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Let The Buyer Beware: Medicare Part D

Stanley Feld M.D.,FACP,MACE

The mystery of buying drugs under Medicare Part D increases each year. The plans offered become more costly and complicated. https://en.wikipedia.org/wiki/Medicare_Part_D

Medicare did not cover outpatient prescription drugs until January 1, 2006, when it implemented the Medicare Part D prescription drug benefit.

Congress authorized Medicare Part D with the heading the “Medicare Prescription Drug, Improvement, and Modernization Act of 2003.”

Private insurance companies administer Medicare Part D plans for the government. The government is not allowed to negotiate drug prices with the pharmaceutical companies.

The VA healthcare system negotiates prices with the pharmaceutical companies. The prices are at least 60% lower than the Part D prices.

Multiple plans are offered with increasing premium prices and deductibles each year.

The increases in deductibles are significant. Below are the increases between 2016 and 2017. Most seniors do not pay attention to the increase in premiums, deductibles or coverage because they automatically enroll each year.

They become aware of the changes changes when they go to pay for their medication

Initial Deductible:
will be increased by $40 to $400 in 2017.

Initial Coverage Limit:
will increase from $3,310 in 2016 to $3,700 in 2017.

Out-of-Pocket Threshold:
will increase from $4,850 in 2016 to $4,950 in 2017.

Coverage Gap (donut hole):
begins once you reach your Medicare Part D plan’s initial coverage limit ($3,700 in 2017) and ends when you spend a total of $4,950 in 2017.


In 2017, Part D enrollees will receive a 60% discount on the total retail cost of their brand-name drugs purchased while in the donut hole.

Generally, not all drugs are covered at the same out of pocket cost to the beneficiary. This gives participants incentives to choose certain drugs over others. This is most often implemented—as is the case for drug coverage for those not on Medicare—through incentives to use generic drugs over brand-name drugs.

The incentive is also often implemented via a system of tiered formularies in which some brand-name drugs are less expensive than others and not subject to step therapy.

Generic drugs are less expensive than brand named drugs. Patients learned this quickly. They encouraged their physicians to provide them with a prescription for generic drugs.

When patients buy drugs with Medicare Part D the deductible price is the patients’ cash outlay. However, the Medicare Part D plan charges patients the total retail price of the drug against their donut.

For example if a 90 day supply of a generic drug is $10 and the retail price is $60 dollars, the $60 is charged against the patient’s donut to be added to future purchases.

If patients paid $10 cash already shouldn’t only $50 of the $60 be charged against the donut?

Many generics can be purchased for a cash price or using a discount drug card coupon for $10 without using Medicare Part D and incurring the $60 retail charge against a donut.

Many generics can be purchased for less using a discount drug card coupon than the cash price a senior on Medicare Part D has to pay using Medicare Part D insurance.

It is not uncommon for senior patients to reach their donut in less than a year. At that time those senior patients have to pay 100% (60% in 2017) of the retail price for a drug until they reach $4,950.

The amount is an additional cash price of $1,250.

It was difficult to figure this out before discount drug cards became available.

How do these discount drugs card work and the discount drug card companies make money?

The Middle Men are:

“1.    Cardholder – the consumer

  1. Pharmacy – the retail outlet in which the purchase is made
  2. Pharmaceutical Company – the manufacturer of the medication
  3. Adjudicator – the organization that negotiates the discounts with the drug makers
  4. Card Marketer – the organization whose brand is on the card
  5. Card Marketer Affiliate – an organization that assists the Card Marketer in distribution

 Each time a card is used there is a transaction fee applied to the purchase price. 

 That fee is split 3 or 4 ways (though perhaps not evenly) between the Pharmacy, the Adjudicator, the Card Marketer and their Affiliate.

This transaction fee comes at the Cardholder’s expense.

However, usually the negotiated discount cost of the medication far exceeds the transaction fee so the Cardholder still wins. 

