Consumer Driven Health Care

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Let’s Get Smart

August 28, 2016

inChronic Disese Management, Consumer Driven Health Care, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

Let’s forget the forget what President Obama and the mass media (Paul Krugman) are telling us about how wonderful Obamacare is.

Obamacare is a failure.

National Health Expenditures 2014 Highlights

In 2014, U.S. health care spending increased 5.3 percent following growth of 2.9 percent in 2013 to reach $3.0 trillion, or $9,523 per person.

Obamacare has not bent the cost curve. The only thing it did was raise taxes with 10 hidden taxes in years it did not provide services.

It also increased out of pocket expenses. The first year of services was 2014. Increase in taxes started in 2011.

The faster growth experienced in 2014 was primarily due to the major

coverage expansions under the Affordable Care Act.

Healthcare expenditures increase from 17.2 % of the GNP to 17.5% in 2014.

Hospital Care: Spending for hospital care increased 4.1 percent to $971.8 billion in 2014 compared to 3.5 percent growth in 2013.

People used hospital services more because the population is becoming sicker. The increase in the Medicaid population brought sick people to the hospital who couldn’t afford to go to the hospital previously.

Physician and Clinical Services: Spending on physician and clinical services increased 4.6 percent in 2014 to $603.7 billion from 2.5 percent growth in 2013, pre Obamacare spending for services, when spending was at a historical low.

Physicians are receiving less reimbursement. The increase in physician and clinical services is a result of a sicker populations and overuse of the system.

There are at least 22 more increases in expenses in the CMS report.

The consistent common denominators are:

Cost of complications of chronic diseases
Overuse of the healthcare system because of under education of consumers about their disease
Lack of adherence to prescribed therapy
Insufficient availability of education about disease
Consumer dependence on providers to fix them and their illness
The increasing incidence of obesity in the population
The increasing administrative and bureaucratic overhead

A large part of the overuse of the healthcare system is the onset of illness as a result of the increase incidence of obesity.

Obesity leads to an increase in chronic diseases such as Type 2 Diabetes Mellitus.

Type 2 Diabetes Mellitus affects 22 million Americans at a average cost of $14,000 year. This includes complications of diabetes mellitus. The average cost of care for all consumers is $6700 dollars.

Healthcare policy wonks should concentrate on how to change the eating habits and exercise patterns of Americans.

A decrease in the incidence of obesity would decrease the onset of Type 2 Diabetes Mellitus.

The healthcare policy wonks have not been successful in changing the methods of payment to decrease the cost of healthcare.

The only initiative that will be successful is a consumer driven healthcare system with financial rewards being built into the healthcare system for consumers who work hard to b responsible for their health.

Obamacare has failed to improve the quality of care in the treatment of Type 2 Diabetes Mellitus.

Obamacare has not increased access to care, increased quality of care or decreased the cost of care for Type 2 Diabetes Mellitus.

Type 2 Diabetes Mellitus is an excellent demonstrating the failure of Obamacare.

The incidence of Type 2 Diabetes Mellitus is even increasing in teenagers as obesity is increasing in teenagers.

This fact has been demonstrated scientifically.

“The total estimated cost of diagnosed diabetes in 2012 is $245 billion, including $176 billion in direct medical costs and $69 billion in reduced productivity.

The largest components of medical expenditures are:

hospital inpatient care (43% of the total medical cost),
prescription medications to treat complications of diabetes (18%),
anti-diabetic agents and diabetes supplies (12%),
physician office visits (9%), and
nursing/residential facility stays (8%).

People with diagnosed diabetes incur average medical expenditures of about $13,700 per year, of which about $7,900 is attributed to diabetes. People with diagnosed diabetes, on average, have medical expenditures approximately 2.3 times higher than what expenditures would be in the absence of diabetes.

For the cost categories analyzed, care for people with diagnosed diabetes accounts for more than 1 in 5 health care dollars in the U.S., and more than half of that expenditure is directly attributable to diabetes.”

In the last decade, there have been multiple advances in the treatment of Type 2 Diabetes Mellitus. Over 40 new pills or injections have been approved to lower the Hemoglobin A1C (HbA1c) in the Type 2 Diabetes Mellitus population.

Many of these drugs individually and in combination can normalize the HbA1c to normal.

A normal HbA1c is between 4.5% and 6%. Human being are constantly refreshing their red blood cells. The complete turnover takes about 3 months. If newly born red blood cells are born in a high glucose environment those red blood cells (rbc) are denatured from normal Hemoglobin(Hb) to Hemoglobin A1c (HbA1c). The structure of the protein hemoglobin is distorted.

Certain foods raise the blood sugar in normal people. Normally people have 4.5-6% of their hemoglobin denatured.

People with Type 2 Diabetes Mellitus have HbA1cs as high as 13%. HbA1c is a surrogate for the average blood sugar over a 3 month period of time.

