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Disinformation and the healthcare system

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Keeping Obamacare’s Failures Out Of The News

Stanley Feld M.D.,FACP, MACE

The Obama administration has tried its best to keep Obamacare’s failures away from the people. However, it has been almost as difficult as putting toothpaste back in the tube. The reasons are clear to me.

People are paying attention now because most are personally affected by the failures of Obamacare.

These failures along with President Obama’s other policy failures such as the IRS scandal, Benghazi scandal, Fast and Furious, border control failures, immigration failures, foreign policy failures, NSA privacy intrusions and his lying about those intrusions, attempts at Internet takeover, and unconstitutional unilateral changing of laws through executive orders have lead the American people to lose confidence and trust in whatever President Obama and the Obama administration say.

The traditional mass media has tried mightily to protect President Obama. They have tried to help him keep Obamacare’s failures out of the news.

They have been unsuccessful. If our only source for news was the traditional news media we could be fooled.

Americans must work to stay informed in order to maintain our freedoms.

I will list some of Obamacare’s failures of the last few months.

These failures have had little coverage in the traditional media.  Obamacare has continued to move forward to hobble and then destroy the medical care system in America.

President Obama’s goal is to prove that a free market healthcare system does not work. He has disregarded the fact that the healthcare system is not a free market system.

In a recent blog I presented the reasons for physicians’ discontent with Obamacare.

Survey of Physicians And Their Discontent

In July 2014 the “Physicians Foundation” published a survey sent to 660,000 physicians. Twenty thousand physicians completed the survey.

“Forty-six percent of doctors give President Obama's healthcare law a "D" or an "F," according to a new survey from the Physicians Foundation. In contrast, just 25 percent of those surveyed gave the law an "A" or a "B."

A large number of physicians complained about the vast new bureaucracy that has been added to the medical profession.

A physician comment read, "I'm a Canadian physician practicing in the United States. The politicians and policy makers need to understand that government involvement in healthcare never works."

The only newspaper that reported the survey to my knowledge was the Washington Examiner.

Enrollment Failures

President Obama and his administration are playing a numbers game with the enrollment figures. His March 31,2014 figures were inaccurate. The figures were grossly inflated.

President Obama said on March 31st, "this thing is working” successfully. President Obama claimed that 8 million enrolled in Obamacare.

“At a hearing Thursday September 18, 2014 at House Oversight and Government Reform Committee, Marilyn Tavenner, head of the Centers for Medicare and Medicaid Services, finally confessed that 7.3 million were enrolled in ObamaCare plans as of mid-August.”

The 7.3 million figure is also fiction. At least 115,000 additional enrollees have not validated their citizenship or legal status.  The validation must be completed by September 30,2014.

An additional 360,000 could lose their Obamacare subsidies because of discrepancies over their income. Eighty-five percent of the enrollees are receiving government subsides for healthcare coverage.

Most do not pay taxes because they make less than forty thousand dollars a year. They will not be able to afford the overpriced premiums.  

How many of the 8 million have not continued to pay the premiums? No one knows or is telling. Enrollees have a three-month grace period.

California reported in late August that an additional 100,000 of those who enrolled through its state-run exchange were at risk of losing their coverage over citizenship issues.

By my calculations less than three million of the forty-eight (48) million people who were uninsured pre Obamacare became insured. An additional 7 million people lost their healthcare insurance in the individual market.

President Obama provided the American public with a grossly overestimated enrollment figure.

Ms. Tavenner had to put a positive spin on this latest revelation of the fictional enrollment numbers by saying,

 "We are encouraged by the number of consumers who paid their premiums."

No one is buying this explanation.

She didn't provide answers to important details for these latest enrollment figures.

  • How many who dropped out were young and healthy?
  • How many have signed up through the so-called special enrollment process?
  • How many are keeping up with premiums?
  • How sturdy are the back-office computer programs in order to detect enrollment misinformation?
  • How will the government collect the money due to it from these non-paying enrollees?
  • Is the November 15th open enrollment period going to go smoothly?

 

Next Open Enrollment Disaster

It is easy to see that President Obama has delayed the open enrollment time from October 15th to November 15th for political reasons. He wants the potential disaster to occur after the mid-term elections.

 Kevin Counihan, the former chief executive of Access Health CT, Connecticut’s online marketplace, was just named head of the insurance marketplaces for the federal government.

 He said, “Part of me thinks that this year is going to make last year look like the good old days.”

 The front end of the web site looks like it will run smoothly. The back end of the web site still needs work. The government is still trying to see if the links to the IRS, the healthcare insurance industry and social security are functioning properly.

There were not enough healthy young subscribers to keep the insurance rates low. The premiums were too high for many young and healthy uninsured people.

This year the healthcare insurance premiums will be up at least 20%. Healthcare insurers fear it could be even more difficult to sign up young healthy people than it was last year.

Adding to the problem is that the sign up period for choosing a new policy this year will be shorter than last. It will be 3 months instead of six months.

President Obama will probably break the law again and extend the signup period an additional 3 months.

This year it should be more difficult to receive subsidies than last year.

People will drop out of the pool because of the increase in insurance rates. The renewal procedure has not been worked out yet.

