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A More Logical Plan Than “Obamacare”

June 8, 2011
inConsumer Driven Health Care, Medicare, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE 

I do not think President Obama understands basic healthcare economics. Patients and physicians will always drive spending for healthcare. The government will not be able to control spending centrally.

Forty to sixty cents of every healthcare dollar is spent on administrative costs. CMS claims that Medicare spends only 2.5% on administrative services.  This 2.5% is the cost for CMS to outsource Medicare coverage to the healthcare insurance industry.

The healthcare insurance industry takes 40% to 60% of every healthcare dollar for their administrative fees. The law says they can only take 15% out of every dollar for administrative fees. Eighty five percent of the premium dollar must go to patient care. 

 The problem is the 85% includes many fees that are, in reality, administrative expenses such as certifying physicians for their plans and insurance sales fees among others. There is a profit margin for each of these “expenses.” President Obama has permitted these administrative fees to be included in the 85% category for direct healthcare costs.

Physicians get 15% and hospitals get 20% of every healthcare dollar. Where does the rest of the money go?

Forty percent gets taken off the top by the healthcare insurance industry. A good place to start is by setting up a system that creates competition among the healthcare insurance companies. 

The government always blames physicians for the waste. Physicians and patients drive healthcare expenses. Waste occurs as a result of perverse incentives and middlemen abuse. All the stakeholders are to blame. The healthcare insurance industry generates the most waste. Defensive medicine is the second leading cause of waste. Legislation using common sense could eliminate most of this waste.

"A 2005 report by the National Academy of Engineering and the Institute of Medicine found that 30-40 cents of every dollar spent on health care are spent on costs associated with "overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency. Medicare is especially vulnerable to waste, fraud and abuse.”

Medicare spending must be decreased. The best way to decrease the spending is to provide incentives for seniors to drive the system rather than the system driving seniors.

 “Unfortunately, the debate on Capitol Hill and in the media is too often fueled by partisan fear mongering instead of a thoughtful examination of the facts.” 

No amount of price cutting or central-government dictates will mitigate these problems.

A consumer (seniors) driven healthcare system providing incentives for providers and patients is the only way to fix the system.

Accountable Care Organizations (ACOs) are being proposed and organized to harness the spending of the fee for service systems.

ACOs are systems in which doctors and hospitals team up to offer coordinated care. Both are held accountable for cost and quality in a disguised capitation system. “Quality” is not effectively measured.

 Hospital systems and physicians have long had an adversarial relationship because hospital systems have leveraged its brick and motor value off the intellectual property and mechanical skills of physicians.

More and more physicians are realizing this fact. Physicians are building their own hospitals and outpatient surgical clinics. Physicians are consciously or unconsciously resistant to hospital systems dividing the money and participating in the reimbursement sharing judgments.

Neither group wants to be at risk for “poor outcomes” that might be the patients’ fault.

The incentives to form ACOs are too weak. The regulations are 400 pages too long and complicated.  Physicians do not have the time or money to fully understand the regulations.  “Trust me” does not work anymore.  The major hospital systems have backed out of forming ACOs under the regulations because they put the hospital system at too great a risk.

Paul Ryan’s plan of “premium support” can potentially encourage formation of Accountable Care Organizations The ACOs have to be attractive enough for patients to choose to join them. Hospital systems would have to be successful in organizing them.  Ryan’s plan is a “managed competition model.”  The government would make defined contributions for beneficiaries depending on the beneficiaries’ means. The subsidy would be a total subsidy for the poor and a sliding scale subsidy for others.

Beneficiaries would have a choice from a variety of health plans with no discrimination based on health status or wealth. Standard coverage contracts understandable by ordinary people would be required to make comparisons possible. Internet FAQs would be made available.

Competition for consumer (seniors) business would drive health plans to innovate in ways that would cut waste and improve “quality.” The use of well-designed healthcare insurance exchanges would drastically reduce healthcare insurance company marketing costs. The completion by healthcare insurance companies in effective healthcare insurance exchanges could result in healthcare insurance companies not taking 40% off top as they currently do. The system could be set up so that consumers could buy the insurance across state lines.

The Ryan plan does not deal with defensive medicine. States could easily be presented with an ideal tort reform model to adopt or modify. In Texas the model is not ideal but it is effective and would be effective nationally. If a model included a “loser pays” clause it would decrease frivolous law suits and decrease defensive medicine testing dramatically. In most instances physicians do not receive increased compensation for the increase in testing. Therefore the motivation is not testing simply to make more money.

President Obama needs to understand the basics of healthcare economics before he goes on and totally destroys the healthcare system.

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

 

 

 

 

 

 

 

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You Cannot Lead Without A Posse

May 28, 2011
inConsumer Driven Health Care, Disinformation and the healthcare system, Medicare, Medicine: Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

Paul Ryan has been one of a few Republicans that has demonstrated the belief in what is right rather than what is politically expedient. I thought the Republican caucus understood his budget plan and were behind it.

