healthcare. Reliable education must be provided to give consumers the opportunity to become informed consumers.

There are preconditions.

Prices must be transparent so consumers know what they are buying. The insurance industry should negotiate the price with the physicians and the hospitals. The industry can remain the surrogate broker for the payment of money belonging to the consumer. Consumers’ who overspend will not receive the financial incentive. They will lose their medical saving account money. Patients who have an expensive illness, like diabetes, can be rewarded for spending money if they keep themselves in good health and prevent complications of disease.

The consumers are then the responsible party purchasing their medical care. It is not the healthcare insurance industry or the government.

The healthcare insurance industry or any financial industry with an adequate computer system can be the administrator and adjudicator of payment.

Medicare director Mark McClellan M.D. said that 90% of the healthcare dollar of a specific disease (Diabetes) is spent on the complications of disease. If we reduce the complications of a disease we could save at least 45% of the current healthcare expenditure for that disease.

Obamacare gives this vital fact lip service. It puts the responsibility of outcomes on physicians’ shoulders. If physicians have poor outcomes they get penalized.

The medical outcome is a dual responsibility of both consumers and physicians. Consumers should be made aware of physicians’ outcomes. Some of the poor outcomes are the result of consumers not taking the responsibility to learn about their disease, prevent the complications of their disease, or comply with the treatment recommended. The result is a poor outcome.

Consumer overspending is another important aspect of increasing healthcare costs. Consumers do not have incentive to be cautious with their healthcare dollars because they have been given first dollar coverage. They do not have financial incentives to save money on medical care.

Consumer overspending was best described by Victor Fuchs an economist from Stanford.

He made the case for a Consumer Driven Health Care System.

The Health Saving Accounts that congress has approved in my opinion is impotent. It does not provide a strong enough financial incentive for consumers to want to save money.

The trust account of $1,000 per year is too low to motivate consumers to become wise shoppers. A Medical Savings Account of $6,000 per year begins to represent financial motivation.

HSA’s represent the same false hope HMO’s and managed care represented in the 1980’s and 1990’s.

Dr. Fuchs calls it “The Restaurant Check Problem.”

“You go out to a restaurant with a bunch of friends and you sort of understand that you will split the check,” he said.

“The waiter comes along and says, ‘the lobster looks very good, and how about a soufflé for dessert?’

The restaurant check balloons, but you are not so careful because you figure everyone is splitting it.

“That’s the way medical care gets paid for,” he said.

Dr. Fuchs added, “We want to spend our money on the things that will bring the most value for the dollar.

When we are spending collective money as we are in health care, then it becomes much more difficult.”

We want Diabetics to spend money for good medical care in order to prevent complications. Prevention of complications will keep Diabetics out of the hospital and out of the emergency room. The result will be a decrease in medical costs.

The consumer driven healthcare plans can be set up to give provide Diabetic consumer the financial motivation to take care of himself. This reward is much cheaper than paying for a hospitalization or emergency room visit.

If an insurance product is overloaded with salaries, waste, overhead and unnecessary benefits patients will not buy the product.

The insurance product would have to be modified. It would become more cost efficient.

Patients have it in their power to remove the waste and inefficiency in the system.

Some very clever entrepreneur will realize the consumer is the customer. He will develop an insurance product that everyone wants. State governments have the power to encourage development of this product.

The examples in industry in America are numerous. Sam Walton revolutionized retailing in America with Wal-Mart and Sam’s. Michael Dell almost brought IBM to its knees and revolutionized the distribution of information technology.

My goal is to describe the necessary components of a healthcare insurance product that does not offer another and false hope.

I hope to show the way to develop an insurance product that can work for patients first and then all the other stakeholders.

There is no reason we cannot provide excellent affordable insurance coverage to all including the corporate employed, the small business employed, the self employed, the unemployed, and the Medicare covered seniors, with all the stakeholders making a reasonable profit in a simplified system.

President Obama, I have provided a viable alternative long before you became President.

I also provided this alternative to you when you became President in the letters I wrote to you.

For you to say no one has come up with a better alternative than Obamacare is disingenuous on your part.

I hope you are listening now.

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

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How Are Accountable Care Organizations (ACOs) Doing?

