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Consumer Driven Health Care


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

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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

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If You Like You Doctor

Stanley Feld M.D.,FACP,MACE

 This is a message for the Republican majorities in the House and Senate. Obamacare is a disaster built on a failed ideology, deceptions and lies.

Obamacare started off with lies and continues to deceive the American public.  

Its emotional seductions have also deceived many physicians.

All one has to remember is Jonathan Gruber’s statement about the lack of transparency being a powerful political tool. Gruber said given the lack of transparency, the public is too stupid to figure out the truth.

President Obama told us; ”If you like your doctor you can keep you doctor, period.”

This statement was not true for an instant. President Obama knew it but ideology trumps reality. Many have blamed Obamacare’s failure on President Obama’s inexperience as a manager. This is not the reason.

The failed progressive ideology of big government controlling choices and freedoms of the American people is the reason for Obamacare’s failure.

Last week, Senator Charles Schumer (D-N.Y.) admitted the passage of Obamacare was a mistake. Not surprisingly, the mainstream traditional media has not mentioned Schumer’s admission.

The mainstream media has been a shill for Democrats and President Obama. It has helped the Obama administration keep the truth from the American public.  

President Obama keeps the American public uninformed with the help from the traditional mainstream media. His goal is central government control of Americans’ choices and freedoms. President Obama’s support is derived from his appeal to Americans’ emotions and not from the facts.

His problem is Americans are not stupid. They can separate reality from appearance when they pay attention. Obamacare is now affecting them directly and they are paying attention.

President Obama is waking up the sleeping tiger of Patient Power.

Obamacare is failing, but Obama’s lies keep coming. One recent lie is Obamacare’s open enrollment period is going well. I have shown evidence to the contrary in my last blog. So far the administration is 50% behind their estimated sign ups.

As of 12/05/2014 open enrollment is still (884,354/1,050,000) behind with 59% of estimates to sign up.


Confirmed 2015 QHPs: 884,354 as of 12/04/14


Estimated 2015 QHPs (Cumulative):11/21: 610K (462K • 11/28: 1.02M (765K
12/05: 1.50M (1.12M (special: 1.64M / 1.23M HCgov)

Thru 12/06: 1.57M (1.18M

 The biggest lie, since “you can keep your doctor, period” is that healthcare spending is decreasing because of Obamacare. This lie is a complicated lie. It is important to understand this lie.

 Obamacare is not lowering healthcare spending. It is increasing healthcare spending. Premiums and out of pocket costs are increasing for consumers.

 As a result of Obamacare deductibles have increased beyond affordability. Consumers cannot afford to utilize their “healthcare insurance” until absolutely necessary. The result will be higher costs when patients are forced to use the insurance because of the development of complications from a chronic disease.

 “The Bureau of Economic Analysis issued its advance estimate of first-quarter growth in 2014, which barely made it into the black with an annualized GDP growth rate of 0.1 percent.

Healthcare spending rose at an annualized rate of 9.9 percent, far outstripping inflation and standing in stark contrast to other components of the BEA report.

 Exports fell 7.6 percent, and demand for imports declined by 1.4 percent. Consumer consumption rose 3.0 percent, but that came in part from the high rate of health-care spending.

Without the spending on health care in 2014 Q1, annualized GDP would have dropped to a recessionary -1.0 percent, according to economist Ian Shepherdson.”

 In 2008, pre Obamacare, the US had seen a drift downward in health-care spending.

 The downward trend began to reverse as Obamacare first officially launched in October 2013. In the fourth quarter of 2013, health-care spending rose 5.6 percent, far above the 2.6 percent growth rate of the economy, to which it significantly contributed.

 The New York Times writes article after article claiming that the cost of healthcare is decreasing. The implication is that Obamacare is working.

 Nothing could be further from the truth.

“The rapid increase in spending does not indicate that the system is working to lower costs, an absurd if not Orwellian construct by President Obama.

“Nor is the debate “over,” no matter how many times Obama claims otherwise. Too bad the White House chose not to take advice from National Journal’s Ron Fournier

“The president risks insulting a vast majority of Americans by dismissing their concerns with a consultant's talking point,” Fournier wrote before the economic figures were released, “and Obama can't afford any more blows to his credibility.”

Consumers are tired of President Obama’s lies. He has lost all credibility with the American public.

The Obama administration keeps telling us how well Obamacare’s Accountable Care Organizations are doing. The Obama administration keeps saying hospital systems must set up integrated healthcare systems (ACOs) to increase the quality of care.  

 Hospital systems have been promised increased revenue incentives by setting up ACOs. Most hospital systems are losing money with their ACO’s.

As a result of losing money hospital systems are dropping out of the federal ACO program.

 This week, the Obama administration published regulations to decrease the hospital systems’ risk and increase its financial incentives, in order to decrease the ACO dropout rate.