All the proteins in a person’s body are denatured when the blood sugar is high. This leads to a thickening in the lining of the blood vessel (endothelium) and closure of the vessel.

The end result is myocardial infarction, stroke, blindness, amputations and end stage kidney disease. All of these illnesses are very expensive to treat acutely and chronically. They add to the cost to the healthcare system as well as markedly decreasing the quality of life.

National Health and Nutrition Examination Survey (NHANES) is a national database that measures all kinds of big data.

NHANES has the ability to measure HbA1c by zip code. Despite new medications and systems of care including uncoordinated educational systems to teach patients about their disease and self-management the new NHANES analysis demonstrated no improvement in the last 10 years.

In fact the average HbA1C has increased and is far from the American Diabetes Association’s HbA1c goal of 7%.

The American Association of Clinical Endocrinologists goal is 6.5%

It has been shown that decreasing HbA1c to 7% will decrease the complication rate of Type 2 Diabetes Mellitus by 33-50 %.

The treatment of the complications of Type 2 Diabetes Mellitus consumes 80% of the healthcare dollars.

A 50% decrease of 80% of the Diabetes related healthcare dollars spent is a very significant decrease in healthcare dollars. It will result in healthier Americans living better lives.

Americans should get smart and demand the government create an environment that helps them stay healthy.

The government should not try to social engineer a system consumers do not want and force them to do what the government wants.

Consumers and the government should start to get smart.

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

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Why Vermont’s Single Party Payer Healthcare Plan Failed

August 19, 2016

inConsumer Driven Health Care, Defective scientific studies, Disinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D., FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

The question was:

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

Dr. Hsiao.

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

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

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

Dr. Hsiao.

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

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

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

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

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

What are the system’s weaknesses?

Dr. Hsaio

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The American public eventually figures it out.

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

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

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

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

Watch out Colorado!

Why doesn’t a single party payer system work?

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

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

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

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

Consumers must be a the center of the healthcare system.

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

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

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

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

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

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If Something Works, Destroy It!

April 8, 2016

inConsumer Driven Health Care, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

If a program is working well the Obama administration starts regulating the program out of existence. In a very quiet and deceptive way the Obama administration is destroying Health Savings Accounts.

The fastest growing health insurance plan in the private healthcare market is Health Saving Accounts (HSAs). HSAs are also available in Health Insurance Exchanges.

Consumers love HSA’s because the money not spent for their yearly deductible expenses go into a personal trust fund, which goes to pay future medical expenses. Consumers, employers or government can fund the deductible. Healthcare coverage starts after the deductible is reached. The trust fund can grow tax-free until funds are withdrawn.

HSAs are not ideal but they do act to provide a mild financial incentive to consumers to be responsible for their health and healthcare dollars. Consumers decrease their overuse of the healthcare system.

Health Savings Accounts are not as powerful as my ideal Medical Savings Accounts. Medical Savings Accounts provide greater financial incentive for consumers to be responsible for their healthcare and healthcare dollars.

Consumers seem to lack the desire to prevent obesity, which is responsible for many chronic diseases and their complications. These diseases are responsible for 80% of the healthcare dollars spent.

With my ideal Medical Savings Account consumers or the consumer’s sponsors (government or employers) pay a high deductible. The sponsor then buys first dollar reinsurance for healthcare coverage. The unspent deductible goes into a Medical Saving Account tax-free retirement fund. It does not stay in the healthcare system.

The Medical Saving Account provides greater financial incentive for consumers to become more responsible for their health care and healthcare dollars.

Why and how does Obamacare want to regulate Health Savings Accounts out of existence?

In case you missed it, final regulations published on March 8 will make it impossible to offer HSA-qualified plans in the future.

The health insurance industry has been opposed to HSAs and MSAs because the premiums the healthcare insurance industry receives is lower than regular healthcare insurance premiums.

Once the premiums are put into a trust it does not belong to the healthcare insurance industry to invest.

The healthcare industry has tried to influence HHS to dissuade consumers from buying HSAs through Health Insurance Exchanges since the exchanges began.

However HSS has done nothing “(a) to help consumers identify HSA-qualified plans on the exchanges or (b) provide information to individuals that choose HSA-qualified plans about where to get more information about opening and contributing to an HSA.”

Last year’s proposed standardization of healthcare plan design rule gave no hint that the proposal would eliminate the possibility of HSAs surviving.

This year’s rule change made it clear that this was President Obama’s goal.

1)” Plans must apply specific deductibles and out-of-pocket limits that are outside the requirements for HSA-qualified plans.”

2) “Plans must cover services below the deductible that are not considered “preventive care.”

“ Regarding the deductibles and out-of-pocket limits, no Bronze, Silver, or Gold plans adhering to the standardized benefit designs will likely be HSA-qualified for 2017.”