Andrew Slavitt, principal deputy administrator for Medicare said they are working hard to make the process as easy as possible.

“We’re putting in place the simplest path for consumers this year to renew their coverage.” 

 This is another Obamacare smokescreen.

I predict it will be a price disaster.

Obamacare And Zeke Emanuel Setting Us Up For Rationing

One of the most bizarre articles imaginable was Zeke Emanuel’s article in the Atlantic Monthly  “Why I Hope to Die at 75”

Dr. Emanuel, one of Obamacare’s authors, gives all the reasons why he doesn’t want to live past 75 years old.

His argument is why should you live longer since you probably are not useful to society.

You have contributed all you are going to contribute. After 75 years old affliction will accumulate and disabilities will make life less pleasant.

It is apparent to me that he is setting us up for government rationing of healthcare for seniors.

The government controls Medicare. It is cheaper for the government not to pay for procedures such as hip replacements, knee replacements, for coronary artery surgery or cardiac pacemakers. All these procedures will extend the life of seniors over 75 years old who need them.

We have also heard rumors that this bureaucratic thinking is already in progress.

Don’t we live in a free country?

Isn’t it up to individuals to make their own life decisions? 

Should we leave these decisions up to the government and bureaucrats?

Should they decide our choose of treatment for us?

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



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The Charade Of Price Transparency

Stanley Feld M.D., FACP, MACE

The government and the healthcare insurance industry have been collecting cost data for years. The data is not reimbursement data.

The government has released a hard to understand database on what they pay per procedure and treatment.

However, the database is very hard to get to and very difficult to understand.

Theoretically one can discover what clinics charge for an MRI and what hospitals bill for childbirth. It is another thing to find out how much they get reimbursed.

New Choice Health’s web site provides hospital charges for some procedures and treatments but it is difficult to navigate. You have to give the site a lot of personal information before you can see anything.

New Choice Health published the following range of prices charged in the Dallas area.

The title of the chart is the Dallas costs for top procedures. The title is totally misleading to the public. The prices charged have nothing to do with the prices negotiated between healthcare insurance companies or the government as the third party payers with the payee being the hospitals, physicians or others  providers.

The chart is meaningless. It is a bogus attempt at transparency. It gives the impression that people are overcharged by physicians and hospitals.

It has nothing to do with what reimbursement is by the third party payer.

 At times it seems to me as if the deeply discounted reimbursement to physicians and hospitals are too much for the service rendered.

Surgeons do better than Primary Care Physicians. Hospitals do much better because of inflated revenue codes.

The easiest example of inflated hospital revenue codes to remember is the price paid by third party payers for chemotherapy in a hospital outpatient setting compared to a private practice setting.

  Difference in prices for 8 27
The charade of this kind of price transparency does not relate to patients’ problems with the healthcare system.

A patient calling the hospital for prices for a certain surgery with a certain insurance company is still going to be in the dark. Patients have to make many calls and go through many bureaucratic barriers to understand their liability.

These continued barriers and pretense of transparency lead to the erosion of confidence in our entire healthcare system.

Txpricepoint.org, the Texas Hospital Association’s pricing site, is a very useful comparison tool.”

This is what is published in the traditional mass media. It is not.

Consumers cannot get the information they need for their individual case.

With Texas Price Point you can receive the average retail price for specific hospital procedures, total patient mix for inpatient care between Medicare 46.4%, Medicaid 7.6%, and other insurance 46%.

Medicare pays 28% of the average retail fee, Medicaid pays 27% and the private insurers pay 41% of one specific procedure.

The bad debt for that procedure is 2.36% of the total bill and charity is 3.446% of total charges.

These numbers are to the benefit of hospitals and the third party payers. They do not help the patients determine their liability for a bill with insurance payment and their deductible..

It took me about twenty minutes to glean this information from the web site for only one disease entity.

The Internet has provided some transparency and choice in drug pricing. However, it has a long way to go.

The Texas Price Point web site does not do an individual patient any good.

It tells the hospital that private insurance pays more than Medicare or Medicaid. If the hospital was smart it would increase the number of private insurance patients over Medicare and Medicaid patients to make more profit.

I think the hospital knows that without the Big Data on the web site.

The healthcare system has a long way to go to have pricing be transparent to individual consumers.

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



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http://www.newchoicehealth.com/Quote?ProcedureTypeId=3&CBSACityID=278

 

 

 

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Anyone Can Get An Exemption From The Obamacare Mandate

Stanley Feld M.D.,FACP,MACE

The third big deal that occurred in Obamacare in the last few months was the elimination of the mandate to buy healthcare insurance in the individual market.

The waiver qualifications have become broader as they have been clandestinely declared by President Obama’s executive orders.

It took the mainstream media four months to discover the new executive order waivers for the mandate.

The Supreme Court didn’t repeal the mandate to buy insurance. The Supreme Court called the mandate a tax.

President Obama insisted the mandate was not a tax. His campaign promise was any family making less than $250,000 a year would not experience a penny of increases in new taxes.

 

This campaign has clearly been a lie. President Obama felt victorious about the Supreme Court decision. The traditional media gave President Obama a pass on its social, political and economic implications.