For example, the retail price for a medication is $100. The prescription discount card has negotiated a 40% discount, so the cost would be $60 but there is a $10 transaction fee. So the Cardholder pays $70 instead of $100. Of the $10 transaction fee, the Pharmacy might take $2, the Adjudicator $2 and the Card Marketer $6.

The Card Marketer might pay out $1 to their marketing

affiliate.”

Many Medicare Part D patients have figured out how to optimize their drug cost through the use of the discount drug cards.

None of these government policy manipulations are to senior recipients of Medicare Part D advantage. They all benefit the middlemen.

A simple solution is to change the Medicare Part D law so the government can negotiate the cost of drugs just as all the middlemen in the Discounted Drug Card industry are negotiating the price of drugs to the advantage of seniors.

Sometimes the discount cards yield different discounts in different pharmacies in the same zip code.

Sometimes the pharmaceutical companies figure out how to combine two medications that are just as effective when taken separately to increase the cash price to senior patients.

These companies do it with FDA approval.

I became aware of the vast price differences recently with two commonly used drugs Dutasterile (Brand name Avodart) and Tamusulosin (Flow Max). Both drugs have been on the market long enough to be sold as generic drugs.

Using the Good RX discount card these are the variation in prices for the combination drug and the drugs sold separately in one zip code.

Dutasterilde +

Tamsulosin 90

Dutasterile 90 Tamusulosin 90
Walgreens $183.00 $183.08 $113.93
Kroger $316.98 $45.61 $30.62
CVS $388.69 $84.63 $58.62
Tom Thumb $391.85 49.85 $31.85
Albertson $391.60 $52.60 $31.85
Walmart $475.10 $398.71 $55.23
Target $388.69 $388.71 $136.41

Table 1

None of the pharmacies receive an appropriate discount for the combination of Dutasterile plus Tamulosin. Only Kroger’s negotiator received an appropriate discount for the two drugs sold separately. The total price is $76.23 for 90 pills vs. $316.98 for the combination.

However, seniors have run into a problem in shopping for the best price in a neighborhood.

The government provides a bonus to physician practices that have meaningful use electronic medical records.

One criterion for a meaningful use electronic medical record is the electronically ordering prescriptions for patients.

If a patient usually used the Wal-Mart Pharmacy that telephone number would be in the record. The physician’s prescription would automatically be sent to the Wal-Mart Pharmacy. If the physician wrote for the combination for it would cost $475.10. If the physician wrote the prescription for each medication separately in would cost the patient $453.94 as opposed to cost him $76.23 at Kroger’s.

Compounding the complexity of the electric medical records unintended consequence the pharmacist would automatically fill the combination prescription using that senior’s Medicare Part D insurance. It would be much cheaper than the cash price.

The senior would pay only $146.50 for the combination but his donut would be charged the full retail price of $475.10.

The physician’s office should be aware of the difference in price between the generic combination and the generic drugs sold separately. However, that is not the physicians job.

He should be able to give the patient a paper prescription for both the combination and separate medication so the patient would be able to shop for the best price in his zip code if he was so inclined.

Clearly Medicare Part D is a mess and needs straightening out.

The discount drug cards are not the answer on top of the rising Medicare Part D premiums.

Many retired seniors are living month to month on a pension. The Medicare Part D premiums are paid with after tax dollars not pre-tax dollars.

Many seniors simply cannot afford to pay for their medication. If they do not take their medication they will develop complications of their disease.

Medicare Part A and B will cost the government more and become more unsustainable.

A few simple fixes can solve the problems in Medicare Part D that policy makers and congressmen do not seem to be aware of.

Patients must be responsible for their medical care and their healthcare dollars.

It would be nice if the government would help a little with fixes in information and policies that work for senior patients.

In the meantime it is imperative to “Let the Patient Beware.”

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

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


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Profoundly Disappointed

Stanley Feld M.D.,FACP, MACE

I am profoundly disappointed in Paul Ryan, the Republican caucus and the RINO establishment for introducing the Paul Ryan bill to repeal and replace Obamacare.

It doesn’t completely repeal Obamacare or completely replace it.

In fact the supposed anti- entitlement party (Republicans) are adding another entitlement.

