Stanley Feld M.D., FACP, MACE Menu

Consumer Driven Health Care

Permalink:

Social Engineering

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

$3 Trillion And Rising

Stanley Feld M.D.,FACP, MACE

The Obama administration is spending money on Obamacare like a drunken sailor. It has no respite for the budget deficit. Paul Krugman even said deficit spending is not a problem.

The deficit could almost be justified if there was a possibility that Obamacare could work.

If Obamacare could provide universal healthcare at an affordable price, increase the efficiency and quality of care, and align all the stakeholders’ interests the increasing deficit caused could almost be justified.

Obamacare can’t work. Its business model is just accelerating the path to the total collapse of the healthcare system.

The dysfunction and inefficiencies didn’t happen overnight. It started when the government set up its bureaucracy for Medicare in 1965 and has gotten worse as progressives tried to adjust to the unintended consequences and rising costs.

Obamacare has accelerated the path toward total collapse of the healthcare system. It has caused more rules and regulations. The increase in bureaucracy leads to more inefficiency and increasing adjustments by providers to make the defective business model work for their vested interests rather than the patients’ vested interests..

Little tweaks to fix the healthcare system have lead to unintended consequences, greater dysfunction and higher costs.

In 2010 with the passage of Obamacare, bureaucracy increased. Businesses have invested great deals of money to adjust to new regulations imposed by Obamacare.

David Brooks said on the PBS News Hour on January 8, 2016 that Obamacare cannot be repealed because it was embedded in the business model of too many healthcare businesses.

I thought healthcare reform was dedicated to the proposition of providing universal healthcare and improved healthcare at an affordable price to patients.

In the last two years there has not been an increase in the number of new patients insured in the Federal Health Exchanges.

There has been an increase in the number of Medicaid patients insured. However, Medicaid provides such poor insurance reimbursement that few physicians participate.

The few physicians who do participate have to see many patients a day using many physician assistants. “These Medicaid Physicians” are frequently accused of running “Medicaid Mills.”

The physicians are accused of corruption and gaming the system. Then they come under federal investigation. Some of these physicians are corrupt but most aren’t.

David Brooks is drinking the Kool Add of the progressives and President Obama. He stated that Obamacare is now embedded in the fabric of our culture.

None of the stakeholders are having any fun. I believe everyone would jump at being given a viable alternative. The viable alterative is not a single party payer system.

Countries which have a single party payer system are working hard to avoid bankruptcy.

All one has to do is read Canada’s Fraser Institute Report.

Obamacare is an entitlement. It does not promote consumer responsibility for their care or healthcare dollars.

There is a better way. The Republican political establishment just refuses to listen. The Democratic establishment continues to make fun of the Republican establishment for not having an alternative.

Meanwhile all of the stakeholders, including the government, are experiencing increased pain.

Last month government officials announce that healthcare spending in the United States was 3 trillion dollars or an average of $9,500 a person.

A soon as the figure was announced the Obama administration’s spin machine got started with disinformation about the 3 trillion dollars.

The New York Times continues to report that Obamacare is working. The logic used is America has had a lower growth in healthcare spending in the last five years.

The New York Times completely ignores the fact that healthcare taxes have increased yearly over the last five years while Obamacare healthcare coverage has only been in effect for two years since 2014.

The spending curve for every aspect of healthcare experienced a sharp upturn in 2014.

The Obama administration is trying to blame the upturn on drug prices. Drug prices are partly to blame increase in cost. If one digs deeper it will be seen as a small part of the cost increase.

The increase cost is due to the accelerated dysfunction caused by Obamacare.

“Health spending in the United States last year topped $3 trillion — an average of $9,500 a person — as five years of exceptionally slow growth gave way to the Affordable Care Act’s expansion of Medicaid and private insurance coverage, and as prescription drug prices resumed their sharp climbs, the government said Wednesday.”

Only a few of the major provisions in the Affordable Care Act (Obamacare) took effect in 2014.

What is going to happen when all of the major provisions of Obamacare take effect?

“Total spending on health care increased 5.3 percent last year(2014), the biggest jump since 2007, and accounted for 17.5 percent of the nation’s economic output, up from 17.3 percent in 2013, the Department of Health and Human Services said in its annual report on spending trends.”

 “By contrast, health spending grew 2.9 percent in 2013, the lowest rate of increase since the federal government began tracking it in 1960.”

2013 was three years into increased Obamacare healthcare taxes that affect all taxpayers including those that make less than $250,000,000 per year.