The first step was for HHS to change the definition of a qualified plan. The next step was to force the plan design to be incompatible with HSAs.

HHS and CMS have given the healthcare insurance industry another gift. Maybe it is a payback for CMS short changing the insurance industry on its reinsurance payback promise.

In any event HSAs look doomed. The Obama administration has succeeded in destroying the development of a viable healthcare system that the free market, not the central government controls.

John Dunn M.D.,J.D. wrote a wonderful summary of Obamacare’s failed attempts to control the healthcare system to his chat group followers.

He has summarized all the policies that have failed in the Obama administration’s goal to destroy the private healthcare market and eliminate the free market system.

“ Subject: HSAs being eliminated?

Yep, Obamacare strikes again to accomplish the real goal, elimination of private capitalist free market healthcare.

Now let’s tally up the failures of Obamacare in its attempt to destroy the healthcare system—

more expensive, less accessible,
restrictions on hospitals and care givers,
promotion of mid level practitioners, extraordinary inefficiencies created by computer mandates,
penalties for hospitals and physicians that are created by apparatchiks,
no decline in the uninsured,
in fact there might be an increase in the uninsured because of the cost of premiums and deductible,
more movement of people to Medicaid where coverage is free,
bankruptcies of COOP insurance programs,
exchanges failing with insurers leaving the market for taking big economic hits from adverse selection,
and most of all—the death spiral of private market insurance—with the goal being to destroy the private market ????
Why of course, Medicaid for all.

The goal of government bureaucrats is control and power, achieved in this case by the growth of single payer government controlled medicine—Medicaid on steroids—

The result will be mediocrity as far as the eye can see, and destruction of innovative and creative health care,

but also the loss of the ethics and patient consideration that comes from physician guided health care,

instead a trade for mandarins with frowns and red pencils,

Checking the data banks that aren’t secure from hacking.

It leaves one almost breathless, but it started a long time ago.

Good intentions and unanticipated results—Bastiat von Mises, Fredrick Hayek warned us about the fatal conceit and the problem of government actions to protect certain interests or promote a cause—ignorant of the realities of markets and the benefits of free markets.

Socialism and statism will produce mediocre, expensive healthcare run by bureaucrats and apparatchiks who aren’t interested in good patient care,

They are only interested in control.

Looks like I am not the only one who has figured it out.

I do not understand why the political establishment cannot understand why Americans are getting ready to cast a protest vote against them.
The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

All Medical And Healthcare is Local | Stanley Feld M.D., FACP, MACE
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Social Engineering

March 10, 2016

inConsumer Driven Health Care, Medicine: Healthcare System, Physician's Problems, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

Obamacare has been a failed attempt at social engineering.

As I have said previously President Obama and his administration have backed off and are continuing to back off many of the deadlines in the law.

Many of Obamacare’s new ideas are ideological utopia. Theses ideas cannot work in system that is dependent on physician judgment and interpersonal patient/physician relationships.

Social engineering’s goal is to eliminate judgment (craftsmanship) and reduce production of goods and services to a commodity production.

I believe the origin of the dysfunctional healthcare system began with government intervention over the last 60 years.

I want to start with some basic points. The delivery of medical care should be between physicians delivering medical care and surgical care to patients. Without physicians or patients there is no need for a healthcare system.

The two main participants (physicians and patients) have a large responsibility to the healthcare system in order to have good outcomes. The patients’ responsibility in the system has been constantly ignored by healthcare policy wonk.

Patients should exercise, must not become obese, do not do dangerous things that could injure themselves, don’t smoke, diligently take their recommend medicine and follow their physicians orders.

Eighty (80%) of the healthcare dollars are spent on the complications of chronic disease. Much of this expense could be avoid if patients were responsible for the care of their health and avoid the onset of chronic diseases and their complications.

At the beginning of the 20^th century the United States was growing rapidly. It was believed that our institutions could not handle this growth adequately.

Social engineering of our industries, manufacturing and political systems became the fad of the day in the early 20^th century.

What is social engineering?

“Social engineering is a discipline in social science that refers to efforts to influence particular attitudes and social behaviors on a large scale, whether by governments, media or private groups in order to produce desired characteristics in a target population.”

The discipline of social engineering attempts to manipulate a population of people by manipulation of norms and ideas using tools available to institutions whether it is a government, the media or an industry.

The goal was to modernize social systems that where outmoded in the society that existed in the late 19^th and early 20^th century in order “to achieve the intelligent management of Earth’s resources and human capital with the highest levels of freedom, prosperity, and happiness within a population.”

The obvious question is who has the authority to manipulate the behavior of billions of people?

The wrong decision-making can affect the safety and survival of literally billions of people.