They are even leaving the healthcare insurance industry in charge of the money and the access to care.

It doesn’t even fulfill the five principles President Trump listed in his address to congress.

Those five principles alone would not Repair the Healthcare System.

The bill does nothing to encourage consumers to be responsible for their health and their healthcare dollars.

Consumers must be involved in driving the healthcare system in order for the healthcare system to be viable.

The bill continues to allow the government and the healthcare insurance companies to drive the cost and the healthcare system.

The Republican bill does not provide incentives for consumers to use their healthcare dollars wisely.

It does not include malpractice reform.

If President Trump buys the nonsense Republicans are calling a repeal and replacement for Obamacare, then the RINO’s have pulled the wool over his eyes.

It would be a gigantic mistake to push this bill in its present form. You would be producing political capital for the politically bankrupt Democrats.

This bill is a typical bait and switch. Rand Paul is correct. It is Obamacare lite.

It does not put consumers in charge. It keeps the healthcare insurance industry in full control of medicine, healthcare and the government.

Rather than discontinuing an entitlement it creates another one.

Refundable tax credit is another term for redistribution of wealth. You give money to everyone. You then take it back from some and let the others have it.

It does not repeal most of the Obamacare regulations.

It extends many of the programs past 2019.

President Trump, it does not help drain the swamp as you promised. It makes the swamp worse.

The insurance companies are not returned to a free market. It is a clever way to support the insurance companies by switching from a mandate and penalty to a tax credit (giving the money away to everyone).

This is another entitlement to further enrich the healthcare insurance industry.

Americans elected these Republican politicians to drain the swamp. This bill is no different than Obamacare.

Dr. Jane Orient, executive director of the Association of American Physicians and Surgeons said:

Refundable” tax credits – for those who don’t owe taxes – are still a subsidy. It is still redistribution of wealth, with winners (those who get the subsidy) and losers (those who pay for it). And the chief winner is the “health plan.” It gets money; the supposed beneficiary may get nothing, or only rationed care from a narrow network.

“The problem is comprehensive third-party payment,” Orient adds. “The bill perpetuates this disastrous concept. A true free-market bill – “there shall be a free market in health insurance” – would remove all federal mandates, subsidies, barriers to competition, or protections or advantages for cartels.”

“Instead of returning the insurance market to the vigor of a free market, the government will be supporting it with tax credits – the flip side of the ACA insurance penalty.”

Americans are not stupid. The Republican bill will expose all the Republicans who are for the bill. They are not working for the good of the people

Democrats have already demonstrated they do not work for the people.

An group like the tea party can put up candidates against these guys and elect people who are for the people.

Where are the plans for consumer driven healthcare, patient centered healthcare, malpractice reform and the physician patient relationship?

Where are incentives for consumers to focus on their health, to help cure the obesity problem in order to decrease the incidence of diabetes and other chronic diseases?

Where is a free insurance market?

Paul Ryan’s plan is the road to failure.

The next step would be replacement of the Republican’s failure with a government controlled single party payer system.

It will fail as it is in so many countries.

President Trump. Wake up!!! Keep your promise to the American people.

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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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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War on Obesity: Pre Diabetes Part 20

 Stanley Feld M.D.,FACP, MACE

This is a continuation of my War on Obesity.

The New York Times has criticized Donald Trump’s healthcare plan without even knowing what is in it.

I hope all the features of a healthcare plan missing from President Obama’s healthcare plan are included in President Trump’s healthcare plan. I believe Dr. Tom Price knows most of what needs to be included. He also knows that Obamacare is a disaster. It must be repealed.

I have written a series of articles outlining what should be included President Trump’s replacement healthcare plan after he repeals Obamacare.

I believe the critical element necessary for Repairing the Healthcare System is the development of a healthcare system in which consumers are responsible for their health and healthcare dollars.

This is the main reason Obamacare needs to be repealed. Obamacare makes consumers of healthcare dependent on the government and less responsible for their own healthcare.