The people making less than $250,000/year were promised they would not spend one dime more for Obamacare.

I believe many American are aware of the mind games the Obama administration has played on them and are ready for an alternative that is a consumer centered and consumer driven system with them being in control of their health and healthcare dollars.

Republicans should at least offer the public a choice of My Ideal Medical Saving Account.

 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

 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

ACOs Are Failing

Stanley Feld M.D.,FACP,MACE

A major component of Obamacare is the development of functioning Accountable Care Organizations (ACOs). The theoretically the ACO concept is good. The practical execution of ACOs is very difficult.

The way the bureaucrats in the government wrote the rules and regulations for executing ACOs make them almost impossible to execute.

The inevitable failure of ACOs was further guaranteed by the complicated reimbursement rules created by Medicare’s bureaucrats.

The goal was to create integrated health care systems that would efficiently deliver quality medical care at a lower cost.

ACOs are one part of this Administration’s vision for improving the coordination and integration of care received by Medicare beneficiaries.

ACOs are groups of doctors, hospitals, and other health care providers that work together to give Medicare beneficiaries in Original Medicare (fee-for-service) high quality, coordinated care.

ACOs can share in any savings they generate for Medicare, if they meet specified quality targets.”

Defining quality care is a problem. Another problem is designing systems to execute quality care. To date no one has defined quality medical care correctly.

I said from the onset of the development of ACO’s that the project would fail. Many experts criticized me. They called me  a dinosaur. They said I did not understand systems of medical care.

These people did not know that I was the guy that wrote the AACE guidelines for A System of Intensive Self-Management of Type 2 Diabetes Mellitus.

The way the Obama administration has designed ACOs, they are in reality HMOs on steroids.

They shift the responsibility of the cost of medical care to physicians and not the government.

In reality the cost of quality medical care should be the patient’s responsibility. Patients should be responsible for their care and their health care dollars.

I cannot understand why physicians do not protest.

I am a big believer in systems thinking. However, it has to be a system that is well thought out and well constructed. ACOs are neither.

It is clear to me that the bureaucrats do not know anything about medical practices or hospital politics.

The Obama administration originally picked 30 healthcare systems to be ACO Pioneers. They were called Pioneer Project Goups. Nineteen of the original Pioneer Groups remain.

The Mayo Clinic and the Cleveland Clinic were included in the original group of healthcare systems. These clinics were considered the most integrated health care clinics in the country.

The Mayo Clinic and the Cleveland Clinic turned down the Obama administration’s offer. They said they were happy with their system of care. The Mayo Clinic said they would not participate because they knew they would lose money participating in the ACO project.

I have written extensively on the reasons the ACOs would fail. I invite you to read or re-read these articles so as not to be puzzled by the upcoming outcomes of failures.

“Three out of four Medicare accountable care organizations did not slow health spending enough to earn bonuses last year.”

 In 2014 there were 353 accountable care organizations approved by Obamacare.  There are potentially 2700 hospital systems eligible to develop ACOs. The 353 accountable care organizations represent only 13% facilities available to participation rate.

The hospital systems not participating either fully understood why they could not form an effective or efficient ACO with the physicians on their staff or they did not have the money to execute the system and make a profit.

President Obama’s administration has bragged that the 353 participants represent a large number. The traditional mainstream media has parroted his assertion.

The mainstream media publishes this deception to the public as if It represents facts.  It is just one more deception by the Obama administration.

Private health insurance companys’ subsidiaries are in the process of setting up ACOs. They are trying to recruit physicians to shift the financial liability to physicians from insurance companies the same way unsuccessful HMO companies tried to shift financial liabilities onto physicians in the late eighties and early nineties.

The 353 participants include hospitals, physicians’ groups and healthcare insurance company ACOS. These groups have agreed to meet Obama administration targets for quality care and decreased costs.
In 2014 only 97 ACOs earned bonuses. The money these 97 ACOs saved was a total of $833 million. The 97 hospitals shared  $422 million dollars of that total.

Let us assume it was equally distributed among the 97 systems. Let us assume each of the 97 hospital systems has 1500 beds or 97 times 1500 for a total of 145,000 beds. Four hundred twenty two million dollars divided by 145,000 beds equals $2,910 dollars a year per bed or $7.91 dollars per bed per day.

A $7.91bonus per bed per day is an awful return on investment for the work and money necessary to develop an ACO.

What is more bizarre is there are only a few quality targets measured. Some of those measurements are not an accurate measurement of quality medical care.