President Obama refuses to believe that even though the ACO model sounds great its successful execution is difficult to impossible. 

The chances for ACOs to succeed is not only dependent on the hospital system’s ability to decrease utilization, it is heavily dependent on patients taking responsibility for their own care. Patients must follow instructions.

President Obama believes he can lie his way out of reality. The American public is not buying these lies any more.

Republicans must focus on the reasons for the obvious failures of Obamacare.

Consumers want to have freedom of choice. They do not want the government to control them.

Republican must focus on creating programs to provide incentives for consumers to be in control and responsible for their health and healthcare dollars. 

Republican must focus on ways to permit consumers “to keep their doctors if they like their doctors period.”

My ideal medical saving account will do all of the above.

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

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Obamacare Post Mid-Term Elections

Stanley Feld M.D.,FACP,MACE

The mid-term elections are over. The Republicans captured majorities in the House and Senate. The election was a clear repudiation by the people of President Obama’s policies.

President Obama has denied this reality. He has pledged to pursue his ideological goals that have hobbled the people and the country so badly.

 The polls have indicated that the public is opposed to Obamacare and all of its unintended consequences.

We ain’t seen nothin yet. The unintended consequences are going to escalate starting with the delayed open enrollment season on November 15 2014. This opened enrollment was unnoticed, so Democrats did not suffer any blowback from Obamacare during the mid-term elections.  

Larger categories of people and businesses will be affected by Obamacare’s rules and regulations on January 1,2015. Last year only people in the individual healthcare insurance market were affected.

President Obama continues to mock Republicans by telling them he will be happy to listen to them to see if they have a better idea than Obamacare.

Everyone knows he has no interest in changing or repealing his legacy healthcare law.

The majority of people are dissatisfied with Obamacare. All the Republicans have to do is come up with an idea that is compelling to all of the public. The power of public opinion can demand that Obamacare must change.

 It has to be a simple idea. It has to teach consumers how to be responsible for their health and their own healthcare dollars. It has to educate consumers on how to drive the healthcare system and remove government from controlling their healthcare choices.

The basic problem with our present healthcare system is medical care is fragmented. In addition, all the stakeholders’ vested interests are misaligned. 

President Obama, with his forced passage of Obamacare, has added to the dysfunction of the healthcare system.  .

 Obamacare is meant to be a step toward a single party system. 

 The government cannot afford, and the nation will not accept, a government controlled single party payer system. 

Obamacare does not do anything to repair the distortions of to the system that have led to the dysfunction of the healthcare system pre Obamacare.

The most important stakeholder in the healthcare system is the consumer. Obamacare has marginalized consumers/patients even further.

It was hard for consumers to have notice the dysfunction in the healthcare system because only 20% of consumers use the healthcare system at one time. The remaining 80% thought their healthcare insurance was fine.

Since Obamacare was passed into law it is affecting everyone directly and they are starting to complain.

The current state problem are shown in the figure below.


 A dizzying array of stakeholders is all fighting for a competitive advantage, or at the very least survival, in the dysfunctional current state.

Obamacare’s rules and regulations have made the current state more difficult for everyone.  This is leading to the impending collapse of the healthcare system.

Republican Party should not tinker with legislation to try to fix Obamacare.

It should step in right now and educate the consumers about their consumer power. Republicans need to present a market driven solution that is easy to understand.

 My ideal medical saving account can provide the financial incentives for consumers to act and drive the new healthcare systems.

Once the public understands what they can do, it will change its attitude from the helplessness and hopelessness to an empowered reaction to do something to change the system.  

There are many other things that need to be demanded by the public. I believe empowering the public to demand a market driven system is crucial to a viable and affordable healthcare system.

Almost all the stakeholders believe something must change. The centrally controlled healthcare system’s business model will not work or be sustainable. All one has to do it look at the VA Health System.

Consumers and businesses are becoming frightened and beg the government for help.  The government will institute a single party payer system.

 The result is that consumers will not be able or willing to tolerate a centrally controlled healthcare system.

 As I see it, the nation has two choices: Alternative 1 and Alternative 2.

Alternative 1:

  Alternative 1 future state

 If we extend the course of our present healthcare system to a single party payer system (Alternative 1) the costs will escalate, and access to care will decrease. It is inevitable the rationing of care will occur.

 Alternative 2

Alternative 2 Future state
 Alternative 2 would be a market-based system that would put the consumer in the center of the healthcare system.

Provider systems and administrative systems would have incentive to make its products attractive to consumers at the lowest price possible with the highest quality of care.

Consumers, by owning their healthcare dollars, would have the freedom and resources to choose. Government and its bloated and inefficient bureaucracies should not be making medical care choices for consumers. 

Two things must happen. Republicans must teach consumers the advantages of a market based business model.