Joan Colgin R.N. was Endocrine Associates of Dallas P.A.’s first fulltime Diabetes Educator. I nominated her for Diabetes Educator of the year some years back. She came out second to a woman who was trying to provide diabetes education to an indigent population. Endocrine Associates of Dallas P.A. was providing effective Diabetes Education on a one on one basis to consumers of all socioeconomic groups.

Joan provided Diabetes education to all people who were interested in learning to be responsible for the self-management of their Diabetes Mellitus. Patients live with their disease 24 hours a day and must learn how to manage it.

Endocrine Associates of Dallas P.A. was extremely successful in motivating people to be responsible for their own care.

Joan is presently the nurse member of the Texas Diabetes Council. Recently she asked me to publicize the CDC’s new position statement on Pre-Diabetes.

The National Institute of Diabetes (niddk.nih} 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.”

 

My personal observation has been that 80% of patients in the Cardiac ICU have Type 2 Diabetes. Almost all have Type 2 Diabetes that was just discovered on this admission to the hospital.

We know the complications of Type 2 Diabetes Mellitus take at least 8 years after the onset of the disease to occur.

The Cardiac ICU patients either had Pre Diabetes (asymptomatic) or undiscovered Type 2 Diabetes Mellitus (also asymptomatic) for at least 8 years prior to their heart attacks.

The CDC position paper can be extremely helpful in reducing the cost of medical care to our healthcare system if it is rolled out effectively.

Eighty percent of our healthcare dollars are spent on the complications of all chronic diseases. Type 2 Diabetes Mellitus is the most prevalent.

The summary of the position paper is as follows:

“What Prediabetes is Trying to Tell You”

Did you know that people can have prediabetes for years without any clear symptoms?

It often goes unnoticed until serious health problems show up, like type 2 diabetes or heart disease.

But if you find out you have prediabetes early, you could make lifestyle changes proven to help safeguard your health.

Knowing your risk is the first step. If you have any of these risk factors for prediabetes, don’t wait—talk to your doctor about getting your blood sugar tested:

  • Being overweight
  • Being 45 years or older
  • Having a parent or sibling with type 2 diabetes
  • Being physically active less than 3 times a week
  • Ever having gestational diabetes (diabetes while pregnant) or giving birth to a baby who weighed more than 9 pounds
  • Being African American, Hispanic/Latino American, American Indian, Pacific Islander, or Asian American 
  • Want to find out your risk right now? Take the 1-minute quiz at organd be sure to share the results with your doctor.

 The summary is all you have to know.  DoIHavePrediabetes.org is an excellent questionnaire that takes two minutes to complete to determine if you are at risk for Type 2 Diabetes.

The CDC division of Diabetes Prevention includes a detailed position statement entitled:

The Surprising Truth About Prediabetes

The first sentence says it all!

It’s real. It’s common.

And most importantly, it’s reversible.

You can prevent or delay prediabetes from developing into type 2 diabetes with simple, proven lifestyle changes.

 The reason for the statement is simple to understand. We are all born with an inherited genetic make-up. About 33% of us have the genetic make-up that predisposes us to Type 2 Diabetes Mellitus.

Obesity will bring out the tendency to develop Type 2 Diabetes Mellitus by causing us to be resistant to our own insulin.

Our body in response to exposure to sugar secretes our insulin. If we are resistant to our own insulin our sugar level will increase to the point of officially having Type 2 Diabetic Mellitus.

America has an Obesity Epidemic.

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

Americans are constantly exposed to too many calories. The only way to gain weight is to eat more than you burn. The only way to lose weight is to eat less and burn more.

One third of those 68.8 percent of obese people will get Type 2 Diabetes unless they lose weight to prevent its onset.

Unless those people lose weight they will be destined to suffer the morbidity and mortality resulting from Type 2 Diabetes Mellitus.

The only one in control of a person’s weight is that person. This is the reason that individuals must be responsible for their own care.

The government cannot provide weight loss. The government can provide education and incentives for individuals to be responsible for their own care.

Preventing the onset of Type 2 Diabetes will precipitously decrease the cost of medical care.