In fours years of delays in implementing Obamacare’s deadlines imposes by the law have been changed by executive orders and collecting the laws new supportive taxes on time, no one has questioned what Americans have gotten for these new taxes.

President Obama has changed many aspects of the law without the consent of congress. 

No one in congress has challenged him.

The new mandate waivers were predicted to be the death knell for Obamacare's most controversial component. We had been told that the individual mandate was crucial to the survival of Obamacare.

Very few know about the new waivers. The new waivers allow anyone to skirt the mandate in the individual market. Almost no one has to buy insurance or pay a penalty. The waivers made through executive order, essentially exempts everyone from the mandate to buy insurance or pay a penalty.

 “There already had been 13 distinct exemptions, but this document added one more — apparently it was added in late December. 

 The problem is no one was made aware of the waivers by either the government or the traditional media.

“The most recent exemption was included in an ObamaCare application document. The document said that individuals can now qualify for a "hardship exemption" — meaning they would not have to pay a penalty for not buying insurance — if they "experienced another hardship in obtaining health insurance." 

The document does not define what "another hardship" means, and suggests the administration might not be a stickler when it comes to proof either. It says anyone seeking this exemption should "submit documentation if possible." 

New waiver, number 14, was quietly extended through 2016 on March 14th 2014. The mandate is to go into affect 2017. 

The first 13 exemptions were created for people who are homeless, who filed for bankruptcy, who experienced a fire and who dealt with other financial emergencies. These exemptions covered millions of people.

Waiver 14 reads as follows:

An individual has been notified that his or her plan will not be renewed and

believes that the available plan options are more expensive than the plan that was not renewed."

Patients only have to claim they believe that the available plans are too expensive for them to buy.

The wavier is not well known. It is advertised on purpose by the Obama administration. It has not been picked up by the traditional mainstream media.

The then Health and Human Services Secretary Kathleen Sebelius defended the "hardship exemptions" and blamed them on Republican governors who did not expand Medicaid.

This attack is the typical progressive attack against the enemy and is meant to act as a diversion.

"It's been really aimed at people who could not afford coverage one way or the other," she said. She noted that the list includes people who live in states that did not expand eligibility for Medicaid.” 

Kathleen Sibelius statement is meaningless. The list of states include those states that expanded Medicaid.

To date the federal government has not processed 3 million applications. Republicans have not called out the Obama administration on the unprocessed applications.

Holtz-Eakin, former director of the Congressional Budget Office under the George W. Bush administration, said,

That for someone to qualify for waiver 14, they could simply say they couldn't get through on HealthCare.gov or plans were too expensive or a special condition they have didn't appear to be covered.” 

Adverse selection of patients is certain to be the result in the independent insurance market. Only people with preexisting illnesses or people making less than $50,000 a year have bought the health insurance exchange insurance. The later group receives a large subsidies.

The problem will be compounded whenever small business waivers expire.

In any event all American will experience double-digit increases in healthcare insurance premiums as a result of Obamacare and its unlawful waivers.

All Americans are paying higher taxes for Obamacare since 2010. Taxes to fund Obamacare have been increasing yearly for the last 4 years.

Obamacare was supposed to be fully implement in 2014. It has been minimally implemented so far.

Obamacare taxes have been implemented. Therefore, increased taxes should produce a decrease in the budget deficit.

Nevertheless the budget deficit has continued to increase yearly by over $1 trillion dollars a year.

There is something wrong with the math unless Obamacare is generating bureaucratic waste.

A reader wrote

"Good judgment comes from experience and a lot of that comes from bad judgment"

 Will Rogers

 

 

A reader sent me this list of increased taxes starting January 1,2014

In case you didn't notice


> Here is what happened on
> January 1, 2014:



> Top Medicare tax went
> from 1.45% to 2.35%

> Top Income tax bracket
> went from 35% to 39.6%

> Top Income payroll tax
> went from 37.4% to 52.2%

> Capital Gains tax went
> from 15% to 28%

> Dividends tax went from
> 15% to 39.6%

> Estate tax went from 0%
> to 55%

> Remember this fact:
> These taxes were all passed only with democrat votes,
> no republicans voted for these taxes.


> These taxes were all
> passed under the Affordable Care Act, aka Obamacare.

Is Obamacare worth the increase in taxes?

What are we getting for the increase in taxes?

What it is doing to the economy?

Why are Republicans afraid to say anything? Who should say something?

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

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Obamacare Application Data Is Wrong For 2 Million Applicants Receiving Subsidies

Stanley Feld M.D.,FACP,MACE

The second really big deal is the fact that over two million people lied on their application for Obamacare through the federal health insurance web site www.healthcare.gov.

We do not know how many of the 1.2 million who received insurance through state exchanges lied. 

Unfortunately, the Obama administration throws so many numbers out of context at the American public that it is impossible to follow the true facts and subsequent disastrous consequences.

Let us look at the numbers slowly. President Obama was claimed that 8 million people signed up for Obamacare by March 31,2014.

President Obama and the healthcare insurance industry were terrified about adverse selection by the people signing up. Both worked hard to get young people with no preexisting illnesses to sign up so the insurance premiums would not increase next year.