January 23, 2013

inChronic Disese Management, Consumer Driven Health Care, Medicine: Healthcare System

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Stanley Feld M.D.,
FACP, MACE

In a word the formation
of Accountable Care Organizations is doing poorly.

If one believes the CMS
press releases one would believe the formation of ACOs is doing well.

In the past, I have gone
into great detail on why I believe Accountable Care Organizations will fail.

I believe physicians and
hospital systems should be accountable for outcomes but only the outcomes they
can control.

They should not be
accountable for outcomes they cannot control.

ACOs are really HMOs on
steroids. Risk is transferred from the government to the healthcare providers.

HMOs failed in the 1980’s
and 1990’s because physicians and hospital systems realized that they could not
evaluate risk or manage risk.

It is impossible for
providers (physicians or hospital systems) to control patients’ behavior in
adhering to treatment for their disease.

It is almost impossible for
the government to commoditize reimbursement accurately for diseases unless the
government can weigh the risk of poor disease outcomes.

No one has figured out
the way to accurately risk weight the outcome of a patient’s disease and
treatment.

CMS believes by
increasing the number of codes in ICD-10 to 68,000 codes vs. ICM-9 18,00 codes, the old coding system, the
government will be able to weigh risk leading to accurate cost assessment.

I believe this is a
fantasy of healthcare policy wonks working for the Obama administration.

Many physician groups
and hospital systems believe they will lose money taking on these risks. These
are the groups that are holding back and not forming ACOs.

It is the reason the
Mayo Clinic and the Cleveland Clinic have refused to form ACOs.

Nevertheless on January 1^st CMS proudly announced that
it has nearly doubled the number of ACO programs in the country by adding 106
new ACOs to the existing 148 programs for a total of 254 programs to date.

The CMS announced its latest and
largest round of accountable care organizations under the Medicare
shared-savings program.

I would not be as proud as CMS is to applaud this level of
participation in the ACO program. ACOs are the keystone of Obamacare.

Complete national participation is supposed to occur by January
2014.

There are a total of 254 ACO’s signed up in 50 states or 5.08 ACO’s
per state. There are many more potential
ACOs per state than 5.08 per state.

“CMS said half of ACOs are physician-led and
care for less than 10,000 Medicare enrollees.”

This is not a good sign.
The success of the ACO program is defined as shifting the risk of medical care to
hospital systems and physicians.

What is the problem?

The problem is obvious.
The definition of insurance is,

“Insurance is the
equitable transfer of the risk of a loss, from one entity to another in
exchange for payment. It is a form of risk management
primarily used to hedge against the
risk of a contingent, uncertain loss.”

“An insurer, or insurance carrier, is a company selling the
insurance; the insured, or policyholder, is the person or entity buying the
insurance policy. The amount to be charged for a certain amount of insurance
coverage is called the premium.

“Risk management,
the practice of appraising and controlling risk, has evolved as a discrete field of
study and practice.”

Risk management is far
from an exact science. Risk management depends on a large number of people
paying premiums who are not at risk for disease.

Obamacare’s goal is to
have all the low risk consumers pay for the higher risk consumers.

However, President Obama
has provided low risk consumers an out. The penalty for not participating is
modest compare to the cost of the insurance. If a low risk consumer gets sick
he can immediately join the health insurance exchange program without
restrictions.

The increased cost of
illness is compounded when a large number of patients have chronic diseases.

A contributing factor to
developing chronic disease is obesity.

America has a national
obesity epidemic.

Patients with Diabetes
Mellitus are vulnerable to multiple diseases such as hypertension,
hyperlipidemia, kidney disease, eye disease and vascular disease.

Each might be at a
different stage of progression. The risk for costly complications is different
for each at each stage of disease progression.

The diabetic might or
might not adhere to the treatment regime outlined. It is difficult to risk
weight these patients. It is risky to take the responsibility for the medical
care outcomes for these patients.

In reality the principle
risk managers are consumers.

Healthcare policy
experts have not practiced medicine. They either do not understand these risks
or they want to place the risk with physicians and hospital systems and provide
undervalued reward.

Many medical outcomes are
dependent on patient responsibility for managing their own risk. Patients must
participate in their own care to receive maximum benefit and the best medical outcomes.

Patients must become
professors of their disease.

