Defective scientific studies

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Here Comes The Defective Judge (CMS)!

July 29, 2012

inDefective scientific studies, Medicine: Healthcare System

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Stanley Feld M.D., FACP, MACE

President Obama’s goal is to have the government be the single party payer for the entire healthcare system.

There is no doubt in my mind that the government as the single party payer will not work for patients or physicians.

President Obama cannot control CMS’s misuse of it assignments because bureaucratic complexity. One area of abuse and misuse of the department’s power is its attempt to eliminate fraud and abuse in Medicare and Medicaid.

There is no question that some healthcare providers abuse the Medicare and Medicaid payment system.

No one ever asks the critical question. Should the payment system used in Medicare and Medicaid be changed to prevent fraud and abuse?

Never the less President Obama is expanding the old punitive system. He thinks he is going to stop abuse with his expansion.

“ Stepping up their game against health care fraud, the Obama administration and major insurers announced Thursday they will share raw data to try to shut off billions of dollars in questionable payments.”

I don’t know how many times I have shown that claims data to determine quality of care or fraud and abuse is defective.

"Fraud is estimated by the administration to cost Medicare about $60 billion a year, and the Obama administration has beefed up the government's efforts to stop it, bringing in record settlements with drug companies for marketing violations as well as using new powers in the health care law to pursue low-level fraudsters with greater zeal."

This is a small amount compared to the $2.5 trillion dollar healthcare system cost when one considers the government’s investigative costs and the hardship these errors impose on many innocent physicians and patients investigated.

The hardships are enough to destroy physicians’ trust in the government and their desire to deal with the government.

It also serves to destroy the physician patient relationship.

Physician patient relationships are essential to the therapeutic success of a treatment regime.

Physicians have complained about this bureaucratic abuse to their congressmen. Congress has looked into this abuse. CMS’s approach has been to criminalize physicians using questionable data and decisions by unqualified judges.

Chairman Charlie Gonzalez of the House Small Business Committee outlines the problems brought to his attention several years ago. His hearings did not receive much attention.

Opening statement by Chairman Charlie Gonzalez

http://www.youtube.com/watch?v=0SmKmLMPu-s&feature=relmfu

Dr. Karen Smith a former President of the North Carolina chapter the American Association of Family Practitioners describes her encounter with CMS’s subcontractor for investigating fraud and abuse. CMS’s assignment is to discover Medicare and Medicaid underpayment or overpayment as well as fraud and abuse.

http://www.youtube.com/watch?v=3v4Sq7oDCgo&feature=player_embedded

I believe it is important for anyone who is interested in what is happening to the healthcare system to view the several You Tubes I am including in this blog.

Dr. Michael Schweitz, Vice President of The Coalition of State Rheumatology Organizations in West Palm Beach, FL discusses the defects in the RAC system and the need to change.

http://www.youtube.com/watch?v=E5K8iPqsmjY&feature=relmfu

Dr. Schweitz states that administrative costs in dealing with the government is overwhelming to physician practices. The stress imposed on physicians detracts from their ability to deliver quality medical care to their patients.

Most important is the government’s attitude toward the physicians and their practices. The physicians are guilty until they prove themselves innocent. Government’s subcontractors use claims data to prove the physicians guilt

Another problem is the more the outsourced company collects from physicians, the larger the commission it collects from CMS.

Mr. Timothy B. Hill is Chief Financial Officer, Director of the Office of Financial Management, Centers for Medicare & Medicaid Services. He answers questions from Chairman Charlie Gonzalez

http://www.youtube.com/watch?v=FBpXubSY8O8&feature=relmfu

The questions continue to Mr. Hill. He says CMS recognizes its abuse of physicians. He hopes to improve.

Since Obamacare has expanded physicians’ complaints have increased.

http://www.youtube.com/watch?NR=1&feature=endscreen&v=uRX1M31T8LA

Can anyone believe this testimony given by Mr. Hill? I hope his message is not believed by congress. Mr. Hill does not document his department policy changes

“ This week White House officials said a "trusted third party" would comb through data from Medicare, Medicaid and private health plans and turn questionable billing over to insurers or government investigators. That third party organization has yet to be selected.”

With the impending a thirty percent reduction in Medicare payments on January 1, 2013 physicians will not be able to afford care for Medicare and Medicaid patients.