This is the reason a consumer driven healthcare system with consumers being responsible for their care is vital to a successful healthcare system.

I hope President Trump and all of congress is listening.

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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Dear President–elect Trump Part 4

Stanley Feld M.D.,FACP, MACE

In 2008 I thought President Obama was the real deal.

I thought he cared about Americans and cared about repairing the healthcare system. I wrote six letters to him giving him suggestions on how to repair the healthcare system.

Then, I realized he was not interested in the improved delivery of healthcare to all Americans. He was interested in the central government controlling the healthcare system in order to control the people and limit their freedoms.

Obamacare was the answer to his goal. Most physicians did not agree with his plan. Many felt powerless to object. Many felt they should go along to get along.

Many in the healthcare industry figured that greater government involvement in healthcare financing would lead to its economic benefit.

Everyone has been deceived. Everyone is starting to believe that government managed healthcare leading to a better healthcare for all and a better healthcare system is a myth.

In my letters I tried to explain this to President-elect Obama. My explanation fell on deaf ears.

Dear President Obama Part 1

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/11/dear-president-elect-obama.html

Dear President Obama Part 2

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/11/dear-president-elect-obama-part-2.html

Dear President Obama Part 3

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/11/dear-president-elect-obama-part-3.html

Dear President Obama Part 4

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/12/dear-president-elect-obama-part-4.html

Dear President Obama Part 5

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/12/dear-president–elect-barack-obama-part-5.html

Dear President Obama Part 6

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/12/dear-president-elect-obama-part-6-why-dont-you-listen-to-practicing-physicians.html

Over the last seven and a half years I have developed a simple but effective consumer driven healthcare system that should replace Obamacare after it is repealed.

Obamacare is missing the major ingredient necessary to create creating a successful healthcare system.

The healthcare system must be market driven, with consumers being responsible for their healthcare and healthcare dollars. The tool that will accomplish this is my Ideal Medical Saving Account. Please include reading the article  My Ideal Medical Savings Account Is Democratic! among all the articles in the group explaining My Ideal Medical Savings Accounts.

The Republicans in the House got many things right in its legislation to replace Obamacare. However they have left out the three most important elements necessary to Repair the Healthcare System.

The first is the revival of the physician/patients relationship.

Consumers must control their health and their healthcare dollars. America must have a consumer driven healthcare system.

Consumers can be taught to drive the healthcare system though public service education.

Consumers must be taught through public service education to change their eating and exercising habits. The emphasis must be on the health dangers of obesity and its development.

Secondly, consumers must be given financial incentives as outlined by my Ideal Medical Savings Accounts to control their own health and have access to available care available in necessary.

Third, there must be significant tort reform included in the replacement of Obamacare.

If the Republicans simply send you the bill they have passed in the house and you sign it you will have an impending disaster as large as Obamacare.

If you include my suggestions in your bill, you would excite consumers and physicians. All the people who have been hurt by the failures of Obamacare will cheer you.

The repeal of Obamacare is vital. It should only be replaced with a consumer driven healthcare system that I have outlined. It will be economically sustainable. It would win over all conservatives and independents. It would even make progressives rethink their ideology.

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

 All Rights Reserved © 2006 – 2016 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

  • Naina Katyal

    Really impressed! Everything is very open and very clear clarification of issues. It contains truly facts. Your website is very valuable.
    Desi chhokri kurtis

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Dear President-elect Trump Part 3

Stanley Feld M.D.,FACP, MACE

The following is Part 3 of my review of your healthcare reform platform. You have a viable alternative to Obamacare. Your alternative needs some vital additions.

In my last blog I omitted the link proving that only 1 million people signed up for Obamacare health insurance exchanges.

I apologize for the oversight. Today enrollment is only 2.3 million. I also noticed that the enrollment date was extended to January 30 from December 31 without fanfare. The site I omitted that follows daily enrollment is acasignups.net.

Obamacare is still a long way from the 20 million claimed and the actual 10 million enrolled for 12 months.