There are many reasons ACOs will fail

1. ACOs
do not empower consumers to be responsible for their own medical care.
Healthcare should be consumer driven with consumers controlling their healthcare
dollars. They will then make informed choices about their care and insurance
coverage.

2. ACOs create artificial
incentives to improve quality medical care and provider performance.

3. Consumer driven healthcare creates real
incentives to promote price competition by physicians and hospital systems. True
competitors will constantly work to improve their products, attract
consumers, and ultimately increase market share.

In a systems of ACOs consumers do
not play a role in stimulating completion. Consumers are passive recipients of
treatment from an assigned ACO.

4. Most physicians are reluctant
to assume accountability for patient outcomes. Physicians recognize that
most medical outcomes are directly under consumers behavioral control.

5. ACOs structure does not include consumers’
incentive to be responsible or accountable for their own medical care.

ACOs undermine any attempt to create a truly
accountable healthcare system that can drive down medical costs.

6. ACOs do not encourage provider
accountability. ACO’s shared savings incentive
does not seem to be adequate for the risk assumption.

Providers will continue to
be paid for each service they perform until the government provided
funds run out for that ACO.

7. There are also grave uncertainties and
practical complications of distributing government funds and savings if any
between the hospital system and physicians on the hospital systems staff.

8. ACOs create an
unfair competitive advantage for large organizations that are hospital system centric.
Eligibility requirements are vague and ambiguous. The eligibility
requirements suggest that larger organizations have an unspoken
eligibility advantage.

9. This is the reason
hospital systems are trying to form ACOs. Hospital systems think they will make
money. I believe hospital systems will lose money. The government will have to
supplement payment for hospital systems to stay afloat.

10. When hospital systems lose
money they will fight with their staff physicians over the distribution of
government reimbursement.

The cost of hospital services will then
skyrocket further. Consumers will be the losers.

11. Groups of independent
practitioners as well as other types of small and mid-sized practices may
lack the infrastructure, information technology facilities, or other resources
needed to qualify for ACO eligibility.

12. They will be forced to join hospital systems.
Hospital systems have a long history of taking advantage of physicians
skills and intellectual property.

Tension between hospital systems and staff
physicians will be created. Hospital systems’ ACOs will crumble. The cost of
medical care will continue to increase further.

These are just a few of the reasons ACO’s will fail.

No matter how hard CMS tries to change the narrative
these are some of the reasons explaining the lack of hospital and physician participation
to this point.

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

Chassidy • October 22, 2013

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Big Data Is A Major Problem For The Healthcare System.

October 31, 2012

inChronic Disese Management, Consumer Driven Health Care, Information Technology in Healthcare, Medicine: Healthcare System

• Leave a comment

Stanley Feld M.D.,FACP,MACE

President
Obama is blinded by his ideology. His healthcare policy goal is to eventually
have a single party payer system. Medical care will be commoditized with
treatment decisions made by the central government.

It
is a charade that his health insurance exchanges will lead to affordable
private insurance. It is misguided to believe that a non-elected central
committee (IPAB) will be tolerated to make treatment decisions for the
population.

The
larger pretense is that President Obama is building an inexpensive bureaucracy.
Last week he again stated that government overhead for Medicare and Medicaid is
very low. He again declared that the overhead expense is only 2½ percent.

It
cost two and one half percent for the central government to outsource administrative
services to the healthcare insurance industry. The healthcare insurance
industry, in turn, charges the government 18-40% to administer the programs.

Everyone
knows most everything government run is inefficient. President Obama is
enlarging the scope of government in all areas at a time when government is too
large and inefficient. The government’s income is $1 trillion dollars less than
its expenses per year since he has been President.

President
Obama thinks if he spends enough money he will spend his way out off the jam.

President
Obama believes one way to become more efficient is to gather more data. He can
then figure out which hospital systems and physicians are inefficient and
penalize them.

This
philosophy has two potential pitfalls. If the data is faulty the conclusions
are wrong. The second pitfall is that penalties do not encourage cooperation
and meaningful improvements.

“Decision-making in
healthcare can be painfully slow, as any physician will tell you. Hospital systems and
physicians are being spurred on in part because healthcare is beginning to deal
with a shift in reimbursement toward one that rewards quality and disincentives
inefficiency and waste.