It also means that the remaining 258 ACOs of the 353 ACOs either lost money because they did not reach targets or they came out even.

In 2013 hospital systems that lost money on certain targets had to pay the government back. The rule was dropped by the Obama administration after the bureaucracy figured out that this was not the way to promote the development of additional ACO’s.

I think I did the math correctly.

“Bonuses are awarded under formulas that account for hospital system performance on quality targets after the first year in the program.”

The results suggest that ACOs might not be the answers to bending the cost curve just as fudging the books is not an answer to delivering the quality healthcare improvement the Obama administration is seeking to have us believe.

The delivery of high quality coordinated care is very difficult to achieve in a government-regulated system of ACOs.

I believe the Obama administration’s plan for Obamacare has failed and has been very costly.

The government should develop a consumer driven healthcare system using my Ideal Medical Savings Account.

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

Please have a friend subscribe

 

Consumers must drive the healthcare system. Consumers have to be provided with the financial incentives to drive the system.

 

If America continues to go in the direction Obamacare is going, the cost will bankrupt the country.

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

Lies About Government Spending

Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Americans will be older and sicker.

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

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

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

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

Medical Care Must Not Be Converted To A Commodity

Stanley Feld M.D.,FACP,MACE

This blog post is a follow up to my last blog "Restricting Access To Care." I published this blog on May 10 2010. The Obama administration has ignored every word. As consumers and physicians might have notice the quality of medical care and the patient/physician relationships have deteriorated as I predicted because Obamacare.

Medical care is not patient centric. Healthcare reform (Obamacare) has been focused on process and not patients. This focus has distorted the effectiveness of medical care even more that it was pre Obamacare.

President Obama has increased the complexity of healthcare in an attempt to make medical care a commodity. His scheme is failing at the expense of consumers.

President Obama keeps on telling the same lie. “Obamacare is a success.” Consumers are not that stupid.

The public must start understanding what is happening now and not complain about why medical care has been destroyed later.

Once the public understands what is happening, individuals must write their congressperson and protest.

Consumers must not believe every lie thrown at them by the traditional media especially when the lie is counter to their every day experience.

I am republishing a previous blog that explains the attempt of turning medical care into a commodity.

Medical Care Must Not Be Converted To A Commodity

Stanley Feld M.D.,FACP,MACE

" President Obama is creating a new bureaucratic agency. It is called the Independent Payment Advisory Board. The Independent Payment Advisory Board will not be measuring clinical judgment or patient compliance when judging the effectiveness of treatment. Its measurement will be physician compliance with evidence based medicine. President Obama, please reexamine your premises.

I am in favor of clinical practice guidelines and evidence based medicine. However, both should be used as an educational tool for physicians and not as a punitive tool to judge payment.

The USPHTF will determine the evidence based medicine to be used. I have pointed out the deficiencies in the USPHTF in the past.

This bureaucracy is an attempt by the government to commoditize medical care. Once medical care is commoditized the cost for medical care is suppose to decrease.

Intensive control of the blood sugar for Type 2 Diabetes Mellitus can be expensive in the short run. If intensive control decreases the complications of Type 2 Diabetes Mellitus it can decrease costs in the long term.

The conclusion of the ACCORD study was intensive control was not worth the cost of medical care in the short term or long term. After the data was reexamined it turned out that the ACCORD conclusions were incorrect.

“It was not hypoglycemia from intensive control or intensive control itself that caused the increased deaths in the ACCORD study.”

Unfortunately, this information was not being reported on every TV station as the original study results were. The original study results set back universal use of intensive control of Type 2 Diabetes at least a decade.

“ It was important to say that in the intensive group it really was not the people with lower A1c who had problems, it actually was those who had the higher A1c who, despite intense efforts, we couldn't get under control."

This means patients did not comply with their responsibility to intensively control their chronic disease or their physicians did not teach them to control their blood sugar adequately.

"This reexamination gives a stronger momentum to the idea that we need to be thinking that one size doesn't fit all, we need to have different targets for different groups of people and perhaps different treatment strategies to reach those different targets as well. That's troubling both clinically and to the trialist.”

"This is something of a new idea, because previously there has been a strong impetus to having standardized guidelines for doctors and people with diabetes, but it's probably not the right thing to do.”

The reader can sense the discomfort of the academic physicians. They are realizing they cannot commoditize medical treatment. Ask any experienced practicing physician about their patients. Patients have different attitudes about their disease and treatment.