The Obama “experts” still believe that Obamacare is viable. They refuse to believe it has been a healthcare disaster as well as a disaster for America’s economy.

Your next proposal is;

  1. Allow individuals to use Health Savings Accounts (HSAs). Contributions into HSAs should be tax-free and should be allowed to accumulate.

Health Savings Accounts (HSAs) should be changed to Medical Savings Accounts (MSAs) to provide better financial incentives for people who choose this form of insurance. The Medical Savings Accounts can easily be customized so that consumers can choose the level of insurance they desire.

The cost of first dollar reinsurance for coverage after the deductible is met plus the MSA contribution is much cheaper than the first dollar coverage Medicaid coverage. The insurance vendor will still make a sizable profit by providing first dollar coverage reinsurance.

The contribution to the MSA should be flexible to provide an adequate amount of money to be put into the savings accounts to provide financial incentivizes to consumers to maintain their health.

Obesity is a huge problem to health maintenance of health. Obesity can be effectively cured behavioral change of consumers.

The incidence of chronic diseases in obese people is five times that of normal weight people. Financial incentives must be provided. The is also the area that social engineering might be helpful.

Obese children are becoming diabetic and hypertensive at a young age. This must be prevented because of the potential explosive cost effect of complications of both diabetes and hypertension on individuals. The overall costs to patients, Medicaid and society will be devastating.

Medicaid must be converted to a system where the recipients are responsible for their health with financial incentives. Only then Medicaid patients will not be treated as a commodity. Service will improve. .

  1. Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals.

Price transparency is an essential provision for individuals, businesses and groups in order to produce smart consumers of healthcare.

It is also necessary to require insurance companies to provide verifiable price transparency for their administrative costs and their direct patient care costs.

Consumers must be empowered to be responsible and shop for the best healthcare service value. They must look for the best prices for procedures, exams or any other medical related procedure.

The only way to decrease the cost of healthcare services is to produce smart and motivated consumers of healthcare.

The Healthcare System must be converted to a Consumer Driven Healthcare System.

Social networking should be used as the backbone for the establishment of consumer empowerment.

The success of Angie’s list, Trip Advisor and Open Table are a result of social networking.

All medical care is local. Local communities have their individual social networks that empower people in their neighborhood to know which vendors provide the best value in their community.

Healthcare consumers can use this simple procedure to decrease the cost of healthcare and medical care.

This could also be a place where government can lead the way in establishing accurate educational resources.

  1. Block-grant Medicaid to the states.

These block grants can be used by the states to fund MSAs without a threat of increasing state budget deficits or giving up states’ rights to the federal government.

Block grants for social networking should be used to provide incentives to help individual Medicaid patients seek out and eliminate fraud, waste and abuse of some of its local providers.

It would eliminate expensive big data collections that often times are inaccurate for policy making by central federal control.

  1. Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products.

Federal and state governments should help their citizens choose safe, reliable and cheaper products for the treatment of their diseases.

This would help with compliance and adherence to recommended treatment and also decrease the cost of care.

It would provide consumers with information to take responsibility for their own health and healthcare dollars.

  1. Encourage Congress to step away from the special interests and do what is right for America.

One example is allowing consumers access to imported, safe and dependable drugs from overseas. It will stimulate competition for consumer dollars in the U.S. and lower the cost of brand and generic drugs sold here. Drug prices are artificially high in the U.S.

This is only one example of many ways to decrease the cost of drugs in this country.

You have made many proposals to make a lot of important changes to the healthcare system.

Some are good proposals. Some are not very well thought out by your advisors.

You left out Tort Reform, which is one of the most important proposals. Effective Tort Reform will result in a precipitous decrease in the cost of medical care.

It is absurd to let Obamacare “experts” like Ezekiel Emanuel and Jonathan Gruber heckle your “non viable” healthcare reform plan.

However, you are missing the other important elements in reforming the healthcare system. Those elements are the elements of the use of consumer power, consumer initiatives, and consumer incentives.

 By utilizing these elements you will begin to “Drain the Healthcare Swamp.”