One problem is that quality is not clearly
defined and is sometime false. The government must reexamine its premises.

Most hospitals and health systems have lots of
data that might improve outcomes and cut waste.

The
problem is getting that data, which is often unstructured, into a format that
allows clinicians to make decisions faster and in a more coordinated fashion.

All
of the innovation is happening without input from physicians. It is being done
to decrease the cost of the hospitals. One thought would be to get rid of a few
excess salaried, $750,000 a year hospital administrators and $2,000,0000 plus
healthcare insurance company administrators which would go a long way to reduce
the cost of healthcare coverage.

Instead
the government is looking to penalize physicians. Physicians are the providers
that deliver medical care.

There
is software being developed that deals with real time processing of clinical
data. The software can communicate those data to networked physicians instantly
and help physicians deliver more timely care.

Many
hospital systems are trying to install these real time systems. Unfortunately,
many hospital administrators do not understand its power as a teaching tool to
increase the efficiency and effectiveness of medical care.

The hospital systems’ only interest is in the
financial result and the question of whether the huge investment is worth the
capital expenditure.

Some
physician group practices, independent of hospital systems, are incorporating
these software systems into their electronic medical records. These groups recognize the potential
importance of having instantaneous predictive data.

Most
physicians do not have an EMR and only 7% of physicians have a fully
functioning EMR.

In
the monograph from “Pathways to Data Analytics” two things were very apparent. It
looks like the healthcare insurance industry controls the committee and its
plans is to continue to control the healthcare dollars and hope to control the
healthcare data.

Increasingly, a
data-driven approach to healthcare is necessary.

The complexity of clinical care requires it, says Glenn Crotty
Jr., MD, FACP, executive vice president and chief operating officer at CaMC.

“We’re moving from an
individual practitioner cottage industry to a team-based process now . . .. [Medical
care] is beyond the capacity of any one individual to be expert enough to do
that. So we have to do it in a team.”

A team requires information. The changing dynamics of healthcare
spending and reimbursements also require data to navigate.

“Our analytics are not just for finance, which traditionally is
what hospitals invested in,” says St. Luke’s Chief Quality Officer Donna Sabol
, MSN, RN. “When you look at how [hospital] payment is changing [to] a value-based
equation, you have to have good analytics for finance and for quality.”

Absent from the report is the patient and his/her responsibility
to the therapeutic unit. Until some policy maker understands the role of
patients to the therapeutic unit they will get nowhere in improving the
healthcare system.

A glaring example is the money spent by hospital systems to
improve the discharge process to avoid re-hospitalization within the 30 days
post discharge.

Obamacare has instituted the rule November1,2012 that if a
patient is re-hospitalized within 30 days of the initial hospitalization the
hospital system will not get paid.

I can think of 5 ways hospital systems can get around this rule
without suffering the penalty.

None-the-less the hospital systems are buying software to study
and automate the process to avoid re-hospitalization using its clinical data in
real time.

The Seton Hospital System in Austin Texas
might have figured it partially out.

It started what it calls an extensivist
program. It is acting as an extension of its physicians care to help avoid re-hospitalization
and use the best data it can collect.

Its is helping clinicians identify patients who
would benefit most from extra attention following discharge. The program
started with congestive heart failure patient

"A
lot of it is about enabling decision-making," Ryan Leslie says

"It's taking the whole universe of
information we have and cutting out what's extraneous and giving clinicians the
information they need to make decisions."

Ryan Leslie is vice
president of analytics and health economics at Seton Healthcare system. He is taking
unstructured clinical information and connecting that with billing or
administrative information and social demographic information.

He says, "you start connecting all those things
together and you get a more complete picture of the patient as a person, rather
than as a recipient of a bill," he says. "That's been the exciting
thing recently. You realize that a patients' success or failure may not have to
do with the care plan details or the clinical attributes of the patient as much
as the social attributes."

Physicians
outside the hospital work with a team of social workers, nurses, and others to
visit patient homes and figure out what's keeping a patient from effectively
following treatment protocols that will likely keep them out of the hospital.

The software
helps determine, based on a host of combined data, which patients are most
likely to be re-hospitalized within 30 days. Targeting the patients is like
looking into a crystal ball. The hospital system cannot afford to service all
the patients with congestive heart failure. The program is in its early stages.
If successful the plan is to expand it to diabetes and other chronic diseases.