Each patient has to be related to differently. This is clinical judgment. Physicians communicating with their patients is called the physician patient relationships. Patients should be responsible for their outcomes along with physicians. This is the art of medicine. Neither patient nor physician can be treated as a commodity.

President Obama, I hope you are listening. Medical care is difficult to commoditize.

The ACCORD study originally suggested that the goal to normalize the HbA1c resulted in an increase in cardiovascular deaths. It turned out not to be true.

On the other hand an observational study was just published concluding that the lower the HbA1c the lower the complication risk.

The Atherosclerosis Risk in Communities (ARIC) study is a community-based assessment of 11,092 middle-aged adults in four US communities with normal HbA1c were followed for up to 15 years (4 visits at about 3-year intervals) for onset of new diabetes, new CVD, stroke, and all-cause mortality.”

The higher the HbA1c the higher the average blood sugar and the greater the risk for chronic complications of Type 2 Diabetes Mellitus. HbA1c is a measure of the average blood sugar over the previous three months.

Table. HbA1c Levels and Corresponding Multivariate Hazard Ratios

HbA1c Level

Multivariate-Adjusted Hazard Ratio

< 5%

0.52 (0.40-0.69)

5% to < 5.5%

1.00 (reference)

5.5% to < 6%

1.86 (1.67-2.08)

6% to < 6.5%

4.48 (3.92-5.13)

≥ 6.5%

16.47 (14.22-19.08)

HbA1c = hemoglobin A1c

“The hazard ratios for stroke were similar, but for all-cause mortality, HbA1c displayed a J-shaped association curve. All associations remained significant after adjustment for the baseline FPG.”

The study found HbA1c values predicted Cardiovascular Disease (CVD) or death, whereas fasting plasma glucose (FPG) levels were not significant after adjustment for other risk factors.

“The recent ADVANCE [Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation], ACCORD [Action to Control Cardiovascular Risk in Diabetes], and VADT [Veterans Affairs Diabetes Trial] trials left us wondering about the value of tight glycemic control in reducing CVD risk.

“One of the many shortcoming of each of these trials was that most participants had had diabetes for many years, and the designs could not account for the long-term accumulation of glycemic burden.”

The authors claim that the vascular damage from high HbA1c may have already occurred. Tight control during the trials might have had relatively little effect. This is probably not true.

There is evidence that normalizing the blood glucose can lead to regression of the vascular lesions that cause the complications of Diabetes.

The current ARIC analysis demonstrates that higher HbA1c levels, even in the normal range, increase CVD risk.

These results are not conclusive because it is an observational study as opposed to a double blind placebo controlled study. The USPHTF and President Obama’s Independent Payment Advisory Board would not give this study as much credit as the ACCORD study.

The ACCORD study was a placebo controlled double blind study. Its conclusions have more power than an observational study (ARIC). The problem is ACCORD measured the wrong endpoint. ACCORD has resulted in a great disservice to the standard of medical care of diabetes.

The results of The Atherosclerosis Risk in Communities (ARIC) study suggest that maintaining a HbA1c as near normal as possible even before the onset of diabetes may help prevent CVD.

As President Obama tries to quantify the standard of care he could be picking the wrong standard of care in order to reduce the cost of medical care. All medicine is local. Standards of care are always evolving. The standard of medical care should be determined by local medical leaders who are respected as teachers by local practitioners. It can also be enforced by local peer review with no monetary interest in the outcome.

President Obama’s effort to improve medical care at a reduced price will not succeed if it is interpreted as a punitive measure by a national bureaucracy.

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

May 30, 2010 "

A healthcare system that would work and be cost effective must be a consumer driven healthcare system. It must be patient centered and not stakeholder centered.

It must put consumers in a position of responsibility for their health and healthcare dollars and not in a position of dependence on the government.

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

Please have a friend subscribe

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

Medical Care Must Not Be Converted To A Commodity

Stanley Feld M.D.,FACP,MACE

This blog post is a follow up to my last blog "Restricting Access To Care." I published this blog on May 10 2010. The Obama administration has ignored every word. As consumers and physicians might have notice the quality of medical care and the patient/physician relationships have deteriorated as I predicted because Obamacare.

Medical care is not patient centric. Healthcare reform (Obamacare) has been focused on process and not patients. This focus has distorted the effectiveness of medical care even more that it was pre Obamacare.

President Obama has increased the complexity of healthcare in an attempt to make medical care a commodity. His scheme is failing at the expense of consumers.

President Obama keeps on telling the same lie. “Obamacare is a success.” Consumers are not that stupid.