Republicans cannot talk about being fiscally responsible and act frightened.  They are acting frightened by  Democratic Party *“Demagoguery

It looks as if Paul Ryan has been left without a posse. The Republicans should be explaining what would happen if the status quo on the Medicare entitlement spending remained. They should be explaining how the Ryan plan will save entitlement from default.

The Democrats are not explaining how Paul Ryan’s Medicare plan will destroy Medicare.

Two important events occurred this week to further scare the Republican caucus from acting responsibly.

The first was the election of a Democrat in a traditional Republican stronghold in upper New York State.  The Democratic candidate used scare tactics saying the Ryan plan and hence the Republicans are going to destroy Medicare.  She never offered an explanation of how it would destroy Medicare. The Ryan plan is designed to save Medicare.

Neither the Republican candidate nor the Republican caucus stepped up to say why this is false. The Republican candidate deserved to lose. The Democrat won by default.

The second event this week was the Ryan Plan, which passed in the House, was defeated in the Senate. Worse is that six Republican Senators voted against the proposal without public explanation.

“Republicans voting against proceeding to the GOP proposal had raised concerns about the Medicare reform or other provisions – Sen. Scott Brown of Massachusetts, Sen. Lisa Murkowski of Alaska and Sens. Susan Collins and Olympia Snowe of Maine. Sen. Rand Paul of Kentucky said the proposal did not make steep enough cuts.”

Horrifying to me was the smirk on Harry Reid’s face as he pretended to be the savior of middle class seniors. Nothing could be further from the truth.

Reid
  

The truth is Medicare is unsustainable in its present state. There hasn’t been an economist or government agency that has disagreed. President Obama has ignored these predications in forcing the passage of his Healthcare Reform Act. Medicare will collapse and disappear.  There will be restricted access to care and rationed care.

Seniors must be empowered to be responsible for their own healthcare either independently or by the government. Consumers must drive a market driven healthcare system.  

Seniors can control the onset of the complications of their chronic disease. They can do it with early behavioral changes such as stopping smoking, stopping alcoholic intake, losing weight, exercising regularly and adhering to medical treatment regimes. The government cannot legislate changes in behavior. It can motivate and incentivize behavioral change.  

"Their Republican, radical proposal would end Medicare as we know it," said Sen. Patty Murray (D-Wash.), the chairwoman of the party's campaign committee. "We're not going to stop talking about this in states across the country."  

It is not funny. There is agreement that Medicare is not fiscally sound. Senator Patty Murray is saying Democrats do not want a fiscally unsound Medicare program to be changed.

Senator Patty Murray is saying in effect, Democrats, are going to beat the Republicans in 2012 because we are going to support this ongoing unsound Medicare program until it will bankrupt America.

Isn’t this an insult to the intelligence of the American people.  Democrats must really think Americans are stupid.

President Obama wants to win reelection. Obamacare is unpopular. He could lose on this issue alone. He is cleverly trying to distract Americans from his unpopular program and make Paul Ryan’s plan unpopular. He has no facts about any defects in Ryan’s plan. He is using scare tactics.

Paul Ryan has a different view. He thinks Americans are smart. Americans want an opportunity to be responsible for themselves. They do not trust government to make their healthcare decisions.

I believe Americans can understand complicated facts. The government has an obligation to today’s seniors and future seniors to put Medicare on a sound financial footing.

Paul Ryan’s You Tube of May 25th says it all. I know the American people can understand it. I hope the traditional media gives him and other Republican an opportunity to explain his plan.

I hope Republican politicians are not frightened away by the spin misters and their influence on polls.

Paul Ryan needs a posse!!

 



 

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

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Another Big Idea

April 20, 2011
inChronic Disese Management, Consumer Driven Health Care, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

President Obama refuses to listen to this big idea. He is not focused on the real problems in the healthcare system.

A healthcare cost saving of at least $800 billion dollars a year would occur if the complications of chronic disease could be decreased by 50%.  It could occur if he concentrated on changing the culture from medicine’s job is to fix disease to society’s job is to prevent disease. Patients must also learn to be responsible for the self-management of their chronic disease.

The healthcare system is dysfunctional. President Obama’s Healthcare Reform Act will not fix this dysfunction. It is making it worse. He is ignoring many of the real causes of the inefficiencies in the healthcare system. 

The question is who is at fault? All the stakeholders are at fault. The stakeholders are the healthcare insurance industry, the government, the hospital systems, the physicians and most importantly, the patients.

President Obama is ignoring the patient’s role and responsibility in the inefficiency of the healthcare system. He is focusing exclusively on the physician’s role.

Once President Obama is successful in making medical care a commodity the patient-physician relationship will be destroyed. The patient –physician relationship accounts for a large part of the therapeutic effect of a treatment.

The primary stakeholders are patients with physicians. Without patients or physicians we would not have a healthcare system. Healthcare insurance companies, the government, and hospitals are secondary stakeholders. President Obama focus will increase the benefits of the healthcare system to the secondary stakeholders and not to patients.