 The Republican congressional majority must start teaching all the other stakeholders (physicians, hospital systems, the government, the healthcare insurance industry and Big Pharma) the advantages of this market-based system to their vested interest.

 The alignment of vested interests must start right now and not down the line.

 The Obama administration will dismiss the possibility of a successful market based system. Republicans must not be intimidated. Didn’t they win the election this time?

The Obama administration’s conclusions are based on ideology not past history, logic, fact or evidence.

 The Obama administration and its followers will reject the possibility of success for an incentive driven system instead of a government controlled system.

 A market-based system can be presented in a way where all the stakeholders can buy into a successful consumer driven future state.


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

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I Am Not The Only One

Stanley Feld M.D.,FACP,MACE

Readers ask if I think practicing medicine is becoming more difficult because of Obamacare.

 My answer has been it is becoming impossible to practice medicine. The overwhelming bureaucratic rules and regulations are becoming too difficult to understand and even harder to execute.

Patients will suffer the most because of the disappearance of a physician-patient relationship. Patients are being converted from patients to commodities.

Why don’t more physicians protest? Why don’t they describe their problems in the age of Obamacare?”

There are complex reasons that there has not been an organized physician outcry.

Organized medicine (AMA) and other organizations representing specialties in medicine and surgery are afraid to lead an outcry. Their main goal is to not lose their seat at the table.

This is strange goal. Politicians and their health policy advisers have ignored organized medicine for the last 50 years. Many smart physicians in or out of these organizations have tried to have their voice heard but have failed.

Since Medicare was passed (the last 50 years) there have been many outrageous changes proposed by non-physicians The healthcare policy changes were proposed to decrease the increasing cost of healthcare. Instead these changes have increased the cost of care.



The politicians and healthcare policy advisers are always changing the wrong policies. They are always putting more power into the government bureaucrats and healthcare industry’s hands rather that putting power into the patients’ hands.

Physicians who have seen these policy changes work out for their benefit are hesitant to participate in an Obamacare protest. These physicians assume Obamacare will also work out well for them

However, physicians do not realize that their intellectual property and surgical skills have been devalued with each of the present changes in healthcare policy.

In a 2006 blog I described how to cook a frog without the frog jumping out of the pot water. Everyone knows that you increase the temperature of the water one degree at a time. When the frog realizes what is going on he is too weak to jump out.

Obamacare has increased the temperature of the water to an intolerable level. At present few frogs have the energy to jump out of the water.

Most of the changes in Obamacare are going hurt patients by decreasing access to care and rationing of care. The physician/patient relationship has also been destroyed.

Dr. Mark Sklar, a Clinical Endocrinologist in Washington D.C., had enough energy to jump out of the hot water. He launched his protest in an excellent article and got the attention of the editors of the WJS.

My hope is Dr. Sklar’s article will launch a consumer protest demanding that a change be made from Obamacare to a healthcare system that will empower consumers.

The new healthcare system should be a consumer driven healthcare system that puts consumers in control of their health and healthcare dollars. The control of the healthcare system should not be in the government’s or the healthcare insurance industry’s hands.

A consumer driven healthcare system should provide incentives to consumers to remain healthy, and provide financial reward if they do. It should also make shopper of consumers.

A consumer driven healthcare system will drive the other stakeholders into a competitive mode to vie for the business of the consumer.

The financial reward should be for consumers, not to the healthcare insurance industry, government, hospital systems or physicians.

I want to echo Dr. Sklar’s protest. I will try to help Dr. Sklar  make his article  a wake up call for consumers.

Consumers are the only stakeholders that can turn the destruction of the medical system around.

Consumers elect politicians. Politicians like the advantages and perks they receive from their elected positions. Politicians are afraid of the consumers that vote to reelect politicians. They will comply with their voters demands.

Below is Dr. Sklar’s article listing most of the issues that are making the delivery of healthcare very difficult.

"Doctoring in the Age of ObamaCare"

"Endlessly entering data or calling for permission to prescribe or trying to avoid Medicare penalties—when should I see patients?


Sept. 11, 2014 7:35 p.m. ET

‘It has been four years since the passage of the Affordable Care Act, so I thought it may be useful to provide the perspective of a physician providing daily medical care. I am an endocrinologist in Washington, D.C., and have been in solo private practice for 17 years after seven years at an academic institution. Since 1990, the practice of medicine has changed significantly, seldom for the better.

In the 1990s insurance companies developed managed-care plans that greatly increased their profits at the expense of the physician. With the Affordable Care Act, we are seeing new groups profiting from changes to the health-care system. Entrepreneurs and hospital executives are capitalizing on organizing physicians into groups called Accountable Care Organizations from which they will take a very substantial percentage of collected income. Now that physicians are being required to use electronic medical records, the companies that develop them are harvesting money from physicians' practices and from hospitals.