Basketball, baseball and football stars were recruited to advertise Obamacare’s benefits on TV and encourage enrollment.

The population, in the uninsured individual insurance market, was only 14 million out of a population of 350 million people. Three hundred and thirty six million received waivers from Obamacare for one reason or another.

What will happen when 336 million must participate in Obamacare? The percentage of participants in the population will be tiny if the individual market is a guide.

Seven million of the fourteen million lost their healthcare insurance because of Obamacare’s requirements. Eight million signed up for healthcare insurance under Obamacare. This represents an increase of only one million and not and increase of eight million.

Of the 8 million, 85% or 6.8 million people applied and received government subsides. These subsidies were supposed to be tax credits.

The www.healthcare.gov did not have a functional back end to the website to check if these people were lying about their income, job status, and even citizenship.

 If people intentionally misstated information, they were warned they could be charged with perjury. I assume President Obama will waive that charge.

Only citizens and legal immigrants are eligible under the law for subsidized coverage.

 The government signed up about 5.4 million people, while state-run websites signed up another 2.6 million.

Only 1.2 million of those were not eligible for subsidies.

Are these 1.2 million the part of the 7 million who lost their insurance because of Obamacare? Are the 8 million the people who did not have insurance before Obamacare?

Both are important questions that we have not gotten answers to.

My guess is the people who signed up were people who could not get insurance because of preexisting conditions or people who could not afford insurance in the individual market.

In either case the will be adverse selection and increased healthcare utilization. Insurance premiums will increase for everyone in the health insurance exchanges. 

 Some 80% of all those who have enrolled in plans nationwide, according to federal statistics released today, have chosen a silver plan, meaning deductibles of $2,000 for singles and $4,000 for families, or gold or platinum plans, which have no deductibles. “

“Only 18% have opted for bronze plans, which offer lower premiums, balanced by deductibles of $4,500 for singles/$9,000 for families.”

Many consumers can hardly afford the bronze plans with subsidies much less the high deductibles. Those consumers will be forced drop out of Obamacare.

“The Associated Press reports that of the 5.4 million people who signed up for health insurance through the federal marketplace 2 million submitted information that does not match up with federal data.”

The discrepancies could affect their subsidy adversely. Applications were accepted on boy scouts’ honor. The subsidies were determined on the basis of the information on the application. These people will owe the government the difference plus a penalty. They are also liable for perjury.

The back end of www.Healthcare.gov is still incomplete.

“Serco, a foreign contractor already under investigation, was awarded a $1.2 billion contract to process Obamacare’s paper applications, and the AP reports they will be tasked with resolving these application issues. “

Despite having had three years and more than $600 million to work with the federal governmentand its chosen contractor could not build a functional website. It cost an additional $200 million dollars and four months to get the front end to work.

The $600 million to build www.healthcare.gov was more than it cost Apple to develop the iPhone. Apple is an American company with American jobs. 

It should be recalled that another foreign contractor (CGI of Canada) got the first contract. Michelle Obama’s Princeton classmate happened to be an executive,

 

Serco is a foreign company riddled with a history of transgressions. The most recent transgression was that Obamacare contractors were literally being paid to do nothing.”

The White House has attempted to dispel concern about the website being dysfunctional.

However, the report of over 2 million falsified applications has reignited the questions of government incompetence and misleading information about the dysfunctional website as the enrollment period approached.

As Americans for Prosperity reported in the Washington Times early last month, “the website was originally intended to function automatically, calculating premium subsidies, making government payments, and tracking enrollment information that would affect future costs.”

“ But the interim system currently in place (that resulted in the newly revealed data discrepancies) is “pretty much a spreadsheet and some informed estimates,” according to Politico.

Compounding www.healthcare.gov  problems are a Roll Call report that almost 3 million Medicaid enrollees have not yet had their applications processed.

These issues are all separate issues from Obamacare’s cancelled healthcare plans, physicians opting out or retiring, and the scandal with the Veterans’ Affairs health care system.

In reality all the issues are one with the Obama administration making it clear that a government run bureaucratic healthcare system is a nightmare that will destroy the healthcare system in America.

8 20 2014 Obamacare-Delays

 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.

Finally,

“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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Holy Cow!

Stanley Feld M.D., FACP,MACE

 I cannot believe it.

President Obama continues to deceive the America public about his "Accountable Care Act" (ACA or Obamacare). Our elected officials continue to do nothing to stop him. Unelected administrative officials are making spending decisions that neither congress nor the public is aware of until after the fact. A case in point is www.healthcare.gov.

William T. Woods, a senior official at the Government Accountability Office in testimony prepared for a House hearing on Thursday, warned of “significant risks in the next open enrollment period, which begins Nov. 15.”

He said, “the marketplace and its website,HealthCare.gov, were over budget and behind schedule because of “new and changing requirements” imposed by administration officials.”

This is in direct contrast to what Sylvia Mathews Burwell, the secretary of Health and Human Services told the congress and the American people a few weeks ago. She said the problems were mostly solved.

The American people have still not gotten an accurate accounting of how many people have signed up legally through the health exchanges. My best estimate it is less than 3 million and not 8 million.