Mr. Joseph A. Schraad, MHA Chief Executive Officer Oklahoma Allergy and Asthma Clinic, in Oklahoma City, describes the challenges that the practice he manages face. Less and less providers are going to accept Medicare.

http://www.youtube.com/watch?v=cINHOZmo_wA&feature=relmfu

Dr. Forrest in his direct care payment model for patients describes the formula he uses to avoid the government’s interference with his practice of medicine. He talk is riveting.

http://www.youtube.com/watch?v=dUX4P7XfY8o

Other formulas can be used. The You Tubes presented here demonstrate that the Judge (CMS) is using the wrong formula. The CMS cannot control their outsourced venders who have inappropriate incentives.

The are driving physician away from accepting Medicare and Medicaid payments. In the process patients lose

The way to solve fraud and abuse is to have patients police the healthcare system. Patients can uncover fraud and abuse if they own their healthcare dollar and have financial incentives to save unspent money in a retirement fund.

Education and financial incentives will make consumers productive consumers.

The way to approach physicians is not to assume they are criminals and subject them to the stress and expense to defend them in a defective evaluation system.

Physicians must be educated on how to improve coding efficiency and the government’s system of measurement must be made more accurate and less complex. ICD 10 is a big mistake. It makes coding complicated.

The best formula, in my opinion, is to empower and educate patients.

Government and employers must provide patients with financial incentives to become educated buyers of medical care services. Patients must be given the opportunity to own their healthcare dollars and be responsible for their own health and healthcare.

My ideal medical savings account provides patients with that opportunity.

Physicians collect only 10% of the healthcare dollars spent.

The real question is who collects the remainder of the 2.5 trillion dollars spent?

America should not depend on increased bureaucracy and bureaucratic staff to administer medical care with increased and confusing rules.

Everyone knows this will only result in increased inefficiency and higher costs.

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

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Let’s (Not) Get Physicals

June 12, 2012

inDefective scientific studies

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Stanley Feld M.D.,FACP, MACE

When ELISABETH ROSENTHAL’s article was published in the New York Times on June 3,2011, I bristled.

This article could be President Obama’s way of using the traditional media to set us up for restricting access to care as the government is moving toward complete control of medical care.

In my opinion this New York Times healthcare article does not inform consumers. The article Let’s (Not) Get Physicals confuse consumers.

The article implies the US Preventive Task Force (USPTF) has advocated no more physicals and no more standard lab screenings.

“The last few years have produced a steady stream of new evidence against the utility of popular tests:

“Prostate specific antigen blood tests to detect prostate cancer? No longer recommended by the United States Preventive Services Task Force.

Routine EKGs? No use.

Yearly Pap smears? Nope. (Every three years.)

The only routine blood test currently recommended by the United States Preventive Services Task Force is a cholesterol check every five years.”

The U.S. Preventative Services Task Force is a precursor to President Obama’s Independent Payment Advisory Board (IPAB). Many physicians object to a non-specialty board of physicians deciding unilaterally on best practices in specialties they do not represent.

One of my chief objections to the USPTF is its method of evaluating clinical research.

President Obama’s Independent Payment Advisory Board (IPAB) is going to reimburse physicians on the recommendation made by the USPTF without consulting subspecialty experts and dismissing clinical experience or judgment.

The USPTF should present its finding to the clinical specialists’ organizations in open forum for debate. There is plenty wrong with many of evidence based medicines’ conclusions.

Otherwise, the USPTF’s conclusions will simply undermine the patient physician relationship.

I believe I am qualified to critique the USPTF’s conclusions about osteoporosis in males.

The USPFT conclusions are dead wrong about evaluating and treating 70 year old men who might have osteoporosis. It is true that there are no large, long term, clinical studies evaluating the value of Bone Mineral Density studies and treatment of males over 70 years old for osteoporosis.

The USPTF concluded there is no clinical evidence to prove that osteoporosis evaluating and treatment in men is necessary. True, but it does not follow that if bone density studies are done and treatment started the treatment would not reduce the incidence of hip fracture by 50% as it does in women.

The incidence of osteoporosis in 70 year old men is high. All anyone has to do is go to a Wal-Mart anywhere in the nation on a Monday morning and stand at the front door. Clinical observation of retired 70 year old men will provide evidence for osteoporosis’ prevalence.

These men should be evaluated by bone density and then treated to prevent further fractures.

It would be cheaper for Obamacare to do this evaluation than restrict evaluation because of the lack of large studies to evaluate and treat.

The subsequent hip fractures will cost more in terms of morbidity, mortality and dollars than restricting access to early evaluation and treatment.

The government should collect the data to see how many men over 70 years old develop hip fractures. Then, calculate the cost of those hip fractures to Medicare against the cost of evaluation and potential treatment.

Males with osteoporosis do not present with back pain at the onset of a vertebral compression fracture. These fractures are mostly silent compared to women’s vertebral fractures. They will have a decrease in height and a low bone density.