Your healthcare changes must include a consumer driven system with an ideal medical saving account. Otherwise, the healthcare system will remain an unmanageable, expensive and abused mess.

You have admitted these proposals are simply a start. You can easily fall into the trap of listening to academicians who have never practiced medicine in a private setting. You need people who understand patients’ needs.

Obamacare has been a disaster that is unsustainable. It is increasing the cost of care week by week, while rationing care and decreasing access to care.

You must repeal and replace Obamacare. No one wants it. You have outlined a viable proposal even if the progressives don’t like it.

It is a good start.

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

 All Rights Reserved © 2006 – 2016 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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Let’s Get Smart

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Why Vermont’s Single Party Payer Healthcare Plan Failed

 Stanley Feld M.D., FACP,MACE

Vermont’s single party payer healthcare plan was doomed to fail from the onset for several reasons.

Healthcare policy consultants do not understand the medical care system. The healthcare policy consultants for the Vermont healthcare system were the same consulting architects President Obama used for Obamacare.

The consultants were Harvard’s William Hsiao and MIT’s Jonathan Gruber.

William Hsiao has spent most of his academic career helping governments install healthcare systems. William Hsiao is the K.T. Li Research Professor of Economics in Department of Health Policy and Management and Department of Global Health and Population, at Harvard T.H. Chan School of Public Health.

Jonathan Gruber is a professor of economics at the Massachusetts Institute of Technology, where he has taught since 1992.[1]

He is also the director of the Health Care Program at the National Bureau of Economic Research, where he is a research associate.

Jonathan Gruber has been heavily involved in crafting public health policy.

He has been described as a key architect[2] of both the 2006 Massachusetts health care reform, sometimes referred to as “Romneycare”, and the 2010 Patient Protection and Affordable Care Act, sometimes referred to as the “ACA” and “Obamacare”.

There is little evidence that the systems he and Dr. Hsaio have built are overwhelming successful, cost effective or preserve consumer freedom of choice.

In fact, a study by NPR and Harvard’s T.Chan School of Public Health concluded that Obamacare is a complete failure.

Dr. Hsaio is on the faculty the Harvard T.Chan School of Public Health.

NPR AND HARVARD T.H. Chan School of public Health SAY: OBAMACARE IS A COMPLETE FAILURE

In a New York Times interview in 2009 Dr. Hsiao discussed the system of healthcare Reform he installed in Taiwan.

The question was:

What’s the most important lesson that Americans can learn from the Taiwanese example?

Dr. Hsiao.

You can have universal coverage and good quality health care while still managing to control costs. But you have to have a single-payer system to do it.

The Taiwan government managed to insure 98 percent of the population with a premium cost of 4.6 percent of wages.

Q.

Has your system of healthcare in Tiawan translated into better life expectancy or lower complication rates from major diseases?

Dr. Hsiao.

“There is evidence of positive health results for select diseases, like cardiovascular disease and kidney failure.”

There is no medical or financial data available to prove outcomes have improved.

“Overall, it’s really difficult to say that national health insurance has improved the aggregate health status, because mortality and life expectancy are crude measurements, not precise enough to pick up the impact of more health care.”

“That said, life expectancy is improving, and mortality is dropping. And everyone now has access to good health care”.

This is not good science. It is not even good social science. This is a biased opinion.

Q.

What are the system’s weaknesses?

Dr. Hsaio

“In the legislative process, compromises had to be made. First, the president yielded on payment reform, so Taiwan kept its fee-for-service payment system. Unfortunately, that encourages doctors and hospitals to give more treatment in order to boost their income.

“Second, the Taiwanese system doesn’t have a systematic way to monitor and improve quality of care.”

“Third, in the legislative process, they rejected a provision to adjust the premium automatically when the national health system depletes its reserves.”

“In every country, health care costs are increasing faster than wages. When that happens, the premium has to go up. But that provision wasn’t incorporated into the law. As a result, the system is running a deficit.”

“National health insurance tries to cut the fees for hospital and physician services. But eventually these fee reductions will adversely affect the quality of health care.”