The push to use electronic medical records has had more than financial costs. Although it is convenient to have patient records accessible on the Internet, the data processing involved has been extremely time consuming—a sentiment echoed by most of my colleagues. To save time, I was advised by a consultant to enter data into the electronic record during the office visit. When I tried this I found that typing in the data was disruptive to the patient visit. My eyes were focused on the keyboard and the lack of direct contact kept patients from opening up and discussing their medical and personal problems. I soon returned to my old method of dictating notes and pasting a print-out of the dictation into the electronic record.

Barrier between patient and physician
 David Klein

Barrier between Patient and Physician

Yet to avoid future financial penalties from Medicare, I must demonstrate "meaningful use" of the electronic record. This involves documenting that I covered a checklist of items during the office visit, so I spend 90 minutes each day entering mostly meaningless data. This is time better spent calling patients to answer questions or keeping updated with the medical literature.

If electronic records ever allow physicians to obtain data from previous laboratory and imaging testing, it will improve costs and patient care. So far, however, the data in electronic records—like paper charts—can't be shared unless physicians work in the same health-care system.

My practice quickly adopted the new Medicare requirements for electronically prescribing medications. Yet patients often do not want their prescription sent electronically. They want a physical copy—either because they don't trust the Internet or because they don't need to fill the prescription immediately. If I don't electronically prescribe for a certain number of Medicare patients, I am penalized with a decrease in reimbursement that can rise to a maximum of 5%. Patients should have a choice in how their prescriptions are delivered, and physicians shouldn't be penalized for how the patients choose.

To prevent physicians from prescribing more costly medications and tests on patients, insurers are increasingly requiring physicians to obtain pre-authorizations. This involves calling a telephone number, often being rerouted several times and then waiting on hold for a representative. The process is demeaning and can take 30-45 minutes. Rather than having physicians pre-authorize expensive medications, the outrageous costs of many non-generic medications must be addressed. I understand that pharmaceutical companies need to make profits to cover investments in drug development. However, they should have some compassion for their customers.

To avoid Medicare penalties, I also must participate in the Physician Quality Reporting System program. Initially, this involved choosing three codes during the patient visit to reflect quality of care, such as blood pressure or blood-sugar control, and reporting them to Medicare. In 2015, the requirement will increase to nine codes.

Coming down the pike, but thankfully postponed from the October 2014 deadline, is something called ICD-10. This is a newer system that will contain about 70,000 medical diagnostic codes used for billing insurance. The present ICD-9 system has about 15,000 codes. The Physician Quality Reporting System and ICD-10 requirements are intended to benefit population research, but the effect is to turn physicians into adjuncts of the Census Bureau who spend time searching for codes—and to further decrease the amount of direct contact with patients.

The practice of medicine in the current environment is unsustainable. The multiple bureaucratic distractions in my day consume so much time that I have to give up what little personal time I have in the morning, evening and on weekends if I want to continue to provide excellent care during office hours.

If high-quality medical care is the goal, the bureaucracies need to be tamed. Our government and insurance companies understandably want to measure outcomes of health-care dollars spent. However, if the health-care system rewards data entry, that is what it will get—the quality of care seems an afterthought.

The patient should be the arbiter of the physician's quality of care. Contrary to what our government may believe, the average American has the intellectual capacity to judge. To give people more control of their medical choices, we should move away from third-party payment. It may be more prudent to offer the public a high-deductible insurance plan with a tax-deductible medical savings account that people could use until the insurance deductible is reached. Members of the public thus would be spending their own health-care dollars and have an incentive to shop around for better value. This would encourage competition among providers and ultimately lower health-care costs.

By contrast, the Affordable Care Act's plans for establishing "medical homes"—a team-based health-care delivery model—and accountability-care organizations will only add more bureaucracy and enrich the consultants and companies organizing these entities.

To improve quality, we need to unchain health-care providers from the bureaucracies that are strangling them fiscally and temporally. We can better control medical costs if we strengthen physicians' relationships with their patients rather than with their computers.”

“Dr. Sklar is an assistant professor of medicine at the Georgetown University Medical Center and at the George Washington University Medical Center.”

I hope all the consumers of healthcare can feel the pain physicians are experiencing in delivering care on their patients behalf because of Obamacare.

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

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A CMS Mistake!!

Stanley Feld M.D.,FACP,MACE

For years practicing physicians knew that hospital outpatient clinics charges were 30-60 percent higher that physicians’ free standing clinics.

CMS didn’t know it or didn’t want to know it.

CMS administers Medicare and Medicaid. CMS was restricting payment for outpatient procedures and tests done in freestanding practicing physicians’ offices while paying higher fees for the exact same outpatient hospital procedures and tests.