About 80% are getting subsidies by signing up on the federal government health insurance exchanges. It is also against the law according to the definition for subsidy eligibility as written the law. President Obama said the administration did did not mean what the law says.

Let us concentrate on the costs of the website until this point. Initially it was supposed to cost $56 million dollars.

The cost rose from $56 million dollars to $209 million dollars from September 2011 to February 2014. The Obama administration launched the disastrous web site in October 2013 without having a quality assurance surveillance plan to monitor the work of the main contractor CGI. A principle in CGI was a college buddy of Michelle Obama. A linkage of their friendship and the contract with CGI has never been proven.

On October 1, 2013 the disaster of the web site became apparent. There was confusion within the Obama administration about who had the authority to approve contractor request to expend funds for additional work.

Mr. Woods said,“In 40 instances, the staff members of the federal exchange inappropriately authorized contractors to expend funds, totaling over $30 million.”

Mr. Wood also said, “As the Oct. 1 deadline approached, federal officials identified significant performance problems in computer systems developed by CGI Federal, but “took only limited steps to hold the contractor accountable.”

The administration withheld only $267,000, or 2 percent of CGI’s $12.5 million fee. There is no indication of the profit CGI made on the work done that cost the government $209 million dollars.

It gets more complicated and bizarre.

In January 2014 the Center for Medicare and Medicaid Services (CMS) awarded a contract valued at $91 million to Accenture Federal Services to continue work on the project.

“Accenture Federal Services costs have ballooned to more than $175 million and the marketplace is still unable to perform essential computer functions needed to pay insurers and update information on consumers.”

The question that must be asked is what in the world is going on?

James E. McAvoy, a spokesman for Accenture said that another “task order” had increased the total to $190 million.

Accenture said, “It is helping the government develop an insurance exchange for small businesses, is expanding the federal exchange to serve additional states and is adding new features to verify the income of people seeking federal subsidies.”

The Government Accountability Office, an investigative arm of Congress, said that through March of this year the administration had made formal commitments to spend $840 million on the federal health insurance exchange and marketplace.

The $840 million dollars is a long way from the original $56 million dollar in the original Obamacare budget.

 The plot thickens.

Andrew M. Slavitt the No. 2 official at the Centers for Medicare and Medicaid Services told Congress that the agency was changing requirements for its contracts to expand the scope of work that must be done.

Mr. Slavitt said that the administration was making improvements in the federal health insurance exchange’s software , but that the second round of open enrollment, starting in November 2014, would not be perfect. “There will certainly be bumps,” he testified at a House hearing.

Mr. Slavitt avoided answering how much the website should cost. 

 Mr. Slavitt said, “That’s a really good question.” He did not specify the proper cost, but he said the nation was getting invaluable results, including new insurance coverage for millions of people.

Mr. Slavitt, who joined the government three weeks ago. A congressional panel has questioned his credibility.

Mr. Andrew Slavitt, a former executive at Optum, the technology company tasked with “saving” HealthCare.gov,ran into sharp questions from a House panel about a potential conflict of interest in his new role.

Rep. Morgan Griffith, R-Va., pressed Mr. Slavitt on his previous job at OptumInsight/QSSI.  Optum, and its parent company, UnitedHealth Group. UnitedHealth Group, one of the nation’s largest insurers, offers health plans on the federal health insurance exchanges. Optum had a large role in the creation of HealthCare.gov and built the data hub, The data hub is still not working properly.

The Obama administration granted an ethics waiver to Mr. Slavitt so that he could participate in decisions affecting his former employer, Optum, and its parent company, the UnitedHealth Group.  

Optum is the tech firm the Department of Health and Human Services picked in October 2013 to straighten out HealthCare.gov. It was awarded an $84.5 million contract with HHS’s Centers for Medicare and Medicaid Services in January 2012 to build the part of HealthCare.gov known as the federal data hub.

The purpose of the data hub is to connect multiple government agencies to streamline verification of crucial consumer information—including Social Security number and immigration status when Americans log into the federal and state exchanges and apply for Obamacare subsidies.

Doesn’t this sound fishy? Can we trust the Obama administration to decide what treatment American should get and what treatment Americans cannot get access to?

It looks like the VA all over again?

Let the buyers beware!

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

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Physicians’ Barriers To Practice Their Profession

 Stanley Feld M.D.,FACP,MACE

Over the past 30 years practicing physicians have seen their revenue fall. As Medicare deficits have increased the government has lower physicians reimbursement.

Who is responsible for the deficit increase if physician reimbursement has decreased?

Private Insurance premiums have increased because of advances in technology and increases in specialization leading to increases in testing and physician visits.

Private insurance reimbursement to physicians has decreased in an attempt to keep premiums as low as possible for the private employers who need to be able to afford insurance for their workers.

Physicians have tried to compensate for this decreased reimbursement by seeing more patients. Despite seeing more patients physicians’ incomes have fallen.

Physicians’ overhead has increased. The need for more full time employees has increased. As government regulations have increased many practices have had to hire full time employees to do coding for care and paperwork. Physicians have tried to buy fully functional computer systems but they have failed.  Computer systems are expensive and not completely functional.