President Obama was so anxious to change the healthcare system in the United States to fit his socialist ideology that he picked two professors, Dr. Hsaio of Harvard and Jonathan Gruber of MIT to be the architects of Obamacare.

Jonathan Gruber has been introduced as the ‘architect’ of the Massachusetts law and/or Obamacare”.[52]

Neither professor had scientific evidence that a single party payer system would work efficiently.

Obamacare was not working efficiently yet the progressives in Vermont hired Dr. Hsaio and Dr. Guber to be the architects for Vermont’s single party payer system.

Jonathon Gruber has turned out to be a honest about the Obama administration’s lies.

Many of the videos show him talking about ways in which he felt the ACA was misleadingly crafted or marketed in order to get the bill passed, while in some of the videos he specifically refers to American voters as ill-informed or “stupid”.

In October 2013, Gruber we said: “the bill was deliberately written “in a tortured way” to disguise the fact that it creates a system by which “healthy people pay in and sick people get money”.

Some of Americans are waking up to the fact that they cannot trust President Obama and his administration to be our surrogate. This is true not only in healthcare but in his decision making in every area of the economy and our live.

Gruber said this obfuscation was needed due to “the stupidity of the American voter” in ensuring the bill’s passage. Gruber said the bill’s inherent “lack of transparency is a huge political advantage” in selling it .[31]

 In 2010, Jonathan Gruber expressed doubts that the ACA would significantly reduce health care costs. He thought lowering costs played a major part in the way the bill was promoted by the Obama administration.[36]

President Obama said he never met Jonathan Gruber and did not think he came to the White House. President Obama forgot he hired him and paid him a $400,000 consultation fee.

In 2014, the Obama administration claimed that Gruber did not have a major role in creating the PPACA.[50]

President Obama acted irresponsibly to the public by hiring healthcare policy wonks to change America’s healthcare system without evidence for the success because their thoughts fit his ideology.

I don’t think President Obama understands he has changed the way hospitals and physicians have changed their approach to healthcare and medical care.

In my opinion, healthcare and medical care has changed for the worse.

Rich Lowry said that the videos were emblematic of “the progressive mind, which values complexity over simplicity, favors indirect taxes and impositions on the American public so their costs can be hidden, and has a dim view of the average American”.[41]

The American public eventually figures it out.

Commentator Charles Krauthammer called the first Gruber video “the ultimate vindication of the charge that Obamacare was sold on a pack of lies.”[42]

 The Vermont governor hired Dr. Hsaio and Dr. Gruber to create a single party payer system in Vermont figuring,the system would be easier in one small state than in the nation.

Vermont Governor Peter Shumlin (D.) announced that he was pulling the plug on his four-year quest to impose single-payer, government-run health care on the residents of his state.

“In my judgment,” said Shumlin at a press conference, “the potential economic disruption and risks would be too great to small businesses, working families, and the state’s economy.”

Watch out Colorado!

Why doesn’t a single party payer system work?

All of the healthcare policy wonks, especial Dr. Hsaio and Dr. Gruber, leave out the most important ingredients in a successful healthcare system.

Consumers cannot be treated as a commodity. Consumers cannot be forced to take what is given to them. The healthcare system must have a viable physician patient relationship provision.

The physician patient relationship is a big part of the therapeutic index. If treatment is to be successful patients must participate in their care.

Consumers of the healthcare system must drive the healthcare system. It must not be government or the healthcare insurance industry.

Consumers must be a the center of the healthcare system.

A system needs to be developed that puts patients in charge, not the government. Consumers must be responsible for their healthcare and their healthcare dollars.

This will motivate doctors and hospitals to compete for patients’ business.

My Ideal Medical Savings Account will provide incentives for the consumers to have a consumer driven healthcare system. This system will in turn drive hospital systems and physicians to compete for their care.

The end result will be to decrease the cost of the healthcare system and improve medical care and consumer satisfaction with the healthcare system.

 

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

 All Rights Reserved © 2006 – 2015 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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