The public must start understanding what is happening now and not complain about why medical care has been destroyed later.

Once the public understands what is happening, individuals must write their congressperson and protest.

Consumers must not believe every lie thrown at them by the traditional media especially when the lie is counter to their every day experience.

I am republishing a previous blog that explains the attempt of turning medical care into a commodity.

Medical Care Must Not Be Converted To A Commodity

Stanley Feld M.D.,FACP,MACE

" President Obama is creating a new bureaucratic agency. It is called the Independent Payment Advisory Board. The Independent Payment Advisory Board will not be measuring clinical judgment or patient compliance when judging the effectiveness of treatment. Its measurement will be physician compliance with evidence based medicine. President Obama, please reexamine your premises.

I am in favor of clinical practice guidelines and evidence based medicine. However, both should be used as an educational tool for physicians and not as a punitive tool to judge payment.

The USPHTF will determine the evidence based medicine to be used. I have pointed out the deficiencies in the USPHTF in the past.

This bureaucracy is an attempt by the government to commoditize medical care. Once medical care is commoditized the cost for medical care is suppose to decrease.

Intensive control of the blood sugar for Type 2 Diabetes Mellitus can be expensive in the short run. If intensive control decreases the complications of Type 2 Diabetes Mellitus it can decrease costs in the long term.

The conclusion of the ACCORD study was intensive control was not worth the cost of medical care in the short term or long term. After the data was reexamined it turned out that the ACCORD conclusions were incorrect.

“It was not hypoglycemia from intensive control or intensive control itself that caused the increased deaths in the ACCORD study.”

Unfortunately, this information was not being reported on every TV station as the original study results were. The original study results set back universal use of intensive control of Type 2 Diabetes at least a decade.

“ It was important to say that in the intensive group it really was not the people with lower A1c who had problems, it actually was those who had the higher A1c who, despite intense efforts, we couldn't get under control."

This means patients did not comply with their responsibility to intensively control their chronic disease or their physicians did not teach them to control their blood sugar adequately.

"This reexamination gives a stronger momentum to the idea that we need to be thinking that one size doesn't fit all, we need to have different targets for different groups of people and perhaps different treatment strategies to reach those different targets as well. That's troubling both clinically and to the trialist.”

"This is something of a new idea, because previously there has been a strong impetus to having standardized guidelines for doctors and people with diabetes, but it's probably not the right thing to do.”

The reader can sense the discomfort of the academic physicians. They are realizing they cannot commoditize medical treatment. Ask any experienced practicing physician about their patients. Patients have different attitudes about their disease and treatment.

Each patient has to be related to differently. This is clinical judgment. Physicians communicating with their patients is called the physician patient relationships. Patients should be responsible for their outcomes along with physicians. This is the art of medicine. Neither patient nor physician can be treated as a commodity.

President Obama, I hope you are listening. Medical care is difficult to commoditize.

The ACCORD study originally suggested that the goal to normalize the HbA1c resulted in an increase in cardiovascular deaths. It turned out not to be true.

On the other hand an observational study was just published concluding that the lower the HbA1c the lower the complication risk.

The Atherosclerosis Risk in Communities (ARIC) study is a community-based assessment of 11,092 middle-aged adults in four US communities with normal HbA1c were followed for up to 15 years (4 visits at about 3-year intervals) for onset of new diabetes, new CVD, stroke, and all-cause mortality.”

The higher the HbA1c the higher the average blood sugar and the greater the risk for chronic complications of Type 2 Diabetes Mellitus. HbA1c is a measure of the average blood sugar over the previous three months.

Table. HbA1c Levels and Corresponding Multivariate Hazard Ratios

HbA1c Level

Multivariate-Adjusted Hazard Ratio

< 5%

0.52 (0.40-0.69)

5% to < 5.5%

1.00 (reference)

5.5% to < 6%

1.86 (1.67-2.08)

6% to < 6.5%

4.48 (3.92-5.13)

≥ 6.5%

16.47 (14.22-19.08)

HbA1c = hemoglobin A1c

“The hazard ratios for stroke were similar, but for all-cause mortality, HbA1c displayed a J-shaped association curve. All associations remained significant after adjustment for the baseline FPG.”

The study found HbA1c values predicted Cardiovascular Disease (CVD) or death, whereas fasting plasma glucose (FPG) levels were not significant after adjustment for other risk factors.

“The recent ADVANCE [Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation], ACCORD [Action to Control Cardiovascular Risk in Diabetes], and VADT [Veterans Affairs Diabetes Trial] trials left us wondering about the value of tight glycemic control in reducing CVD risk.