This will
happen well beyond November 2012 and January 1,2014. This hospital system
finally realized that it can and must be an extension of its physicians’ care
and not a competitor for patient care.

Missing is the
patients responsibility and incentive in not being readmitted to the hospital.
This can only be accomplished when consumers not only have a desire to be
healthy they have a financial interest to stay healthy.

This can be
accomplished in a consumer driven healthcare system where the patients are responsible
for their health and own their healthcare dollars. The easiest way to get there
is using my ideal medical savings accounts.

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

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The PSA Fiasco

June 20, 2012

inChronic Disese Management, Medicine: Healthcare System, Patients Problems, Physician's Problems

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Stanley Feld MD.FACP,MACE

It is common knowledge that prostate cancer is a slow growing cancer. It is also believed that something happens and suddenly this slow growing cancer becomes aggressive and then metastatic.

As the cancer increases in size, the Prostatic Specific Antigen (PSA) value increases. It is obvious that a baseline PSA should be obtained. The PSA’s value should be followed yearly to see if it is increases over time.

The United State Preventative Task Force’s (USPTF’s) conclusions are incorrect. There are problems with the studies reviewed leading to its conclusions.

The media sensationalism of the USPTF’s conclusions was an indictment of PSA testing and urologists’ judgment.

"The USPSTF concludes that there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harm," the report stated.

“The U.S. Preventive Services Task Force said in a report that the PSA test is too inaccurate, creates needless anxiety for patients, and can lead to costly and potentially harmful follow-up procedures”.

Clinical judgment by physicians is ignored by the USPTF. The PSA increases as prostate cancer progresses. How are you going to know if the PSA is increasing, if you do not have a baseline PSA?

The nation's leading urology associations are fuming over a USPTF report that discredits the widely used prostate-specific antigen-screening test for prostate cancer.

"It's an absurd recommendation. It is ill-researched and ill-conceived," Sanford J. Siegel, MD, a board member with the Large Urology Group Practice Association, told HealthLeaders Media. "This will only do damage to all the great work that has been done for prostate cancer awareness and to control the deaths from prostate cancer."

The USPTF should have at least had an urologist on its task force to evaluate the literature of PSA testing.

The USPTF is a “non-government agency” that will be used by the administration to ration medical care.

How can the government say it advocates preventing cancer when it’s setting us up to restrict access to care (prevention)?

American Urological Association President Sushil S. Lacy, MD, said in prepared remarks that he was "outraged" by the report. "It is inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations such as African-American men," Lacy said. "Men who are in good health and have more than 10-15 years life expectancy should have the choice to be tested and not discouraged from doing so."

The American Association of Clinical Urologists issued a similar statement week,

“The AACU called the USPSTF recommendations "misleading and harmful."

The major urological associations say the USPSTF ignored new studies supporting the value of PSA tests, and that the panel refused to address concerns they raised about the conclusions during the comment period. In addition, the urologists complain that there were no urologists or oncologists on the panel.

The major urological groups said,

"It is just a screening test, one of several things we look at when we decide whether a man needs a biopsy or not," he says.

"Yes, it is true that many men can live with this disease their whole life. That is why active surveillance has become a treatment option," he says. "If we knew in advance who would and who wouldn't advance in the cancer, that'd be great!"

"There is no question that men get prostate biopsies that obviously in hindsight shouldn't happen. But we are looking at improving PSA testing and other testing to help us find out which men will progress with more advanced prostate cancer."

The problem is that no one has yet come up with an alternative to determine which patients will develop advanced prostate cancer

There is case of a famous Texan who yearly had normal PSAs. His physicians told him it was not necessary to get further PSA test since he had been normal all these years. He was now past 80.

At 86 he presented with severe bone pain. Laboratory studies and a bone scans revealed a sky-high PSA (over 100) and widely metastatic prostate cancer.

If his PSAs were monitored the rising PSA would have been detected perhaps early enough to cure him. Prior to the bone pain this man felt perfectly well.

Urologists have many of these same stories.

The USPTF conclusion might aid clinical judgment. However, it should not trump clinical judgment.