In a democracy, in which the government should be by the people and for the people, the government should act as a surrogate for the people and not an authority that rules the people.

When something doesn’t work for the people, the government must change to express the will of the people.

“As a result of abuse by authoritarian regimes and other non-inclusive attempts at social engineering, the term has in cases been imbued with a negative connotation.”

In the last 60 years progressives have been enamored with social engineering. However, most of our government’s attempts at social engineering have been a failure.

Universal Health Care”, “Single Payer”, “National Health Insurance”, “Socialized Medicine” are all terms invented in an attempt to social engineer America’s healthcare system. These terms aim is to social engineer the healthcare system so that physicians’ and their patients’ relinquish their autonomy to government control for the sake of the common good.

The unspoken promise to the people is that the healthcare system will be free to the people.

Progressive’s claim that healthcare is a right! Healthcare is rather an individual’s responsibility!

Nothing is free!

Socialized medicine eliminates the need for an individual to be responsible to maintain health and to comply with treatment. The government will take care of us if we get sick.

The people have soundly rejected socialized medicine’s terms and intentions. The present government is ignoring the will of the people.

The result is a mistrust for our elected officials (establishment) and a chaotic and joke-book of candidates on both the Democratic and Republican side.

Who should determine the common good? Who should determine actual good for consumers? The obvious answer to me is the consumer and not some ideology or its attempt at social engineering.

Max Weber was a Prussian 20^th century political philosopher. He laid the foundation for modern sociology and the need for social engineering.

However Max Weber was one of the first to proclaim,

“Bureaucratic administration means fundamentally the exercise of control of institutions on the basis of knowledge. This is the feature of bureaucracy which makes it sound specifically rational.”

However, Weber also recognized the limitations of bureaucracy. He observed that the goal of a rational bureaucracy was more often elusive than realized, if it is ever realized.

In the early 20^th century Frederick Taylor was the leading proponent of scientific management, also called Taylorism. Scientific management is an extension of social engineering.

Taylorism is a theory of management that analyzes and synthesizes workflows.

Its main objective is improving economic efficiency, especially labor productivity. It was one of the earliest attempts to apply science to the engineering of processes and to management.

Taylorism includes the important parts of today’s industrial engineering and management.

“The elements of industrial engineering include analysis; synthesis; logic; rationality; empiricism; work ethic; efficiency and elimination of waste; standardization of best practices; disdain for tradition preserved merely for its own sake or to protect the social status of particular workers with particular skill sets;

It includes the transformation of craft production into mass production; and knowledge transfer between workers and from workers into tools, processes, and documentation.”

The last sentence is exactly what the Obama administration is trying to do to the healthcare system. It is trying to turn the practice and art of medicine into a commodity control by the government.

The major criticism of Taylorism had been;

“for turning the worker into an “automan” or “machine.” Due to techniques employed with scientific management, employees claim to have become overworked and were hostile to the process.”

Consumers are presently experiencing this same reaction from physicians in their response to Obamacare.

Indeed the healthcare system must become more efficient. It can become more efficient with improvements in some processes.

However, a process that causes consumers to be more responsible for their health and the treatment of their chronic diseases must accompany the improved processes.

The expensive creation of bureaucracy that measures physician behavior in inefficient ways and decides on inadequate payment leads to the hostile reaction to the process and increased inefficiency.

Consumers and not the government should drive the healthcare system.

Ronald Reagan said in a 1964 speech long before he was president, “No government ever voluntarily reduces itself in size. Government programs, once launched, never disappear. Actually, a government bureau is the nearest thing to eternal life we’ll ever see on this earth!”

The bureaucracy by ever expanding has given unelected officials the authority to social engineer the healthcare system. The public’s will is marginalized and the central government increases its control over the public’s healthcare decision making.

Obamacare is not working out very well because it is an enormous task to force physicians and consumers to participate in a program that marginalizes the two most important stakeholders, physicians and consumers.

There is little chance that Obamacare will work as intended. Consumers are not interested in becoming commodities.

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

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$3 Trillion And Rising

January 11, 2016

inConsumer Driven Health Care, Stakeholder Mistrust

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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.

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ACOs Are Failing

September 5, 2015

inConsumer Driven Health Care, Disinformation and the healthcare system

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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

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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.

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Lies About Government Spending

August 29, 2015

inChronic Disese Management, Consumer Driven Health Care, Defective scientific studies, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Americans will be older and sicker.

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

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

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

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Medical Care Must Not Be Converted To A Commodity

April 19, 2015

inConsumer Driven Health Care, Disinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Mistrust

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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 A_1c who had problems, it actually was those who had the higher A_1c 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

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Medical Care Must Not Be Converted To A Commodity

April 19, 2015

inConsumer Driven Health Care, Disinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

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

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.

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

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.

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.

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 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 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.

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.

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.

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