“One of the many shortcoming of each of these trials was that most participants had had diabetes for many years, and the designs could not account for the long-term accumulation of glycemic burden.”

The authors claim that the vascular damage from high HbA1c may have already occurred. Tight control during the trials might have had relatively little effect. This is probably not true.

There is evidence that normalizing the blood glucose can lead to regression of the vascular lesions that cause the complications of Diabetes.

The current ARIC analysis demonstrates that higher HbA1c levels, even in the normal range, increase CVD risk.

These results are not conclusive because it is an observational study as opposed to a double blind placebo controlled study. The USPHTF and President Obama’s Independent Payment Advisory Board would not give this study as much credit as the ACCORD study.

The ACCORD study was a placebo controlled double blind study. Its conclusions have more power than an observational study (ARIC). The problem is ACCORD measured the wrong endpoint. ACCORD has resulted in a great disservice to the standard of medical care of diabetes.

The results of The Atherosclerosis Risk in Communities (ARIC) study suggest that maintaining a HbA1c as near normal as possible even before the onset of diabetes may help prevent CVD.

As President Obama tries to quantify the standard of care he could be picking the wrong standard of care in order to reduce the cost of medical care. All medicine is local. Standards of care are always evolving. The standard of medical care should be determined by local medical leaders who are respected as teachers by local practitioners. It can also be enforced by local peer review with no monetary interest in the outcome.

President Obama’s effort to improve medical care at a reduced price will not succeed if it is interpreted as a punitive measure by a national bureaucracy.

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

May 30, 2010 "

A healthcare system that would work and be cost effective must be a consumer driven healthcare system. It must be patient centered and not stakeholder centered.

It must put consumers in a position of responsibility for their health and healthcare dollars and not in a position of dependence on the government.

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

Please have a friend subscribe

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

Simple, Viable Republican Alternatives To Obamacare

Stanley Feld M.D., FACP, MACE

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

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

It is easy for consumers to understand.

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

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

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

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

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

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

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

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

Medical costs cannot be controlled by government price fixing.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

My Ideal Medical Savings Account Is Democratic!

Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Please have a friend subscribe

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

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

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

Please have a friend subscribe

 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

Republican Leadership Is Chickening Out!

 Stanley Feld M.D.FACP, MACE

Since the Republican’s massive victory in November President Obama has been setting up strategy to blame Republicans for all that will go wrong as that majority pledged they would repeal Obamacare.

It was strange that President Obama was not contrite or acted defeated by the election. He said 66% of the people did not vote. He said that those 66% did agreed with his policies and therefore it was a mandate for him to carry on.

President Obama knows he has the RINO’s on their heels

 The traditional mainstream media did not question President Obama’s premise that 66% liked his policies.

Another explanation could be that those 66% disagree with   President Obama’s policies. They believe in President Obama but believe his policies are wrong and did not vote for them.

After all, President Obama said the election was about his policies.

He has not paid attention to needs or will of the Americans people.

President Obama has used the traditional mainstream media (TMM) to promote his agenda. After the TMM publishes the Obama administration’s lies over and over again it becomes the truth even though it remains a lie.

A perfect current example is the administration’s lie that open enrollment for Obamacare is going great.

 The Republican moves come, ironically, as the Affordable Care Act is working fairly well. The three-month enrollment season for 2015 is going smoothly and will likely surpass the administration’s modest second year goals of having 9 million covered in exchange plans.’

After two years of open enrollment if Obamacare signs up the original estimate of 13 million, it still has 320 million people short.  However, President Obama will tout the amazing success ever though Obamacare is unsuccessful and harmful to Americans who were satisfied with their insurance and their doctor before Obamacare.

President Obama has been collecting increased taxes for Obamacare for 4 years.

 “Republicans have been vowing to repeal Obamacare for nearly five years. But 2015 could be the year that Republicans finally define how they would replace it.”

Now Republicans are chickening out. Some Republicans want to delay their repeal strategy until after the Supreme Court rules on the King v. Burwell case in June. Some want to delay it until the presidential campaign in 2016.

I believe Republicans should be aggressive. They should lay out a business model that will work immediately. Then repeal Obamacare . Let the President veto the bill as Republican actively work to replace Obamacare with a carefully explained alternative that makes sense to the public. Republicans can then try to overturn the Presidents veto.

President Obama has asked Republicans over and over again to give him some ideas to fix Obamacare. Obamacare cannot be fixed because of President Obama’s ideology. It must be repealed.