As rules and regulations and the complexity of the business of practicing medicine in private freestanding outpatient clinics increased physicians sold their practices to hospital systems.

The government and the healthcare industry encouraged these sales by increasing the complexity of running a private practice.

The probable logic was they would only have to deal with one entity (the Hospital System) rather than 600 individual doctors or clinics using that hospital system.

The government’s excuse for cutting out freestanding individual practices and clinics was efficiency and patient safety.

The hospitals were overjoyed to be able to buy physician practices.

“As the Affordable Care Act attempts to steer people away from pricey hospital inpatient admissions, hospitals have begun buying up doctors’ offices in hopes of increasing their revenue and market share.”

The hospital systems’ then discovered they were losing money by buying physicians’ free standing practices.

 In essence they were trying to buy physicians’ intellectual property and surgical skills because the traditional brick and mortar hospital building was becoming less profitable. Many surgical procedures were being done as outpatient procedures.

Physicians were less productive as hospital employees than they were when they owned their own practices. They were guarantied a salary.

Hospitals did not bother to calculate the money they made from doing the entire outpatient testing and procedures when presenting the loss to the government.

Hospital systems have been selective, first buying Primary Care Physicians’ freestanding office practices. Next they started trying to buy oncology practices.

The number of oncology practices owned by hospitals increased by 24 percent from 2011 to 2012. By turning what used to be independent medical offices into so-called hospital outpatient centers, hospitals are creating networks that, critics say, give them the power to set prices and ultimately raise costs for private insurers and government programs such as Medicare.”

To further encourage physician owned clinics to migrate to hospital system owned practices the government and the healthcare insurance industry provided separate revenue codes to allow hospital systems to collect more for the same tests and procedures done in physicians’ free standing offices.


“The Medicare Payment Advisory Commission, which advises Congress, are sounding the alarm. In May, MedPAC Executive Director Mark Miller testified before a House panel that these price differences “need immediate attention.”

 Medicare should align rates “to limit the incentive to shift cases to higher cost settings,”

The hospital systems’ excuse for the higher charges is it has higher operating costs than freestanding clinics such as running an emergency room.

Hospital systems receive higher reimbursement than private freestanding clinics doing the same procedure or delivering the same treatment.

The hospital system’s retail price is much higher than what it receives from CMS and the healthcare insurance industry. The discount price is somewhere around 50%

Even with the discount the hospital systems’ prices are 30-50% higher than the freestanding clinics’ prices.

The glossary of charges and discounts should be available to all consumers of healthcare. None of the prices are transparent. Patients’ have to fight hard to get the prices.

The focus or reports of prices has been on the outrageous prices for cancer drugs.

“A treatment of Herceptin, a breast cancer drug from Genentech, cost private insurers $2,740 when used in an independent clinic and $5,350 in a hospital outpatient setting, according to an analysis of 2012 claims by PricewaterhouseCoopers’ Health Research Institute.”

“The price of Avastin, another Genentech cancer drug, increased from $6,620 to $14,100, the Health Research Institute says.”

Echocardiograms in a hospital facility are reimbursed at twice the price as the reimbursement in a private physician owned facility. 

Dr. Keith Smith with the Oklahoma Surgical Center charges less than some patients’ deductible for some surgical procedures without accepting Medicare or private insurance.

If Medicare paid the lower office rate for 66 outpatient services even when they’re performed in hospital-owned facilities, the government would save $1 billion a year and lower Medicare patients’ bills by $200 million, MedPAC Executive Director Mark Miller said before the House panel. Medicare insured 49 million Americans at a cost of $573 billion in 2012.

This is an analysis of only 66 outpatient procedures. There are hundreds of outpatient procedures. Imagine the savings if all the procedures were captured.

Hospital outpatient visits for echocardiograms jumped 33 percent from 2010 to 2012, MedPAC found, while visits to independent offices declined. Echocardiograms cost more than double in hospital-owned locations.”

As hospital system merge the price will go up even further. The hospital systems are now negotiating from a position of strength. Hospital systems are making the money as private physicians’ reimbursement shrinks.

The government and the healthcare insurance industry are finding their scheme to destroy private practice was a big mistake.

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

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Physicians Are Getting Ready To Fight Back



Stanley Feld M.D.,FACP, MACE

Practicing physicians’ frustrations with the healthcare systems are mounting. It is clear that patients are not first. The secondary stakeholders such as the healthcare insurance industry, pharmaceutical companies, hospital systems and the government come before patients in the healthcare system. Money is first for these stakeholders.

The government tries to control its cost as it outsources most of its administrative services to the healthcare insurance industry.

The healthcare insurance industry, pharmaceutical companies and hospital systems try to maximize their profits by trying to get around many of the government’s complex regulations.

The result of maximizing profit is abusing patients’ ability to get medical care and physicians’ attempts to deliver medical care.