It is not enough for the Obama administration to say it is interested in prevention of disease when it restricts access to prevention measures.

It is not right to restrict access to steps needed to prevent the debilitating or deadly complications of hip fracture.

“The USPSTF concludes that, for men, evidence of the benefits of screening for osteoporosis is lacking and the balance of benefits and harms cannot be determined.”

†For a list of current Task Force members, go to www.uspreventiveservicestaskforce.org/about.htm#Members.

I do not see one osteoporosis specialist in the entire task force group.

The USPTF recommendation is in the vested interest of the government and the healthcare insurance.

" Dr. Mehrotra, an assistant professor at the University of Pittsburgh School of Medicine, has estimated that unneeded blood tests during physical exams alone cost $325 million annually.

The healthcare insurance industry and the government take 40% off the top of every healthcare dollar spent.

What percentage of the $2.5 trillion dollar healthcare bill is spent on the complications of chronic disease such as osteoporosis and other chronic diseases. The answer is 80% of the direct patient care dollars spent. The direct care dollars are $1.5 trillion dollars (150,000,000 million dollars) makes $325 million dollars a trivial amount at 2.16%. of the total spent on healthcare.

If Dr. Mehrotra was misquoted and the number is $325 billion dollars then the total spent on direct care for physicals and lab testing is 21.6%. or 11% of the total $2.5 trillion of healthcare dollars spent.

To me the trend to reduce physical examinations and lab screening is a ridiculous trend. The present spending probably should be modified some but not discontinued.

It has been shown it takes 8 years from the onset of asymptomatic Type 2 Diabetes Mellitus for a complication, myocardial infarction to occur. Diabetes Mellitus is first discovered in the cardiac ICU 8 years after the onset of Diabetes.

It has also been shown that males avoid going to physicians unless they are sick.

If Diabetes Mellitus was discovered early and treated effectively, there is a 50% chance the myocardial infarction could have been avoided.

Many diseases can be discovered on physical examination and routine lab testing. I takes time in the course of the natural history of a disease for the disease to become symptomatic or develop complications.

If discovered early and treated the complications of that disease can be avoided. Many patients’ lives can be saved with proper treatment.

USPTF drawing conclusions without input from specialists is dangerous and irresponsible.

Ignoring the diagnosis can be more costly in the long run for the government than avoiding testing for the diagnosis.

I have pointed out previously the poor quality of some clinical studies.

The USPSTF by drawing conclusions on the basis of insufficient evidence and potentially defective clinical studies without consultation with the proper specialists must be avoided.

Unfortunately, it is going to get worse because there are no checks and balances in the Obamacare bureaucracy.

Next I will discuss the PSA fiasco.

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

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Natural Herbal Products • July 11, 2012

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It Is Easy To Forget

September 21, 2011

inDefective scientific studies, Disinformation and the healthcare system, Information Technology in Healthcare, Innovations in Healthcare, Medicine: Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D., FACP, MAACE

It is easy to forget all the promises President Obama made in order to get support his healthcare reform plan.

“If you like your health insurance, you can keep your health insurance.” That was the promise made to millions of Americans by President Obama and leaders in Congress many times in assuring them that the new health law would not disrupt the coverage they have now.”

President Obama will not be able to fulfill this promise because he cannot manage complexity.

The inability to manage complexity results in unintended consequences that lead to more complexity and in turn other unintended consequences.

I mentioned the importance of developing Learning Systems in my blog, which discussed defective assumptions made to implement of Accountable Care Organizations. A reader asked with “What do you mean by developing Learning Systems?”

There are three types of Learning Systems.

Experience
Complicated-scientific
Complex –pattern visualization

The first type of Learning System is learning by experience. In medicine, medical students, interns and residents get experience from patients with the guidance of senior physicians. Physicians make future medical and surgical decisions based on this experience.

Sixty years ago the experience Learning System was the only learning system available for the practice of medicine.

As technology advanced and the cost of healthcare increased it was obvious physicians had to systemize healthcare in a scientific way as Deming systematized industrial methods in Japan in the 1950s. This movement led to the need to practice evidence-based medicine.

Systematizing the practice of evidence-based medicine is not easy. Rapid medical discoveries change evidence-based medicine. Medical practice must be prepared for rapid cycle changes.

This second learning system is known as complicated-scientific. Complicated- scientific learning must be combined with experience learning to be effective.

The success of evidence-based medicine is grounded in principles common to engineering. In the Learning Healthcare System envisioned by the Institute of Medicine's (IOM) Roundtable on Evidence-Based Medicine, evidence emerges as a natural by-product of care delivery, which is thoroughly documented, pooled for continuous monitoring and analysis, integrated with insights from related studies, and fed back seamlessly to improve the consistency and appropriateness of care decisions by clinicians and their patients.