Republicans have many ideas to replace Obamacare with. For years they’ve discussed tax credits to buy insurance, high-risk insurance pools that work and allowing insurance to be sold across state lines. They need to put these ideas together with a compelling and viable business plan such as my ideal medical savings account.

Republicans must create a consumer driven healthcare system.

President Obama and the media have mocked Republicans for not having a plan or offering a fix for Obamacare. I said previous there is not fix for Obamacare. The American public does not want their freedoms restricted. In addition a single party payer system have failed economically in all of the developed countries except Switzerland.

Various Republican proposals have been put forth over the years, but forging agreement requires bridging deep ideological differences among Republicans about the scope of a plan, the role and responsibility of the federal government in health care, and how much to money to spend.”

A plan must include an entirely new system that includes a business plan. The plan must include the freedom for consumers of healthcare to choose and provide access to care without rationing of care.

The plan must also include systems of care for the most expensive chronic diseases such as Diabetes, Asthma, Cancer and Chronic Infectious Diseases.

The plan must not exclude access of care for the elderly that need hip replacements, knee replacements, cancer treatment or heart disease.  

The plan must develop a system for decreasing the cost of the treatment of chronic diseases. It must have within the treatment system a plan to make the consumers more responsible for the health and healthcare dollars.

It should shift the responsibility of care from the government and insurance companies to consumers. Consumers should decide what they need not the government.

Republicans have had six years to decide on what they should be promoting.

President Obama is in a perfect position to mock and veto any Republican piecemeal suggestion.

President Obama has already smiled regarding the new Republican majorities when he said he has to sharpen his veto pencil implying all they will do is present bills that are stupid.

However, the Republican leadership, rather than passing bills in the senate and house of representative to repeal Obamacare, have chosen to work with the Democrats and President Obama.

The Republican leadership is too afraid to do anything scary. They are afraid to lose votes to the Saul Alinsky tactic of ridicule. It might cause them to lose the 2016 Presidential election.

So what does the Republican leadership do the first day they are in power? They take away key healthcare committee chairmanships of leaders who have voted for the removal of Speaker Boehner.

Next they propose a lame reform to change the definition of part-time employment from 29 hour a week to 40 hours per week.

 President Obama would veto Republican legislation that would alter the definition of full-time work under Obamacare from 30 to 40 hours, the White House said Tuesday.”

 It is a stupid proposal on many levels.

 The Harvard faculty uproar of the last few days is very important. Almost all the faulty were big supporters of Obamacare until it affected them. I hope the rest of the country reacts the same way and demands their local newspapers publish multiple stories about their citizens pain.

Now that the Republicans are in power in both houses they should be educating the public about the irreparable issues in Obamacare and define its business model for 2020.

The Republicans should let everyone know they are feeling the public’s pain. Republicans should define a business plan that will provide healthcare for everyone at an affordable cost.

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

Please have a friend subscribe

 

 

 

 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.

Permalink:

Looking For Alternatives To Obamacare

Stanley Feld M.D.,FACP,MACE

The dice have been loaded against the American people by the rules and regulations in Medicare and Obamacare.

Patients liked their doctors. Once they discovered that they could not keep their doctors under Obamacare they became angry at President Obama for lying to them. The soon to be released new payment rules will increase the anger.

Physicians have found it more difficult to run small private practices.  The complexities of compliance with the rules, regulations and the payment systems for both Medicare and Obamacare are forcing physicians to sell out to hospital systems.

These complexities are in effect ending independent medical practices. This has been intentional. The Obama administration doesn’t want to control 600,000 independent physicians. It wants to deal with the hospital systems the are involved with. The hospital systems can then deal with the doctors.

Republicans are looking for a compelling alternative to Obamacare.

Just as Obamacare was forced through congress, President Obama is trying to force how medicine is practiced in America down the throats of Americans.

It is consistent with Jonathan Gruber’s view that Americans are to stupid to understand what is going on. It follows that Americans are too stupid to be responsible for their own care.

Americans want freedom of choice. They do not want the government to tell them what to do.

Republicans are looking for an alternative to Obamacare. A viable alternative could be to save the private practice of medicine and not subject Americans to the inefficiencies of a government controlled bureaucracy.

 Physicians by nature and education are competitive. Competition leads to improvement of the delivery of medical care.

All medicine is local. The alternative to Obamacare is to have local completion among physicians and permit patients to choose their doctors.

The answer to the Republican’s dilemma is right in front of their eyes.