Traditional healthcare insurance is not the only way of paying for patient care. It is the most expensive way. Traditional healthcare insurance is most prone to political and moral corruption.

Moral and political corruption leads to increased insurance processing costs which lead to higher premiums and higher deductibles. This leads to less health insurance coverage.

Recently, I wrote about physicians being pawns in the healthcare system. They are the easiest to attack because they are the least organized.

Physicians are the easiest to abuse by the secondary stakeholders because they believe patients come first. Physicians are too busy taking care of their patients to figure out how to respond.

A reader sent me an article that appeared in the Dallas Morning News illustrating a tiny fraction of the abuse physicians take and the lack of respect they encounter when their orders interfere with the healthcare industry’s profit.

The article is about the need for prior authorization to reduce drug costs in an insured patient. As you read this, think of the increase in the insurance company’s administrative waste, and the disrespect for the physician’s time and judgment.

Millions of prior authorization letters are sent every day for drugs, hospitalizations, and treatment plans. They are the result of actions that do not fit into a healthcare insurance company’s computer algorithm.

Insurance company workers know little about medical care these prior authorizations are challenging. These workers know little about medical judgment or medical care.

The healthcare insurance industry believes it is an effective way to prod physicians away from more expensive treatments and toward less expensive alternatives.

It makes it harder to prescribe costlier medications. In reality, it is a wasteful administrative nightmare.

The letter in my hand concerned one of my patients, Mr. V., who suffers from stubborn hypertension. His chart is a veritable tome, documenting the years of effort it took to find the combination of four different blood-pressure medications that controls his hypertension without upsetting his diabetes, kidney disease and valvular heart disease or making his life miserable from side effects. We’ve been on stable ground for a few years now, a state neither of us takes for granted.

But Mr. V. had changed insurance companies, and now one of his medications required a prior authorization. The last thing I wanted was for him to be turned away at his pharmacy and have his blood pressure spiral out of control, so I called right away to sort things out.

Twenty minutes of phone tree later, I discovered that the problem was that I had exceeded a pill limit for one of his medications. Mr. V. needed to take 90 of those pills each month for the high dosage that his blood pressure required. I patiently explained this to the customer care representative.

Equally patiently, she told me that 45 pills a month was the maximum allowed for this particular medication.

Three more phone trees and three more customer care representatives later, my patience was flagging. Apparently a request for 90 pills was flummoxing the system. Representative No. 4 went down her checklist. “Would taking 45 pills per month instead of 90 pills adversely affect Mr. V.’s health?” she asked.

At first I thought she was joking. “Well,” I replied, “it would probably make his blood pressure shoot up in the second half of the month.”

She paused, then asked her next question with the encouraging uplift of suggestion. “Has Mr. V. ever tried 45 pills per month instead of 90 pills?”

Then I realized that she was not joking. “Are you out of your mind?” I hollered into the phone. “It’s taken years — years! — to find the right combination of meds to control his blood pressure without killing his kidneys or making him dizzy or nauseated or depressed or ruining his libido or running his potassium off the charts or breaking his bank account. Do you really think I’m going to randomly jiggle the dosages just for the hell of it?”

“A simple yes or no will suffice, doctor.”

This interaction demonstrates a lack of respect for the physician and his judgment, and a lack of understanding of the patient’s illness. I have said over and over again that you cannot commoditize patients’ illnesses or physicians’ skills.

If the insurance company’s computer system has a beef with physicians’ judgment it should get a second opinion by a neutral expert physician in the field of hypertension to review the chart and the patient’s illness. 

The writer says,

 I bit my tongue for the remainder of my conversation with the insurance company, holding back long enough to obtain the prior authorization that would allow Mr. V. the 90 pills he needed each month. I tried not to break the phone when I finally slammed down the receiver.”

These interactions are not good for physicians’ health or morale.

They increase physicians’ cynicism.

 “I’m all for controlling medical costs and trying to apply rational rules to our use of expensive medications and procedures. But in the current system, everything seems to be in service of the corporate side of medicine, not the patient. The clinical rationale and the actual patient — not to mention the doctors and nurses involved in the care — are at best secondary concerns.

In the end, we were able to keep Mr. V.’s blood pressure under control. My blood pressure, however, was a different story.”

These interactions go on daily and waste physicians’ time and energy. Physicians have no ability or representatives to fight back. However, they are ready to fight back. All they need is someone to come up with a plan.

A good start is changing the paradigm of healthcare insurance so that it is a consumer driven healthcare system with consumers being in charge of their healthcare dollars and their health. 

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

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Drug Pricing Is Weird

Stanley Feld MD, FACP,MACE

Many of my readers have asked me to explain drug pricing. I have not covered the pharmaceutical industry’s pricing in this blog because I have not been able to figure out drug pricing.