The healthcare insurance industry has turned out to be the biggest villain . It has taken advantage of the dysfunction of the government and weakness of patients and physicians as lobbying groups. The healthcare industry takes sixty cents out of every healthcare dollar spent by Medicare, Medicaid and private insurance. President Obama’s Healthcare Reform Act’s rules and regulations do not deal with the healthcare industry control over these healthcare dollars.  It has yielded to every demand by the healthcare insurance industry.

The healthcare insurance industry is abusing its power. It has manipulated congress and the administration to serve its own vested interest.

The result is grotesque salaries for executives and excessive administrative fees. Our healthcare system is supposed to be for the benefit of the consumers (patients), not for the benefit of the healthcare insurance industry.

The healthcare industry has restricted access to care. It has decreased physicians’ reimbursement and withheld payments for services rendered without explanation or justification.

The government outsources the administration of Medicare and Medicaid to the healthcare insurance industry.  

There are many examples of healthcare insurance industry abuse of the healthcare system. Medicare Part D provides an excellent example. Medicare Part D fees for 2011 increased once again with the consent of the government. These new fees are abusive to seniors. It is difficult to understand why government regulars do not defend seniors.

Seniors on fixed incomes need a reliable drug coverage plan. The healthcare insurance industry lobbied for four years to get a drug plan passed that would be to its advantage at the expense of the government and seniors.

The government subsidizes Medicare Part D. Yet the government cannot negotiate drug prices. The abuses are the result of high deductibles and a doughnut hole that does not provide drug coverage between $2,700 and $5200 dollar spent. Prices are rigged so a patient can find himself in the doughnut hole in a hurry.

Humana and United Healthcare rushed to insure seniors under Medicare Part D. They visualized the money making opportunity quicker than most of the other healthcare insurance companies.

Both companies also realized that as healthcare insurance premiums increased in the private sector there would be more uninsured consumers. The less lives covered the lower its profit. Therefore a drug plan leveraged in their favor sponsored by the government would cover the decrease in profit in the private sector.

United Healthcare paid AARP over 4 billion dollars to be their exclusive carrier for AARP senior members. There is no shortage of complaining from AARP’s seniors. The payment to AARP for sponsorship has not been fully disclosed nor its ethics been investigated.

United Healthcare made a profit of $4.7 billion dollars last year from Medicare Part D at patients at the government’s expense. Despite this enormous profit the Medicare regulator have permitted United Healthcare to increase the premiums each of the last five years.  

On careful analysis seniors are being ripped off. In response seniors have flocked to Wal-Mart and others to buy $4.00 per month generics drugs. They pay cash and avoid using brand name drugs. Their goal is to avoid the Medicare Part D doughnut.

If seniors used Medicare Part D, their co-pay would be $6.00 for a month’s supply of medication rather the $4.00 paying cash at Wal-Mart. The doughnut could be charged between $20 and $50.  The healthcare insurance company would probably only pay Wal-Mart $4.00. None of these price manipulations are transparent or restricted. Seniors are the losers.

Medicare Part D is a good place to start to understand the abuse of this non-transparent system. President Obama is making a big deal of his token changes to Medicare Part D. His changes are not significant.

Similar abuses occur with government outsourcing Medicare Part A and B.

There is a tremendous waste of government and consumer resources. Real price transparency is essential if there is going to be any progress in reducing the cost of the healthcare system.

What do I mean by real price transparency? It means knowing,

  1. The cost of the drug to the pharmacy.
  2. The cost of the drug to the healthcare insurance company.
  3. The price of the drug calculated toward the doughnut.
  4. The government subsidy for the cost of the drug to the healthcare insurance industry for administration of the program.
  5. The profit for the healthcare insurance industry.

If real price transparency occurred, we would be able to have a competitive pricing system.

The administration is busy penalizing patients with decreased access to care and physicians with decreased reimbursement to decrease healthcare costs. It should focus on the real villain in the healthcare system, the healthcare insurance industry.

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

 

 

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Obama Will Ration Health Care! Wake Up America: Part 3

January 28, 2009
inConsumer Driven Health Care, Healthcare Insurance Industry, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System
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Stanley Feld M.D., FACP, MACE

 

Dr. Tom Price, a Republican member of Congress from Georgia, the new chairman of the Republican Study Committee wrote an article in the Wall Street Journal that mimics my proposal for repairing the healthcare system. Someone should start listening to physicians.

During the last eight years the Republican Party has had a great opportunity to repair the healthcare system. I believe many Republicans in the House and Senate know what needs to be done. No one has taken a leadership position to do.

Now we have leadership that wants to do the right thing. Unfortunately the present leadership does not know the right way to do the right thing.

Consumer driven healthcare with the consumers owning their healthcare dollar is the way to repair the healthcare system. Personal responsibility for one’s health has been labeled conservative idea.

The concept is neither right wing nor left wing. It is simply logical. Self responsibility is the engine of American progress. Very bright liberal thinkers have advocated self responsibility. President Obama strikes me as one who can solve problems using logic and not right or left wing ideology.