“Physicians have seen their incomes fall, their clout with insurers shrink, and their practices weighed down by a plethora of new requirements.

What is the value of a physician’s service? What is the value of secondary stakeholders in the healthcare system?

These are hard questions to quantify. The goal of healthcare policy makers is to reduce the national healthcare costs.

The healthcare system is fragmented, complex and unbalanced. Many physicians feel their skills have been devalued by payers, hospital systems, policy makers.  These groups have become more powerful than the representatives of physicians’ organizations.

Healthcare has become a gigantic industry costing our society 2.9 trillion dollars a year.

Healthcare has, unfortunately, become all about money with the third party payers making the rules. Effective medical care has been stifled.

Physicians barriers’ to effective medical care are,

1. Lack Of Malpractice Reform

Government has estimate the value of malpractice reform incorrectly. It thinks malpractice costs the healthcare system 3 billion dollars a year.

Several good studies estimates the lack of malpractice reform costs somewhere between $200 billion to $750 billion dollars a year without including the cost of the wear and tear on physicians and patients.

2. Problems Trying to Increase Reimbursement

3. Lack of Negotiating Clout

4. Being Turned Into Captives of the Insurance Industry and the Government

Physicians do not have the ability to modify charges on the bases of costs. Medicare and Medicaid won't allow physicians to negotiate reimbursement rates. Physicians must take the reimbursement fees or refuse to participate in Medicare or Medicaid. More and more physicians are leaving the Medicare/Medicaid system.

Private insurers have forced physicians to sign contracts limiting charges. Individual physicians and physician groups have little negotiating power or ability to have loss leaders as do hospital systems with multiple hospitals in a regional area.

Physician organizations have not negotiated for physicians. Some organizations have teaching courses that teach physicians to get around the loopholes in the healthcare system.

Physicians have no incentive to add innovative programs. These programs can increase their overhead without being reimbursement.

All of this is to the disadvantage of patients and patient care as insurance premiums rise and access to care falls.

Intuitively physicians know that the medical care contract is between physicians and patients. Third party interference has stood in the way of this interaction. It has disrupted and/or destroyed patient/physician relationships.

More and more physicians are dropping out of Medicare, Medicaid and private insurance because they cannot deal with the third party interference with the practice of medicine financially or emotionally.

Rob Lamberts, MD, an internist in Martinez, Georgia  said "Doctors have been turned into tools of the insurance industry,"  "You always work for whoever pays you. When you work for an insurer, you are constantly under pressure to do a lot of things that don't improve the care of the patient."

Dr. Lamberts became a concierge medicine doctor.

Concierge medical practices need fewer full time equivalents, do less paperwork, deal with less regulations, have more time to practice medicine and more time to spend with their patients.    

5.Being Pressured to Sell Healthcare as a Commodity

6. Being Force Into Abandoning Clinical Judgment

There are many physicians complaining about the commoditization of healthcare.  They are complaining about the constant need for authorization of care demanded by the government and the healthcare insurance industry.

Physicians complain that insurers and other corporate interests have too much control of healthcare. They are dictating what clinical decisions physicians can make. Physicians are becoming accountable not to their patients but to what other interests decide. The system is forcing doctors to give up their medical judgment in favor of clinical practice guidelines.

The clinical guidelines are used to determine prior authorizations. These guidelines are used to determine reimbursement in many pay4performance contracts and shift the risk burden onto physicians.

Several studieshave questioned the validity of guidelines. Close to half the physicians in the 2012 Medscape survey said quality measures and guidelines will have a negative impact on care.

Mark Shelley, MD, a family physician from Port Allegany, Pennsylvania, decried what he calls the "commoditization" of healthcare. "The art of medicine has been turned into the business of medicine". "Rather than trying to make patients functional and happy, the physician gets caught up in financial issues, such as whether Medicare will pay for a wheelchair."

 Dr. Shelley said. "I know doctors who earn a lot of money and are absolutely miserable."

7. Being Captives Under Hospitals' Thumb

8. Being Shunted Aside by Policymakers

9. Being Shunted Aside by Entrepreneurial Management Companies

Many physicians believe that by being employed by hospitals they are at risk of being co-opted by the hospital's vested interests. In many cases this has been proven to be true.

Many employed physicians have passively aggressively undermined the hospital and its vested interests. Rather than making money from physicians intellectual property hospital systems have claimed that they have lost money.

Hospital employment has been attractive to young physicians just completing residency training. They do not have to make an investment in a medical practice and fear the uncertainty of the future of medical practice.

These physicians’ goals are to have regular and predictable office hours in an outpatient practice setting with adequate coffee and lunch breaks. They do not follow their patients in the hospitals.  They have no connection to patients, their anxiety or fears. Patients are interchangeable and seen by the next available physician as in the VA system. A physician patient relationship does not develop.

This is bad for patients.

Another problem is many physicians believe that policy makers have not been listening to the physicians’ perspective about the problems in the healthcare system. Policy makers are trying to solve the problems of our dysfunctional healthcare system from their perspective and not from the physicians or consumers’ perspective.

“Obamacare is often cited as an example of when policymakers turned a deaf ear to physicians' interests. As many physicians see it, the law lacks substantive tort reform, failed to repeal the sustainable growth rate, and doesn't improve healthcare.