I do know there is a lot profit in both the retail and wholesale drug business. I know government pricing is different that benefit management pricing. I know there has been a growth in drug benefit management companies.

My sense is neither the pricing for Medicare Part D or private insurance drug benefits are for the patients’ advantage.

I recently asked a good friend Dr. Dale Fuller, a retired radiation oncologist, to explain the outrageous cost of oncology drugs (Drugs used to treat patients with cancer).

I wanted to know the reason the government pays almost twice as much to hospitals for the same treatment patients get in the oncologist’s office even though the treatment is given by the same oncologist.

I have added a couple of comments to Dr. Fuller’s note into the body of his reply.


Dr. Fuller writes,


"Is pharmaceutical pricing weird, or what?"

Dale Fuller M.D.

"Lately I have been thinking about pharmaceutical pricing, and as an old pharmacist turned radiation oncologist, it was the pricing of cancer drugs that caught my interest.

Then, my wife showed me some information about a product called “Symbicort” that she uses on a regular basis. 

Introduced into the US in March of 2009, it goes off patent in 2014.  The other day she brought home a 90 day supply for which she had paid $120.00, and Medicare part D allegedly paid $839.89.  At least, the package from Walgreen’s informed her that her “insurance had saved her that $839.89”.

The $839.89 plus the $120 or $959.89 is going to be charged against her Medicare Part D donut.

During the initial coverage phase, you pay a copayment or coinsurance, and your Part D drug plan pays its share for each covered drug until your combined amount (including your deductible) reaches $2840.

Once the patient and the patient's Part D drug plan has spent $2,840 for covered drugs, the patient will be in the donut hole.

Previously, the patient had to pay the full cost of your prescription drugs while in the donut hole.

Starting 2011, the patient gets a 50% discount on covered brand-name prescription medications. The donut hole continues until your total out-of-pocket cost reaches $4,550.

This annual out-of-pocket spending amount includes your yearly deductible, copayment, and coinsurance amounts.

When you spend more than $4,550 out-of-pocket, the coverage gap ends and your drug plan pays most of the costs of your covered drugs for the remainder of the year.

The patient will then be responsible for a small copayment. This is known as catastrophic coverage.

In 2014, Medicare will pay 28% of the price for generic drugs during the coverage gap. You'll pay the remaining 72% of the price.

What you pay for generic drugs during the coverage gap will decrease each year until it reaches 25% in 2020—in 2015, you'll pay 65% of the price for generic drugs during the coverage gap.

Confusing isn’t it.

 That would be a total of $959.89 for her 3 months’ supply of medication, or $319.96 a month, or $2.67 a squirt, of which there are four a day.  Who knows how much Uncle Sam actually paid Walgreen’s for his share of the bill.

 How to save 85% on Symbicort.

However a senior cannot buy this inexpensive brand named Symbicort using his Medicare Part D drug plan because he would be buying it from a Canadian Pharmacy.

So much for competitive innovation in a global economy. Government control trumps innovation.

Similar abstruse drug pricing strategies exist in abundance in the field of medical oncology.

Consider first the situation in the office of the medical oncologist.  The physician purchases pharmaceuticals from a supplier.  He must retain at least a basic inventory of frequently used products, some of which are very expensive.

The “acquisition cost” becomes the basis for the reimbursement the doctor receives from Medicare for the drug.  To the acquisition cost the doctor was allowed to add 6%, which was intended to cover the preparation for administration.

The actual infusion of the medication in the doctor’s infusion room, including the cost of the nurses working there, was reimbursed at a rate of $133 per hour (“chair time”).  Keep that figure in mind.

The US budget debacle in which Uncle Sam cut everything he paid for by 2%, actually amounted to a 33% reduction in the 6% the doctor was allowed,  leaving ~4% to underwite the preparation for administration of the drug required for the care of a Medicare patient.

There are other patients who come to the infusion room, as well.  Some have private insurance, and some have no insurance at all.

The private insurance may carry a different level of reimbursement for pharmaceuticals from that paid by Medicare, or it may not.

Very few uninsured patients have the wherewithal to pay out of pocket for the cost of their care.  The doctor has two choices in handling their situations:  charity or referral to a hospital where the cost of chemotherapy agents and their administration is handled in a different way.

The absence of any significant profitability for many medical oncologists has resulted in the closure of at least 400 practices between 2007 and 2012, and closures continue to this day.  Patients in these situations have been forced to seek outpatient infusion services in local hospitals, where administration reimbursement to the hospital is an average of $299 per hour in comparison to $133 in the doctors’ offices.

It is said that hospital outpatient infusion services use more drugs (see below for how they are acquired), charge higher prices, and require higher co-pays from patients.  Go figure.