Obamacare is getting set to make committee judgments about healthcare policy and clinical care while ignoring physicians’ clinical judgment.

About 250,000 men are diagnosed with prostate cancer each year. The diagnosis is made by physical examination and PSA measurement. The final diagnosis and decision for surgery or radiation is made after a fine needle biopsy of the lesion.

A prospective double blind study does not exist to predict the grade of cancer that will be cured by surgery, radiation or no treatment.

Nor is there a study for the USPTF to grade about quality of life post op compared to the quality of life during progression of disease. Until then the USPTF conclusions on the basis of the studies they did review are relatively meaningless.

The incidence of 250,000 new cases of prostate cancer a year has been stabile over the last 30 years.

With early detection the number of males dying per year from metastatic prostate cancer has dramatically fallen from 48,000 per year to 28,000.

The USPTF statement does not seem correct,

“It could find no evidence to support claims that PSA tests are responsible for "reduction in all-cause mortality."

"Many more men in a screened population will experience the harms of screening and treatment of screen-detected disease than will experience the benefit."

The USPTF report ignores the dramatic decrease in deaths from prostate cancer over the last several decades.

Dr. Marc Siegel, a practicing urologist for 30 years, said,

When I started training, 40% of African-American men at that time presented with metastatic disease. Now that number is miniscule," Siegel says. "Tell me how that happens without early screening? How do death rates go down from 48,000 when I trained to 28,000 now? How do you explain that without screening? You can't! It's impossible!"

I believe the defect in the USPTF conclusions have to do with the specificity of the PSA and not its clinical value. A more accurate PSA test needs to be developed.

The USPTF’s conclusions will save President Obama a little money in the short run.

However, the cost of care for prostate cancer along with the morbidity and mortality will cost Americans greatly in the long term.

The USPTF has to re-examine its premises and methodology.

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

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Jerry The Diabetic Teddy Bear

May 30, 2012

inChronic Disese Management, Medicine: Healthcare System, War on Obesity

• Leave a comment

Stanley Feld M.D.,FACP, MACE

IF YOU CANNOT SEE THE YOU TUBE PRESENTED IN THIS BLOG POST IN YOUR EMAIL OR YOUR RSS FEED PLEASE CLICK ON TO THE TITLE OF THIS BLOG POST ABOVE TO CONNECT TO THE ORIGINAL ONLINE BLOG POST OR OPEN THE URLS POSTED IN THE EMAIL OR RSS FEED.

The You Tubes are usually at the bottom of the email feed.

THANK YOU

Last week two young entrepreneurs showed me a fascinating way to teach children age 3 to 8 with Type 1 Diabetes Mellitus how to take care of their disease.

The onset of Type 1 Diabetes Mellitus in young children is devastating for their parents. Many parents blame themselves for the child’s disease. The child is usually frightened and angry about having to take shots. They are also angry about the food restrictions and the fact that they are different from their friends. Often they become rebellious and try to avoid the shots or do not comply with the rules of food intake.

Everyone has seen a 5 year old mesmerized by Leapster, an educational computer game. Children feel compelled to master Leapster. It keeps their attention for hours.

Two recent college graduates Aaron Horowitz and Hannah Chung designed and are now marketing Jerry The Bear.

http://youtu.be/GptPWHLhiZo

They participated in a wonderful program called Design for America program at Northwestern University while in college.

"Without believing in our ability to develop and implement innovative solutions that can address the world’s challenges, we will not even act.

We can’t innovate if we don’t believe that we can. We must work together with those from all different backgrounds and perspectives, we must work with our community, and we must support each other in our efforts improve the world around us.

Design for America’s vision is a world where people believe in their ability to innovate and tackle the most ill-structured challenges of our time.

Design for America teaches human centered design to young adults and collaborating community partners through extra-curricular, university based, student led design studios to look locally, create fervently and act fearlessly. DFA currently tackles national challenges in Education, Health, Economy and Environment."

http://youtu.be/tYppYU6XV5o

Aaron and Hannah produced Jerry the Diabetic Teddy Bear. After graduating college this year they applied and were accepted to a TechStars affiliated accelerator program in Rhode Island Beta Springs to further develop Jerry.