Obamacare ignores patients’ responsibility in keeping themselves healthy and staying healthy after being treated. It assumes physicians are responsible for maintaining patients’ health.

Ignoring this point alone will cause Obamacare to fail. There are many other issues involved in Obamacare’s ultimate demise at a great cost to our country and our healthcare system.   

America healthcare system is in trouble. Obamacare is causing more trouble for America’s healthcare system. 

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

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Creating Confusion And Blame

Stanley Feld M.D.,FACP,MACE

President Obama is in the midst of a leadership crisis on many fronts. A large number of voters have no idea of the details of each crisis or scandal.

They figure they elected a President who will not only take care of a crisis when it develops but he will look after America’s best interests.

There are other voters who have become news junkies. They are interested in each crisis. The source of their information is the traditional media.  The traditional media provides filtered sound bites that lead them to erroneous conclusions.

People are mistrusting the administration and the traditional media because they are realizing that are being fed disinformation. They realize they are being manipulated. It is becoming clear that the administration is not defending the constitution and the people’s freedoms.

The defects in Obamacare are affecting people directly. All of a sudden seniors cannot find a physician who will take Medicare.

If they sign up with a concierge physician they receive no reimbursement from the government for Medicare premiums they have paid.

People with employer sponsored healthcare insurance are having difficulty finding a physician unless they pay a fee to a concierge physician.

Their portion of the healthcare insurance premium has increased with a threat of higher premiums next year. A 15-50% increase is expected. Their copays and deductibles have also increased.

The employer sponsored healthcare insurance plans are going to be available to only full time employees.

Last month there was an increase in employment of 288,000. However there was a decrease in 708,000 fulltime jobs and an increase in 1,115,00 part time jobs because of Obamacare and its mandate to provide healthcare coverage for people who work more than 35 hours a week or face a penalty.

 Writing in the Wall Street Journal, Mortimer Zuckerman — real estate developer and editor in chief of U.S. News & World Report — says yes. Some data seem convincing. In June, part-time jobs (defined as less than 35 hours a week) increased by 1,115,000, reports the Bureau of Labor Statistics (BLS); full-time jobs fell by 708,000.”

Just think of all those Americans working part time, no doubt glad to have the work but also contending with lower pay, diminished benefits and little job security,” wrote Zuckerman.”

The New York Times and Paul Krugman keep telling us Obamacare is a success. They ignore the facts.

 A few weeks ago a study showed that 85% of the people who signed up for Obamacare on the individual market received subsidies from the government.

It turns out many people lied on their enrollment applications and they will not receive the subsidy. The Obama administration took their enrollee's word because it did not have the infrastructure to check the applications. These people cannot afford the premium now much less after the subsidy is removed and back payment to the government is made.

This will reduce the 8 million claimed valid enrollees to below 5 million enrollees.

The execution and implementation of Obamacare is a great setup for fraud and abuse. It is described in the following You Tube.

I do not think President Obama is going to demand back payment. This is not the first time President Obama has changed the law without consulting congress.  

The law states that people can qualify for tax credits. A tax credit is defined as a deduction off the income tax due. People making under $40,000 do not pay income tax. Some receive a check from the government.

How was a tax credit changed to a subsidy?

The law specifically states that the state health exchanges and not the federal health insurance exchanges can provide the tax credits. Thirty-six states have not set up state health exchanges. 

 Those thirty-six states predicted that the exchanges would be a failure and a tax burden to its citizens.

 Many of the remaining states that set up health insurance exchanges are failing.

The federal government set up health insurance exchanges in those thirty-six states instead. The federal health insurance exchanges have not been a  success despite the statements by the New York Times and Paul Krugman to the contrary.   

President Obama’s pledge to bail out the healthcare insurance industry if the industry does not make as much money as they expected to make because of the demographic profile of the people who sign up is another sign of failure. It points out how dependent the Obama administration is on the participation of the healthcare insurance industry.

Where is President Obama going to get the money to pay for all the pledges? The CBO now predicts Obamacare create a 1 trillion dollar deficit rather than an excess over the next decade. This is after collecting increased taxes for 6 years before full implementation of Obamacare.  

There are many other defects in Obamacare. It is a failure.

The Obama administration with the help of the traditional media is trying to distract the public from the facts by withholding facts and feeding the media confusing facts, disinformation and lies about Obamacare’s success.

The administration blames Obamacare’s difficulties on the Republicans using non-facts.

The Obama administration can get away with this for only so long. The middle class is realizing the economic burden Obamacare has created for the middle class and the economy.

The middle class is realizing this because the facts are affecting them directly.

With the atmosphere of mistrust, and distrust created by the economy, the decrease in the value of the dollar, the lies and withholding of information about Bengasi, Fast and Furious, the IRS, the Ukraine, Syria, Iraqi, Afghanistan, Iran debacles, and the VA scandals it is going to take a lot for the people to regain its trust in President Obama.

Alinsky’s methods of lies, obfuscation of the truth and blame are running out of steam.