And, don’t forget the drugs!  Doctors are now reimbursed by Medicare at acquisition plus 4%, while hospitals, under “340B” programs enjoy a margin of about 30% versus the doctors’ 0-2%.

Remember the Symbicort example I started with?  The 304B acquisition price for  Symbicort  is listed at $88!  Even with a 50% markup for a patient, a month’s supply would come to  $132. Go figure.

 The evolution of this mess has prompted a congressional advisory organization called MedPac to call for changes to equalize payments for oncologists’ care in their offices as compared to payments for services provided in hospital outpatient departments.  And, who can argue against the creation of a level playing field?

Symbicort is now generic. I tried to find the price of the generic drug. I could not without providing a prescription. Go Figure.  Is this transparency?

Patients and physicians are being taken advantage of here. They are the pawns that drive the profits in the healthcare system.

Someone has to stop it for the sake of good medical care delivery.

I wish to thank Dr. Dale Fuller for this submission.

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

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The Wrong View Of The Right Problem

Stanley Feld M.D.,FACP, MACE

Most of the stakeholders in the healthcare industry are not stupid. Most understand the issues very well.

The problem is they all look at the same problem from the prism of their own vested interest. Each government action causes these stakeholders to react in their vested interest.

Each reaction causes a compensatory reaction from the other stakeholders, which in turn causes another chain of reactions.

The healthcare system becomes further twisted into a tighter non-functioning hairball that is more expensive than previously.

Aetna CEO Mark Bertolini was the keynote speaker at HIMSS14. His analysis was correct He said,

“Antiquated systems and out-of-control healthcare costs in the United States are not sustainable.”

He went on to say the healthcare system is plagued by inefficiency and waste.

“ We can’t afford it. It’s unsustainable.”

Employees are now paying 41 percent of their healthcare dollars to the healthcare insurance industry. It includes premium costs, deductibles, and copays.

These costs consume much of employees’ disposable income.  Mark Bertolini predicts that employees will be paying 50% in 5 years as insurance premiums increase.

Mark Bertolini is really saying consumers will stop buying insurance soon. The result will be a decrease in Aetna’s profit.

Who is at fault?

All the stakeholders are at fault. Consumers are at fault for not taking care of themselves. The incidence of the onset of all chronic diseases increases with the incidence of obesity.

When there is an increase in chronic disease there is an increase in the complications of chronic diseases.

Eighty percent of the money spent on treating that chronic disease is spent on treating the complications of that chronic disease.

Patients must manage their chronic diseases under their physicians’ direction. The patient lives with that disease 24/7.

Patients must be taught to be the “Professor of Their Disease” so that they do not get a complication of that disease.

Patients must also be given financial incentives to become the manager of their disease. This incentive can be developed in many ways.

Reimbursement for education is not routine. There is little financial incentive for physicians to set up educational systems.

Hospitals at one time set up educational systems for chronic disease. They found them a financial burden and discontinued them.  The educational systems did not distinguish one hospital from another.

The educational systems were not set up correctly. They should have been set up as an extension of the patient’s physician’s care.

I believe the healthcare insurance industry really wants to lower costs while retaining the profit margins enjoyed in the pre and post Obamacare era.

Aetna’s Bertolini got it right. “We can’t afford it.”

“If we really want to take care of people, we should align incentives around keeping them healthy.”

He is right. His problem is he thinks he controls patients and patient care.

The government thinks it controls patients.

Physicians know they do not control their patients’ behavior.

Neither the healthcare industry and government nor physicians controls patients.

Patients control themselves.

Bertolini said. "Recent data compiled by Aetna found that the top 5 percent of Medicare patients consumed 43 percent of Medicare dollars. They spent on average $108,000 a year per person."

The demographics of these patients disease including past and present lifestyle are not discussed in the data mining survey. This information would be helpful to know the true meaning of this data.

He then concludes, “Let’s not keep sending these people around with 25 different prescription and all these different doctors and hospitals.

Who is the stakeholder sending patients to all the different hospitals and giving all the different prescriptions.

Physicians, of course!

Therefore, let us penalize physicians for spending all this money on our patients.

This is the wrong way to look at the problem.

If there was meaningful Tort Reform, physicians wouldn’t be doing so much unnecessary testing and treating to avoid missing something that could result in a malpractice suit.

If there were meaningful incentives for patients to be responsible for themselves people would stay healthy.

Patients should be responsible for their healthcare dollars not the government or the insurance industry.

People should also be rewarded if they stay healthy just as the auto insurance industry rewards drivers who do not have an accident.

If the government made a meaningful effort to change our eating habits through meaningful education much illness and medical costs would be reduced.

The center of the new healthcare system should be the patients. It should be a consumer driven system.

As soon as all the secondary stakeholders focus on that fact and start helping instead of penalizing patients and their physicians, the cost of the healthcare system will come down.

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

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