I have pointed out the therapeutic magic of positive physician patient relationships. The government’s goal should be to nurture these relationships. It should provide a system that allows access to affordable, quality health care for all Americans. It should not nurture government dependency. It should also ensure that medical decisions are made in doctors’ offices, not in Washington or some by “independent “board (Federal Health Advisory Board) removed from the bedside. It should help educate both patients and physicians about best practices of medicine. Patients should make the decisions for their healthcare.

Dr. Price points out; “Atop the list of worrisome ideas proposed by Mr. Daschle is the creation of an innocently termed "Federal Health Advisory Board." (FHAB)

“This board would offer recommendations to private insurers and create a single standard of care for all public programs, including which procedures doctors may perform, which drugs patients may take, and how many diagnostic machines hospitals really need. As with Medicare, for any care provided outside the board’s guidelines, patients and physicians would not be reimbursed.”

All the stakeholders have been villains in the never ending escalation of costs to the healthcare system. I have blamed the healthcare insurance industry for being the worst villain. Its administrative service cost and waste as well as inflated overhead and excess executive compensation add 150 billion dollars to the healthcare system. It has lead to unaffordable premium costs, increased deductibles and co-pays, decreased patient access to care as well decreased reimbursement to physicians and hospitals. The reason everyone is “gaming” the system is the system reimburses waste and penalizes best practices. .

As Winston Churchill once said; “ Never has so much been paid to so many for so little” in the way of value added service to patient care.

I am presently reading John Bogles book “Enough”. In his book he describes the reason for rise and the fall of the financial sector. He could easily substitute the healthcare sector for the financial sector.

“That any endeavor that extract value from its clients may, in times more troubled than these, find that it has been hoist by its own petard”- proved not only eerily prophetic, but surprisingly timely. The industry has been blown up by its own dynamite.”

I said it less well when I said the healthcare insurance industry is killing the goose that laid its golden egg.

Tom Daschle has stated that the FHAB’s standards would serve only as a suggestion to the private market. Dr. Price points out the impeding results of Tom Daschle’s proposal.

“He has proposed making the employer tax deduction for providing health insurance dependent on compliance with the board’s standards.

In an overtly political ruse, Democrats will claim they are dictating nothing to private providers, while whipping noncompliant insurers in place through the tax code.”

“To be sure, this strategy seeks to eliminate private providers completely. Forced into accepting rigid Washington rules and unsustainable financing mechanisms under Mr. Daschle’s plan, most private insurers would be quickly eradicated.”

I believe the healthcare insurance industry has resigned itself to this faith. It is focusing on generating its income as an outsourced administrative service provider for the government’s massive new healthcare federal bureaucracy. The healthcare insurance industry has done very well with the Medicare Advantage programs and Medicare Part D. They have also done very well in the state of Massachusetts. It is making excess amounts of money under government sanction by controlling the healthcare dollar.

Who losses? The primary stakeholders lose (Patients and Physicians). The government also loses because it has formed another inefficient bureaucracy. America cannot afford Medicare in its present form much less expand it.

Dr. Price goes on to say; “This patient-centered approach must be built upon two pillars: access to coverage for all Americans and coverage that is truly owned by patients.”

“Through positive changes in the tax code we can make health-care cost effective and create incentives so there is no reason to be uninsured. This way, care is purchased without government interference between you and your doctor.”

Consumer driven healthcare using an ideal Medical Savings Account is a healthcare system that will be able to align all the stakeholders’ vested interests.

I expect a great debate to start shortly.

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

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You Can’t Change The Practice Of Medicine With Demand-Side Reforms. Let Us Put An End To Pay For Performance (P4P) Initiatives: Part 1

January 25, 2009
inChronic Disese Management, Consumer Driven Health Care, Medicare, Medicine: Healthcare System, Pay for Performance (P4P), Quality medical care measures, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

I
have pointed out the folly of P4P initiatives as a methodology for improving the
quality of medical care.  Quality
medical care has not been adequately defined. One definition could be to
maintain health at the lowest cost. Physicians have classically been trained to
fix things that are broken. The paradigm shift has been to prevent things from
becoming broken.

Prevention
is a two way street. It is the  patient who needs to prevent disease from
occurring. It is the physician who must teach the patient how to prevent disease
and its complications.

Punitive
measures will not encourage behavior change. The economist, John Goodman,
stated: “You
can't change the practice of medicine with demand-side reforms.”  I have
said repeatedly it can only be changed with innovative and incentive driven
education for both patients and physicians. This will lead to behavior change
and a true increase in quality of care.

Quality medical care should not be judged on what tests are done for a
particular chronic disease in a given year. It should be judged on the basis of
maintenance of health of a patient with chronic disease. It should be evaluated
as a dual responsibility of both the patient and physician. If there is going to
be an increase reimbursement for performance, performance has to be judged
correctly and both physician and patient should be rewarded.

Quality medical care should be judged on the maintenance of health and
avoidance of the complications of chronic disease. The treatment of the
complications of chronic disease utilizes 80% of the healthcare dollar. If
complications of chronic disease are avoided the costs to the healthcare system
costs would be decreased to manageable levels and Americans would be healthier. 