A real Republican alternative to Obamacare would support physician ownership of independent medical practices and preserve local competition between doctors and maintain choice for patients.

Obamacare’s promotion of large hospital systems with salaried physicians eliminates physicians competing for patients. The lack of physicians competing for patients destroys the physician/patient relationship.

Physicians listen to patients if patients have a choice. The interaction is a partnership called the patient /physician relationship.

This solves the problem of President Obama’s lie. “If you like your doctor you can keep your doctor period.” Patients choose their doctors.

Dr. Donald Berwick and Jonathan Gruber’s view the consolidation of physicians and hospital systems as a necessary step to enable payment liability onto providers through hospital systems and away from government programs such as Medicare and Obamacare.

President Obama does not understand that doctors are not stupid either. At the moment physicians feel financially cornered by the government and the hospital systems and are joining hospital systems as a temporary means of surviving.

President Obama also does not realize that over the last 50 years there has been a build up of physician distrust for most hospital administrations.

Most administrators have tried to repair that mistrust but it has not been very successful. Hospital systems have been trying for years to own their physicians’ intellectual property and surgical skills for their hospital system’s profit. It is all about economics. Patient care is secondary.

As hospital systems consolidate competition will be eliminated.  Then hospital systems will realize they are losing money because of the risk they agreed to accept from the government. Hospital systems will demand more money from the government or consumers or go out of business.

Who loses? 

Patients lose, taxpayers lose, and the American healthcare system loses.

The abuses of the healthcare system by all the stakeholders must be fixed. It will never be fixed by forcing stakeholders to fix it. It will only be fixed by aligning incentives of all the stakeholders. Consumers must lead the way.

A recent Physicians Foundation survey of 20,000 U.S. doctors found that 35% described themselves as independent, down from 49% in 2012 and 62% in 2008.

It has also been reported that hospital systems are complaining that they are losing money on their physicians in these integrated systems.

Hospital systems are dropping out of the Obamacare Accountable Care Organization programs. There have been reports that salaried physicians are less productive that independent practicing physicians.

I believe in the team approach to the management of chronic disease. The patient must be at the center of the team with the physician being the head coach or manager and his team being an extension of the physician’s care.

Medical decision making entities must not be the insurance company or the government.

The idea that integrated systems with salaried physicians leads to increased economic efficiency, better quality of care and clinical outcomes than small independent private practices never made syllogistic sense to me.

Patient care becomes depersonalized in large hospital systems. Both patients and physicians become commodities in systems focused on the bottom line.

Small practices have the advantage of providing a personal style of care. Consumers want that comfort when they are sick. They want someone they know who is going to listen to them and talk to them.

In a private setting physicians can practice the way they want, without interference by a large, impersonal organization driving efficiency.

If a physician in private practice does not satisfy the consumer’s need the consumer can leave the practice and go somewhere else.

  "When you work closely with patients and empower them, they are going to make better choices," said Craig C. Koniver, MD, a solo family physician in North Charleston, South Carolina. He said a team of caregivers at a large practice will not have the same impact, because none of them are as close to the patient as he is.”

Health Affairs published a study in August 2014 looking at primary care physicians in small practices and “ambulatory care sensitive” admission rates. The study included such conditions as congestive heart failure in which admission to the hospital can be preventive by high quality primary care. The patient relates positively to the physician and the physician relates positively to the patient (positive patient/physician relationship).

“The study found that practices with 1 to 2 physicians had ambulatory care-sensitive admission rates fully 33% lower than practices with 10 to 19 physicians.”

This is not the only study that shows that small independent private practices can deliver just as high or higher quality of care than large integrated hospital systems with salaried physicans.

“ A 2013 study[2] showed that small practices in general had slightly lower hospital readmission rates than large practices.”

Additionally, “a 2012 study[3] looking at practices ranging from 5 to 750 physicians found that the smaller ones had fewer ambulatory care-sensitive admissions and lower overall costs of care for diabetes.”

 All three studies turned a piece of conventional wisdom on its head; that large practices, with their care management teams and sophisticated clinical information systems, produce better clinical outcomes.

Republicans should start presenting alternatives to Obamacare. The alternative must provide consumers with what they want rather than systems that let the government to tell consumers what they are going to get.

The ideal medical savings account will let consumers choose and keep their doctor if they like their doctor.

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

Please have a friend subscribe

 

 

 

 

 

 

 

 

 

 

 

 

  • Thanks for leaving a comment, please keep it clean. HTML allowed is strong, code and a href.