Jerry the Diabetic Teddy Bear is a fantastic teaching tool for young children. Young kids love their Teddy Bears. Jerry helps kids with Type 1 Diabetes adjust to their new lifestyle. By playing with Jerry children will learn to master their medical procedures.

Diabetic children will transfer the anger they feel at the onset of Type 1 Diabetes into an intense responsibility for taking care of their Jerry the Diabetic Bear.

The child with Type 1 Diabetes learns how to vary insulin doses and food intake through a computer chip algorithm game. The game teaches how to determine insulin dosage and food intake in order to keep Jerry the Diabetic Bear’s blood sugar as close to normal as possible.

In turn the child learns how to take care of his own Diabetes. The child learns to be responsible for Jerry’s care and in turn his/her own care in order to remain healthy. Education must be made entertaining and purposeful. Jerry the Diabetic Teddy Bear is an effective educational vehicle that is simple and purposeful.

There is no reason that innovative teaching applications like Jerry the Diabetic Teddy Bear could not be produced for children with other chronic diseases such as asthma.

Design for America promotes the innovative thinking in young college students. It expands imaginative thinking in order to create new and effective products.

Rather than whine about the obesity epidemic in America we should be teaching children through entertaining and purposeful innovative educational ways to learn about food values, exercise and obesity.

This type of education should be universal if we are going to educate our population about the prevention and care of chronic disease.

This is a powerful way to reduce healthcare costs.

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

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The Relationship Between Type 2 Diabetes Mellitus And Statin Therapy

March 21, 2012

inChronic Disese Management, Consumer Driven Health Care, Medicine: Healthcare System

• Leave a comment

Stanley Feld M.D. FACP, MACE

Readers have continuously reminded me that consumers are not smart enough to purchase the right kind of healthcare.

"Hello Dr. Feld,

What is your solution for patients who simply aren’t educated enough to make these decisions on their own? In “Redefining Healthcare” Michael Porter advocates a role for insurers to help in this regard and I’m wondering what your thoughts are given that the fastest growing demographic in America is poor, uneducated, and potentially (as a result) unhealthy folks."

I refuse to believe that consumers are too stupid to be educated if properly motivated.

I welcome insurance companies trying to educate consumers but they are doing it for their benefit and not the patients’ benefit. The education offered is not an extension of the physician’s care and will therefore be ineffective.

I respect the intelligence of all consumers. They will want to become educated consumers as soon as there is a financial benefit.

Any educational system built will have no effect on about 10% of the population. These people will be a burden to society.

The government and the healthcare insurance companies had their day trying to fix the healthcare system.

It is now the consumers’ turn to use their consumer power to fix the healthcare system. Consumers are starting to realize they need to be responsible for their care. They are also realizing they must control their healthcare dollars.

In order to be a wise healthcare consumer, they must understand their chronic disease.

The recent FDA statement about statins causing Type 2 Diabetes has been confusing to patients. Statins can be expensive. Patients will not spend the money for the statin nor adhere to a treatment plan if they think they will be harmed by the medication.

An understanding of the pathophysiology of Type 2 Diabetes and hypercholesterolemia will make it clear that there is no relationship between statin therapy and its causing diabetes.

At least 20% of the population has genetic insulin resistance. There is a slight difference between ethnic groups with the incidence being 30% in Hispanics and Native Americans.

This genetic defect results in a rising insulin level as the patient becomes obese, older and/or stressed.

The increase in childhood obesity in genetic insulin resistance children is causing an increase in childhood Type 2 Diabetes.

The underlying genetic defect can express itself before the blood sugar rises out of the “normal range.”

Insulin Resistance Syndrome has had several names over the past 30 years. One name was the Deadly Quartet. The quartet consists of obesity, hypertension, hypercholesterolemia, and diabetes.

Insulin Resistance Syndrome’s new name is Metabolic Syndrome. Each disease can present independently at different times. Hypertension, hyperlipidemia and diabetes are usually precipitated by obesity, stress or steroid therapy.

If patients understood the pathophysiology of metabolic syndrome they would try hard to lose weight and adhere to medication prescribed.

Patients must be taught to become the professor of their disease.

It is insufficient to say “doc, my cholesterol is high, fix me”. The only people who can “fix” patients with chronic diseases are patients themselves.

What do we know about Type 2 Diabetes Mellitus and insulin resistance?