Several readers have challenged me on the use of the term “socialized
medicine”. One reader said “our healthcare system is socialized already. The
government through Medicare and Medicaid controls 40% of the expenditures for
healthcare.” This is true.

The term “ socialized
medicine” has been demonized. I believe most physicians’ and patients’
objection to “socialized medicine” is rooted in experiences they have had. It
has restricted access to care and freedom of choice, and it has dictated
permissible care of physicians. It has also produced an added layer of
inefficient bureaucracy.

Medicare
premiums for patients are becoming expensive. The premium is determined by
means testing. It can be as high as $14,000 per year. The government subsidizes
that amount with an additional $6,600.  Medicare advantage costs the government
over $9,000 extra.  Yet there is a decrease in access to care as the costs of
the system are spinning out of control. 

The government has its heart in the right place in wanting to provide
universal care. Americans should have access to healthcare coverage. A few
changes in the tax rules can solve many problems. The self-employed should be
able to purchase healthcare insurance with the same pre tax dollars as
businesses. They should have the same negotiated price structure large companies
have. The self-employed should have the same guaranteed  insurability as those
working in a large company without a premium penalty.

The healthcare system’s costs rise each year. The Medicare premiums rise each
year and patient’s out of pocket expenses rise each year. Medicare is going to
bankrupt the country. It will only be accelerated by putting everyone on
Medicare.

In order to reign in expenses someone came up with the idea of pay for
performance. It is a reasonable concept if a system could be devised that could
evaluate performance accurately and encourage improvement.

In order to test validity of any concept the government subsidizes
initiatives at a great expense. These initiatives are costly because of the
bureaucratic evaluation of the requests for proposals and the measurement
mechanism. 

The list of government initiatives is long. The pilot studies are 3 to 5
years. There have been many cost overruns so that several outsourced study
vendors are dropping out of the management of the initiatives. Most initiatives
have been unsuccessful in proving cost savings.

The reason for lack of proof of cost saving to the healthcare system is
because of errors in design. The wrong questions are being asked and the imposed
bureaucracy is punitive to the healthcare entities. Below are initiatives that
are presently funded for pay for performance.

MEDICARE "PAY FOR PERFORMANCE (P4P)" INITIATIVES

“Medicare has various initiatives to encourage improved quality of care in
all health care settings where Medicare beneficiaries receive their health care
services, including physicians’ offices and ambulatory care facilities,
hospitals, nursing homes, home health care agencies and dialysis
facilities.”

HOSPITALS

1. Hospital Quality Initiative   (MMA section 501(b))

2. Premier Hospital Quality Incentive Demonstration

PHYSICIANS OR INTEGRATED HEALTH SYSTEMS

1. Physician Group Practice Demonstration (BIPA 2000)

2. Medicare Care Management Performance Demonstration (MMA section
649)

3. Medicare Health Care Quality Demonstration (MMA section 646)

DISEASE MANAGEMENT/CHRONIC CARE IMPROVEMENT

Chronic Care Improvement Program (MMA section 721)

ESRD Disease Management Demonstration (MMA section 623)

Disease Management Demonstration for Severely Chronically Ill Medicare
Beneficiaries (BIPA 2000)

Disease Management Demonstration for Chronically Ill Dual Eligible
Beneficiaries

Care Management For High Cost Beneficiaries

So far the chronic disease management initiative have not been proven to save
money.

The pilot initiatives are not directed by physician in private practice.
Physicians are the stakeholders that will make these initiatives work.  Nine
sites selected are either healthcare insurance companies or disease management
groups. Disease management groups can be successful facilitators of physician
care only if they are extensions of physicians care rather than physician
substitutes.

Help desks of the healthcare insurance companies do not work because they are
not an extension of the physicians care. Free standing chronic disease
management clinics do not work because they are not extensions of physicians
care. Many hospitals have tried to set up Diabetes Education Centers only to
have them close because physicians do not refer patients to the centers. The
center is not reimbursed adequately by the government or private insurers to be
profitable. The fees charged in hospitals are at least twice as much as the fees
the physicians charges. Once the physician knows the charges he is even more
hesitant to send the patients to the centers.

The following are the groups selected for the pilot phase: Humana in South
and Central Florida, XLHealth in Tennessee, Aetna in Illinois, LifeMasters in
Oklahoma, McKesson in Mississippi, CIGNA in Georgia, Health Dialog in
Pennsylvania, American Healthways in Washington, DC and Maryland, and Visiting
Nurse Service of NY and United Healthcare in Queens and Brooklyn, New York.

I believe we should give up on trying to produce a pay for performance system
that will reduce medical costs. The health policy wonks should concentrate on
something that will work.

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

  • Call CareNet • April 20, 2009

    I have always gone to Call a Nurse for all of my health concerns. Whenever I have a question I call Call a Nurse and they are always very polite and knowledgeable.

  • Rhinoplasty Beverly Hills • May 28, 2010

    This is quite a comprehensive and interesting posting on the approach to put an end to the system of Pay for Performance Initiatives. This approach may turn out to be effective in the end.