The third type of Learning System is the development of the abilities to visualize and manage complexity many interacting systems.

Complexity management is the ability to visualize the patterns of interactions created by the various systems in order to align stakeholders’ vested interests.

Peter Senge’s “The Fifth Dimension” and my brother Charlie Feld’s “The Blind Spot” have recognized the importance of managing complexity by pattern recognition. Pattern recognition is visualizing the interplay of experiential learning and complicated scientific learning. The visualization can lead to a shift in thinking and strategy among stakeholders. When patterns are recognized it can lead to the avoidance of conflict and unintended consequence.

It is vital to the success of all disciplines in the 21^st century.

Political systems are comprised of both experience and social scientific learning systems. President Obama has ignored the complexity developed by these interacting systems. By ignoring pattern recognition of complexity he has created unintended consequences that are destroying his agenda for healthcare.

Perhaps this is intentional and his goal is to destroy the healthcare system. The void could then be filled with his Public Option and complete government control of the healthcare system.

This brings us back to President Obama’s promise to the American people. “If you like your health insurance, you can keep your health insurance.”

Most large companies thought they would be able to keep the present healthcare insurance for their employees. In fact, many employers believed President Obama’s assurances that their health plans would be “grandfathered.” This promise was a key reason leading to their support or to their taking a neutral stance on passage of his healthcare bill.

Employees valued their health coverage. They were not opposed to Obamacare. Surveys showed that 88% of Americans were satisfied with their health coverage.

As soon as both employer and employee realized that President Obama’s assurance was not going to be fulfilled most opposed Obamacare.

The grandfathering rules are severe. Employers cannot make changes to their health plans to remain grandfathered.

Employers;

• Cannot significantly cut or reduce benefits.

• Cannot raise co-insurance charges.

• Cannot significantly raise co-payment charges.

• Cannot significantly raise deductibles.

• Cannot significantly lower employer contributions.

• Cannot add or tighten an annual limit on what the insurer pays.

• Cannot change insurance companies. (This rule was later amended to allow employers to switch insurance carriers as long as the overall structure of the coverage does not violate other rules.

Employers will be forced to comply with expensive Obamacare regulations that increase their health costs further to maintain healthcare insurance.

Most employers had to make major modification to their healthcare plans such as increasing deductibles to keep their healthcare insurance costs down. These companies are no longer eligible for grandfathering. It is much cheaper for them to pay the penalty than comply with the rules and provide healthcare coverage.

The healthcare insurance industry increased premiums by 15-39% in order to comply with rules such as providing insurance to children up to age 26, insuring everyone on the group plan regardless of preexisting conditions and not rescinding coverage after enrolling a participant

This is an example of not managing complexity effectively.

On top of all that President Obama issued new limits on insurance coverage. In 2011 the limit must be at least $750,000 per enrollee. In 2012, the limit will have to be at least $1.25 million, and in 2013, $2 million. In 2014 there is no limit on payouts for any individual’s care.

No one will be able to afford to provide healthcare insurance coverage especially the federal government.

The restrictions have led to President Obama issuing 1,578 waivers from Obamacare. The waivers primarily cover limited benefit plans offered by employers and unions who said the higher cost could force them to drop insurance coverage. This is another unintended consequence.

These regulations have increased business uncertainty. It has also increased mistrust of President Obama.

The most significant unintended consequence is hesitation on the part of companies to create jobs.

Health costs are directly related to creation of new jobs. Employers continue to face a fragile economy. Higher health costs put additional pressures on companies’ bottom lines. It increases the cost of hiring new workers and in turn discourages job creation.

This is bad news for President Obama, the economy and unemployed workers.

All of the unintended consequences are a result of President Obama and his administration not understanding patterns of systems interaction. It has resulted in not managing complexity of complicated systems and increases in unintended consequences.

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

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What Are The Defective Assumptions Made For ACO Implementation?

September 14, 2011

inDefective scientific studies, Disinformation and the healthcare system, EMR, Innovations in Healthcare, Medicine: Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

It is going to be very difficult for physicians and hospital systems to develop integrated medical delivery systems in the present time frame.

Dr. Don Berwick and his associates have a naïve view of the ability of organizations to form and execute Accountable Care Organizations (ACOs). ACOs fit well into President Obama’s worldview of government controlling our healthcare system.

There are two problems:

The government is broke. It does not have the money to pay for a government takeover of the healthcare system.
New systems need participant cooperation to succeed.