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

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The Problem With Expert Panels

Stanley Feld M.D.,FACP,MACE

It is obvious to me that Obamacare is going to rely on expert panels of the government’s choosing to determine if there is enough evidence for physicians to perform certain tests, prescribe certain medication or perform certain surgeries.

The panel evaluates the quality of data in published studies. The “medical experts” are not experts in the field of medicine they are evaluating.  

Many of these studies do not take into account the natural history of a disease or the common sense use of clinical judgment.

The panels’ conclusions are used by CMS to determine reimbursements for tests, medications and procedures.

The most recent publicized examples have resulted in controversies between the US Preventative Services Task Force (USPSTF) experts and expert specialists in each medical field. The examples include mammogram testing, PSA testing and bone density testing to name a few.   

 Medical care cannot be commoditized. The evidence of efficacy is always changing. Much of the clinical research is not completely vigorous.  It cannot be put into a nice computer evaluation box.

Published studies are restrictive. It is very difficult to define best practices using evidence based medical care. Many studies are poorly designed. Most clinical studies do not include long term follow up.

Most clinical insights into the natural history of disease are the result observational data. Observational data is not given as much credit as double blind placebo controlled longitudinal studies in evaluating strength of data.

Double blind longitudinal studies are becoming rare because they are too expensive to design and take too long to determine if they alter the course of the disease.

Nevertheless the expert panels to be used in Obamacare are set up to determine payment policy. These payment determinations have many deficiencies.

The error in determining payment policy can lead to restriction of access to care. These errors can also lead to the onset of chronic disease complications.  Chronic disease complications can lead to an increase of medical care costs.

One such abuse is the USPSTF refusing to endorse widespread screening for vitamin D levels in healthy adults, despite research suggesting that a majority of Americans may be deficient or insufficient in vitamin D.

“The United States Preventive Services Task Force decided not to recommend routine testing for vitamin D levels in part because it was not clear whether otherwise healthy adults with low levels would actually benefit from taking supplements of the vitamin.”

The panel members concluded that there was not enough evidence to either endorse or advise against regular vitamin D screening in most adults.

The panel members suggested that testing is something that should be considered case by case.

People produce normal vitamin D levels in their blood when exposed to sun for at least 10 minutes a day. Most Americans avoid sun exposure because of fear of skin cancer and skin aging. Sun block is used to avoid UV light that stimulates the production of normal vitamin D levels.

Is the government going to reimburse physicians for using their judgment in testing for serum vitamin D levels? I doubt it.

The panel hedged. “This is not a recommendation for or against it,” said Dr. Douglas K. Owens, a panel member and director of the Center for Primary Care and Outcomes Research at Stanford medical school. “In our view, when people have concerns or questions about vitamin D, they should discuss them with their clinicians.”

In my view the panel knows very little about vitamin D deficiency. Some studies estimate that more than two-thirds of Americans have deficient or insufficient vitamin D levels.

The first symptom in vitamin D deficiency/insufficiency is weakness in large muscles bundles. An easy clinical test is to see if a patient can rise from a sitting position without leaning on his/her elbow or a support. If a patient needs support it is likely that he has a vitamin D deficiency.

The USPSTF panel issued a draft recommendation based on a review of evidence from more than a dozen studies that evaluated the effects of vitamin D treatment in generally healthy adults.

The studies used vitamin D3 doses ranging from 400 to 4,800 international units (I.U.) daily, and the studies were from two months to seven years duration.

400 I.U. per day is insufficient replacement therapy. 400 I.U. per day would have no impact on inhibiting a disease process or preventing a disease from occurring. It would provide no insight into helping prevent chronic diseases implicated in vitamin D deficiency.

Clinical studies lasting two months would not provide any insight into the efficacy of replacement therapy in chronic diseases such as osteoporosis, hypertension, heart disease, inflammatory bowel syndrome or cancer, to name a few.

Vitamin D deficiency has the greatest direct impact is on the development of osteoporosis. Most of the osteoporosis research has been focused on preventing fractures after a vertebral fracture has occurred.

Most patients with osteoporosis have a component of osteomalacia. Osteomalacia is a thinning of the bone secondary to a vitamin D insufficiency and a decrease in calcium absorption from the gut.

Osteoporosis takes 30 years to result in bone fractures.  Meanwhile patients with osteoporosis also have had a vitamin D deficiency.

 A double blind placebo controlled study for osteoporosis would be impossible to conduct or fund.

In recent years observation data has shown that patients with vitamin D insufficiency or deficiency have an increased incidence of several cancers, hypertension, heart disease (probably as a result of hypertension) and irritable bowel syndrome. This is all observational data that has been discounted by the USPSTF.

The natural history of many cancers is unknown. There are many confounding variables to cancer. However, the observed relationship to vitamin D deficiency or insufficiency is strong and should be heeded by the government.

The design of generating these Task Force Guidelines is defective.

When and if Obamacare takes over the total healthcare system as the single party payer, Americans will experience a restriction to access of care that might result in an increase in the complications of many chronic diseases.

It is too late to test a vitamin D level once the symptoms are presented.

It will have no impact on inhibiting a disease process or preventing a disease from occurring.

This onset of the chronic disease will result in higher costs to the healthcare system.

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

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