  • •••
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The Therapeutic Magic Of The Physician Patient Relationship: Part 1

December 22, 2008
inConsumer Driven Health Care, Innovations in Healthcare, Stakeholder Mistrust
• Leave a comment

 

Stanley Feld M.D.,FACP,MACE

A positive physician patient relationship has magical therapeutic powers.

I believe I can best describe it with two very difference personal experiences.

Both are reminiscences of events that occurred long before I was a physician. Both gave me incite into the power of a physician patient relationship and stimulated my desire to be a doctor. One experience was doctor related, the other was teacher related.

During 30 years in private practice as a clinical endocrinologist I always tried to treat my patients remembering the therapeutic effect of those experiences. Those experiences had magnificent healing powers for me.

The first episode occurred when I was a first grader in the Bronx. The year was 1946. In those days being left handed was thought to be a curse. My first grade teacher forced me to write with my right hand to avoid the destiny of the curse. I remember the difficulty I had writing with my right hand. I was forced to persist. I made many mistakes and had great difficulty learning to do anything academically.

I had difficulty learning anything new, especially reading and arithmetic. I thought I was a pretty smart kid. My impression was confirmed by my father when he continually told me I was a smart kid. I was told not to listen to my teacher’s impression of me.

I was never a difficult child at home but something agitated me in school. I remember being a difficult first grader. My teacher considered me a trouble maker. She did not understand why I did certain things.

Finally, my teacher called my mother in for a conference. I was forced to listen to the conference. The teacher told my mother she was positive I was a disturbed child and needed psychiatric attention. I was behind in reading, writing and arithmetic and was not adjusting socially. She told my mother she should act immediately before I was permanently damaged. She said if this continued I could be expelled from school.

My mother was beside herself. She did not know what to do. I felt her anxiety but did not know what to say. I did not know what a psychiatrist was. I was told we could not afford a psychiatrist. I thought the solution to my problem was to be allowed to write with my left hand. No one would listen to me. Everyone, including my parents believed that left handed people were cursed.

My father’s boss suggested we go to Dr. Schultz, a family practice doctor, in the West Bronx. I remember the look of Dr. Schultz’s street. It was tree lined with two rows of attached single family houses with and concrete steps. We lived in a 4 room apartment in a walkup apartment building on Bristol Street across the street from the Boston Post Road movie theater.

The first room we entered was a living room with couches used as a reception area. At six years old I was impressed and terrified. My mother was just terrified.

Dr. Shultz’s office had a desk, a few chairs and a mirror behind the desk. He asked my mother what was wrong. She repeated the teacher’s report almost verbatim. He asked some detailed medical history and took notes. When he finished he turned to me and asked me what I thought was wrong.

This is the first time anyone had asked me to express my opinion. He saw I was nervous and frightened. He calmed me down and told me usually the patient can tell him what is wrong if the patient is given a chance to express himself.

I told him that the teacher made me write with my right hand because left handed people were cursed. He said he heard that was a common superstition but there was no proof it was true. He then asked me to write my name and my brother’s name on a piece of paper with both my right and left hand. I did and he said “son, there is nothing wrong with you.”

My mother looked in disbelief. He then picked up the paper and showed it to my mother. She still did not understand. He then put the piece of paper in front of the mirror. My right handed entry was legible now and the left handed writing which was legible at first was now backward. I was mirror writing.

He told my mother that that problem was the result of the strain put on me being forced to write right handed. After I was permitted to write left handed for a while my ability to write, read and do arithmetic would straighten out. My behavior problems would also vanish. He suggested that my mother listen to my complaints in the future. He wrote a note to the teacher ordering her to let me write with my left hand.

Then he got up from his chair, came over to me and gave me a big hug. He also told me to show everyone they were wrong about me. I felt like a million bucks. All the tension left my body. I felt I could achieve anything.

There is no question in my mind that this approach to medical care and the therapeutic effect of the positive physician patient relationship saved my academic life.

The pressures on physicians today to see more patients, to test for everything so you do not miss a diagnosis, the lack of reimbursement for cognitive therapy, the constant threat of financial penalties and continuous assault on physicians’ judgment has served to decrease the ability of physicians to relate in a human way.

“There is considerable healing power in the physician-patient alliance. A patient who entrusts himself to a physician’s care creates ethical obligations that are definite and weighty. Working together, the potential exists to pursue interventions that can significantly improve the patient’s quality of life and health status. “

The simple way to put it is medical care has and is being commoditized and dehumanized. These attributes are the common denominator to patients’ complaints about the medical care system in 2008. I cannot justify or condone physicians’ behavior.

Our healthcare system has to change. It must support the humanizing elements or the patient physician relationship. It has to nurture mutual trust rather than distrust between patients and physicians. A healthcare system that supports distrust, physician and patient penalties and adversarial interrelationships does not permit this princely profession to offer the kind of care physicians are capable of.

President-elect Obama and Tom Daschle imposing more bureaucratic controls on the healthcare system is not the answer. It is clear to me that the consumers and their needs must drive us back to a more humanized system.