President Obama and Dr. Don Berwick have overestimated the abilities of the healthcare system to respond to their hubristic assumptions.

“The ACO program is based on the hubristic assumption that the federal government can design the best organizational structure for the delivery of care, foster its development, and control its operation for the entire country."

Below are some of the defective assumptions made to implement ACOs.

Physicians and hospitals have little experience or control in managing risk. The experience with HMO’s in the 1980’s proved their inability to manage risk. Most physicians and hospital systems are not very interested in assuming this risk again. The risk of ACOs has been sugar coated by the administration.

Patients are the only stakeholders who can control their healthcare risk. All health policy wonks ignore the role of the patients in controlling and managing their healthcare risk.

Dr. Berwick thinks hospitals and physicians will be motivated to control patients’ healthcare risk with ACOs. He is wrong. I predict participation will be minimal. Those who participate in the ACO program will fail.

Healthcare policy should focus on how policy can provide incentives for patients to be motivated to control their own healthcare risk.

The implementation of electronic health records will be more challenging than President Obama and Dr. Berwick believe. The financial support from President Obama’s stimulus package is going to turn out to be a waste of money. The EMR’s cost more than the government subsidy.

EMR installation disrupts medical practices for at least six months. The incompatibility of information systems can only be overcome at great expense to both hospital and physician.

President Obama should be spending the stimulus money on the Ideal EMR. It would cost physicians and hospitals nothing. They would pay by the click. It would unify all the information systems nationwide. The Idea EMR would remove many of the barriers to achieving the goal of integrating medical data.

Data measurement imposes another difficult barrier to implementation of ACOs. I have wondered what date U.S. News and World Report used to name Parkland Memorial Hospital among the 100 best hospitals in the nation while Center for Medicare and Medicaid Services (CMS) used other data to disqualify Parkland Memorial Hospital from collecting Medicare and Medicaid reimbursement. I believe Parkland is a great hospital with a great CEO, Dr. Ron Anderson. Someone’s data is wrong.

Can physicians and hospital systems trust CMS to measure their performance and pay for performance based on the data used?

The challenge of collecting, analyzing, and reporting performance data will be the ACOs responsibility. CMS will evaluate the data collected and determine payment for performance.

Most ACOs will have difficulty developing the data and reporting capability with present EMR capabilities.

A goal of ACOs will be to implement standardized care management protocols. If successful it will commoditize medical practice. It will eliminate physicians’ judgment. It will destroy the patient-physician relationship.

I believe all physicians should practice evident based medicine (EBM). In the absence of tort reform physicians cannot avoid the practice of defensive medicine.

ACOs are not designed to align the stakeholders’ vested interests. I can visualize hospitals fighting with their physicians over money distribution and medical care decisions. Payments for medical care are going to be bundled. In order to save money and receive the shared saving bonus, patients may have medical care rationed.

ACOs are Primary Care Physician(PCP) centric. There is no requirement for specialists to limit their activity to a single ACO. Specialists will be critical to the effective performance of ACOs in order to qualify for the shared savings bonus.

Who will decide which specialist a PCP will refer patients to? There will be fights about fees to pay specialists. Obamacare’s ACOs make no attempt to align providers’ vested interests. It leaves it up to the providers. Since hospital administrators will control the money fighting is inevitable.

Patients must be the leader of the healthcare team. Obamacare and ACOs make no attempt to put patients in a responsible, leadership position. Patients and family members must participate in managing multiple, complex chronic conditions. Patients need to be taught to manage and take responsibility for their health and health care. They need to be taught to engage their family and have the family participate in medical decision-making.

Obamacare does not outline systems of care for chronic diseases for the potential ACO that might not have experience in team management.

ACOs may not have the necessary management and implementation skills required to improve care delivered to patients. Improvement in medical care will require team management of chronic disease. Patients must be the leader of their team. This will require aligning shared interests and rewards among the different providers. This is where physicians and hospitals will lock horns.

New regulations have to be coordinated with the Stark anti- kickback legislation. It will require costs that have nothing to do with direct patient care. Compliance with new regulatory requirements will require unprecedented and unmanageable levels of transparency and cooperation among hospital systems, physician organizations, and the payer.

There is too much emphasis on central data collection and managing the data. Much of medical management depends upon on the spot clinical judgment.

Learning systems must be built to have rapid cycle improvement in quality care. I suspect many physicians and hospital administrators do not know the importance of learning systems.

Developing cooperation among all the stakeholders to develop preventive medicine systems and systems of care for chronic disease does not develop overnight, especially when payment for those services are vague.

These are just a few of the defective assumptions made by President Obama and Dr. Don Berwick that will prevent ACOs’ success.

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

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