1. The incidence of Clinical Type 2 Diabetes Mellitus is high in patients who are obese.

2. Clinical Type 2 Diabetes (high blood sugar) can disappear with weight loss and exercise in early onset diabetes. These patients still have insulin resistance but the resistance is decreased and the blood sugars become normal.

3. Obesity must be decreased in order to eliminate overt diabetes. If not, the medical cost of treating diabetes and its complications will continue to rise.

4. High LDL cholesterol is a frequent complication of Type 2 Diabetes.

5. High LDL levels cause coronary artery plaques. The result can be myocardial infarction (heart attack).

6. Diabetes Mellitus is frequently first discovered at the time of a myocardial infarction (heart attack). Mildly elevated blood sugars could remain asymptomatic for an average 8 years and discovered after a complication of diabetes (heart attack) occurs.

7. Treating high LDL cholesterol with statins in Type 2 Diabetics decreases the incidence of myocardial infarction.

8. Statins decrease the production of LDL in the liver by inhibiting an enzyme that produces LDL.

9. High blood sugar and high insulin levels also decrease nitric oxide levels in the lining of blood vessels (endothelium). The result is a narrowing of the coronary arteries.

10. Statins stimulate an increased endothelial nitric oxide production. Statins dilate the coronary arteries.

11. The dilatation of the coronary arteries along with the decrease in LDL production decreases plaque formation and the risk of a myocardial infarction.

12. High insulin levels in early Metabolic Syndrome inhibits LDL receptors ability in the liver to attach to circulating LDL. This inability to attach to the liver cells decreases the liver’s ability to sense there is enough cholesterol in the blood stream. The liver then increases the production of LDL.

13. Statins inhibit the liver from producing more LDL. Lowering the LDL produced decreases LDL in the blood stream.

14. Logically, by lowering LDL cholesterol production with a statin the effect of insulin resistance to increase cholesterol production is neutralized. The use of statins in Insulin Resistance Syndrome does not cause diabetes.

15. Therefore data for the FDA’s black box warning is wrong.

Education is the key to chronic disease management.

Physicians must teach patients in terms they can understand. Education will only be effective if patients are motivated to learn.

Physicians must be motivated by consumers to teach. Consumers controlling their healthcare dollars could motivate physicians to teach them at their level. Physicians could use their own social networks to provide customized instruction.

Obesity is the core-precipitating problem in Metabolic Syndrome. My ideal Medical Saving Account with its financial incentive could help change the obesity problem in America.

The ideal MSA might even compel the experts to not throw misinformation around lightly and frighten the public.

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

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Pietr • March 23, 2012

“Those who restrain desire do so because theirs is weak enough to be restrained.”
― William Blake
>It is insufficient to say “doc, my cholesterol is high, fix me”. The only people who can “fix” patients with chronic diseases are patients themselves.
Dr. Feld, this statement is a copout. You throw the responsibility back at the patient and your hands in the air. Since you recognize that obesity is an refractory to treatment, it is easier to blame the patient to sloth and gluttony and absolve yourself.
The treatment of obesity was available 20 years ago with the combined agonists fenfluramine and phentermine. Unfortunately, these drugs were off patent and Dr. Weintraub and his colleagues didn’t see the danger. When the cardiac and pulmonary problems occurred, FEN/PHEN had no advocate and its promise disappeared.
Treatments for OCD and addiction using dopamine and serotonin agonists/precursor have been described. The current protocol uses the immediate precursors levodopa and serotonin. Another duo taken together increases cerebral acetylcholine and crushes nicotine craving. Lecithin and pantothenate (vit B5) are dirt cheap and have absolutely no risk.
These simple treatments do not make money for PHARMA, in fact they are a threat to its very existence. PHARMA would be foolish not to fight against their use. In my case, they destroyed my career, reputation and life.
Tell your alcoholics, cocaine addicts and fatties that the system has failed them rather than blaming them.
I hope you enjoy the Blake quotation.
We seem to differ not only on the price of nude tennis balls (Spaldeens) in 1950 but also the solution for medical management. I hope we can converse civilly in the future for I respect the quality of your writing and the degree of intellect and trust in your motivations.
Pietr Hitzig
http://sites.google.com/site/pietrhitzig/
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