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The Role Of Government In Healthcare

October 5, 2008
inConsumer Driven Health Care, Health Savings Accounts vs Medical Savings Accounts, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests
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Stanley Feld M.D.,FACP,MACE

I believe in the power of the free market if the rules are fair to all.  Logic and common sense should determine healthcare policy. I am suspicious of the validity of pilot studies designed to test healthcare policy initiatives. The studies usually are defective in their design. 

The rules of the free market in healthcare should be in favor of the consumer driven healthcare model . Physicians will listen to patients if the patients control the healthcare dollar. The primary stakeholders (patients) should own their healthcare dollar and their employer should continue to pay for the healthcare benefit. The healthcare insurance industry should not be in control of the healthcare dollar.

The proposed healthcare reforms of both presidential candidates cannot work because the healthcare insurance industry  controls the healthcare dollar and therefore the healthcare system.

Neither Presidential candidate has a chance at constructive healthcare reform.

In order for America’s economy to grow and prosper, America must promote the growth of a strong working middle class. A nation without a strong middle class having an opportunity to enjoy upward mobility is a nation that is stagnating and on the way to bankruptcy. The middle class has experienced a lack of growth lately because they have been disadvantaged to the benefit of the wealthy. They have been disadvantaged in healthcare, housing, finance, education and other social systems that have been declared broken.  Our artificial free market economies have rules that promotes the growth of narrow vested interests and stimulates greed.

The middle class must have the opportunity be educated. It must be provided with incentives to be innovative. It must have affordable healthcare and housing. These incentives must be available for all Americans. Education and health are our most valuable assets. America must develop a cultural atmosphere to encouraged citizens to practice civic and self responsibility. The environment must be free of pollution to protect citizens from disease and illness. The air that we breathe and the food that we eat must not be influenced by the greed of special vested interests.

In recent weeks we have experienced bailout proposals for our financial system.  The proposal initially ignored the protection of the middle class. In my view the first draft of the Bush bailout proposal was an insult to America’s intelligence. It favored special vested interests and furthered citizen mistrust of the federal government. The terms of the initial bailout were for the protection of Wall Street and not the protection of Main Street. The protection of Wall Street was supposed to trickle down to Main Street. The final agreement will hopefully have protections for Main Street  as well as Wall Street with no pork. These dual protections should have been embodied in the initial proposal. We should not reward corporate executives’ failure.

I have written to both John McCain and Barack Obama about my thoughts on Repairing the Healthcare System. All I have gotten back is pleas from both campaigns requesting donations. My input has as many other citizens’ input been ignored by both campaigns.

The media has characterized the presidential campaign and debates as a boxing match. The media count who outscored who on points. I hear platitudes but no specific proposals on how to protect the middle class.

I hear John McCain say he is going to fight and fight hard for the middle class as he has done for 28 years. The few specific proposals he has presented protect wealthy vested interests.

Barack Obama says he is going to look after the middle class at the expense of the vested interested  high wage earners and investors. He does not tell us how he is going to go about it.

John McCain says he is opposed to regulations yet deregulation has gotten us in the position we are in. He reversed himself at twhen it was obvious our economy was about to collapse. A few days earlier he said our economy was basically sound. He did not project the perception of knowledge of economics to America. 

It sounds like Barack Obama wants to fix everything with regulations.  We have seen historically that regulating everything does not work. A simple example is the failure and perverse effects of price controls. A true market economy works if the correct rules are in place for the benefit of all. I am against government regulations that are oppressive to incentives and innovation.

Our legal system is also broken. It is not easy to enforce the law. Corporations, organizations, and citizens get around the law if they can afford the legal expense at the expense of the middle class. There is little penalty for misrepresentation. Congress is controlled by lobbying groups. Who are the peoples’ lobbying groups? The congress should be the lobbying group for the all citizens. Instead, Congress is lobbied and influenced by vested interests.

Government should make and enforce appropriate and fair rules. It should get out of the way and let consumers drive the system. Americans are smart enough to purchase the best products for themselves given the appropriate information. 

I have criticized the healthcare insurance industry. John McCain wants to give the control of the institutions of Medicare and Medicaid to the healthcare insurance industry in order to eliminate this entitlement. The healthcare insurance industry does nothing for the middle class and small businesses and everything for its own bottom line. Obscene healthcare insurance executives’ salaries and corrupt payoffs occur at the expense of ordinary people.

Once again, it is healthcare insurance contract time for hospital systems and employers paying for healthcare insurance. Again, there have been examples of difficulty between the healthcare insurance industry, hospitals physicians and employers. Once again Unitedhealthcare  is using the same tactics they used in the Denver market last year. Neither Congress nor the State Insurance Boards have taken action to protect the middle class.

 

The headline in the Kansas City Star reported that ”

“St. Luke’s Hospital system in Kansas City and UnitedHealthcare go their separate ways as the price of healthcare insurance goes up and the coverage goes down.”

“In July, after a year and a half of trying to come to agreement, the nonprofit St. Luke’s — which encompasses 11 hospitals and several physician practices in the region — said it was done negotiating and would stop accepting United benefits after Feb. 28, 2009”

“St. Luke’s perspective, negotiations had been going on for a year and a half without significant progress. It announced a firm split with United in July so patients and businesses would have ample time to find new coverage if they wanted to stay in St. Luke’s network

“Bonner, who is senior vice president of business development for St. Luke’s, said the increase the hospital asked for would have brought reimbursement rates from United in line with other insurance carriers.”

I suspect both are wrong. I suspect the negotiating tactic UnitedHealthcare uses is the same used in Denver. They yield when they start losing subscribers.

United, which has 504,000 “members” in northwest Missouri and all of Kansas, would continue negotiating if St. Luke’s came back to the table, Tracy said, but he admitted reconciliation is highly unlikely.”

“United’s insurance-carrier competitors said they are seeing a windfall. Since St. Luke’s announcement this summer, Humana has been writing about 40 policies a month for companies leaving United, said David Miller, president of Humana in Kansas and Missouri.”

The losers are the middle class who would buy insurance if they could afford the premiums. The State Insurance boards must develop and enforce real  transparency rules for the healthcare insurance industry. If the rules are not followed the healthcare insurance company should lose its license to sell insurance in the state.  The rules must be made and enforced by the insurance board and state hospital boards before negotiation comes to this point. Presently, there is no simple mechanism for adjudications. State boards of insurance and hospital systems’ mandates must have effective consumer protection.

Patients are not included in the free market determination of price. They are the victims of a market price controlled by the healthcare insurance industry (secondary stakeholders).

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Stinkin’ Thinkin’ Part 2 Health Costs: More Cost Burden on the Employee

September 24, 2008
inConsumer Driven Health Care, Disinformation and the healthcare system, Health Savings Accounts vs Medical Savings Accounts, Healthcare Insurance Industry, Politicians,Healthcare and Vested Interests
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Stanley Feld M.D., FACP, MACE  

Sound Bytes are deceiving. The Republican Party’s Presidential candidate, Republican Party politicians, and Republican policy wonks have often quoted reports that health care costs are expected to ease slightly for employers in 2009. There is deception in this fact. The overall decrease in healthcare costs for businesses is the result of its shifting the burden of costs to their employees. The result is a decrease in cost for the employers nationally. Therefore the sound byte is inaccurate. The cost of healthcare actually will rise 5.7% for the employers. This represents a decrease from last years rise of 6.1%. The direct costs to the consumer increases 29% next year. Once again, the devil is in the details. We can not rely on sound bytes.  The healthcare insurance industry triumphs again.  The result will be an increase in healthcare insurance industry net profits.   

 

 

What does all this mean in the present Presidential campaign?  Why are healthcare insurance premiums increasing when the provider reimbursement is decreasing? Why is the burden of the cost of healthcare insurance shifting to patients away from the government and the employers? President Bush and a McCain presidency’s goal is to shift the burden of healthcare costs to the employee. Is this going to improve the uninsured problem? No! It will make it worse.

It looks like the healthcare insurance industry is killing the goose that lays its golden egg. It looks like John McCain wants to help the healthcare insurance industry accomplish this feat without either of them realizing it.  It will happen at the expense of the consumer until the consumer cannot tolerate it any more.

It also looks like John McCain’s policy of more of the same is helping Barack Obama and the Democratic Party justify universal healthcare coverage by a single party payer. An equally disasterous strategy. Where are the principles that have made America great? All politicians should be forced to read Adam Smith’s “Wealth of Nations“.

Dick Swersy’s comment on my blog about the Nobel Prize winning technique to repair the healthcare system is noteworthy.   Mechanism Design to Repair the Healthcare  is the art and science of designing rules of a game to achieve a specific outcome, even though each participant may be self-interested. This is done by setting up a structure in which each player has an incentive to behave as the designer intends. The game will then implement the desired outcome. The strength of such a result depends on the solution concepts used in the game. 

Mechanism designers commonly try to achieve the following basic outcomes: truthfulness, individual rationality, budget balance, and social welfare. However, it is impossible to guarantee optimal results for all four outcomes simultaneously in many situations, particularly in markets where buyers can also be sellers. Significant research in mechanism design must decide on making trade-offs between these qualities and vested interests. The most desirable outcome in the healthcare system should be sustaining patients’ welfare and physicians’ incentives for innovations in care. These goals will strengthen our healthcare system not weaken it.

Our Presidential candidates are not thinking of these goal as they formulate programs to sustain the goals of the secondary stakeholders. How can you create affordable insurance when coverage decreases, deductibles increase, and the price decreases are defined by increasing the price 5.7% vs. 6.1% a year. It is a charade designed to fool Americans. The charade works because Americans are not paying attention to what is going on. We will complain when it is too late.

“America is at its most powerful and most influential when it is combing innovation and inspiration, wealth building and dignity building, the quest for big profits and the tackling of big problems. When we do just one, we are less than the sum of our parts. When we do both, we are greater than the sum of our parts- much greater” Thomas Friedman

  Our Presidential candidate are way off base. It is up to the people to pay attention and force  politicians to stop their Stinkin Thinkin.

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

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