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Disinformation and the healthcare system

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New Statin Therapy Warnings and Its Science

March 18, 2012
inConsumer Driven Health Care, Disinformation and the healthcare system, Information Technology in Healthcare, Medicine: Healthcare System
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Stanley Feld M.D.,FACP,MACE

I have said repeatedly that patients have to become the Professors of Their Disease. A reader recently wrote, “ The average consumers are not smart enough to evaluat complicated clinical data.”

My answer is that it is the responsibility for their physicians to teach them how to evaluate the data used to decide on their cause of therapy.

Physicians’ goals are to their treat patients with the best possible evidence based medicine. It is the patient’s responsibility to understand the reasons for the treatment and be responsible for adhering to the treatment.

In my opinion, during the last decade, arriving at the best evidence based medical care has become very difficult. The design of clinical research studies has become sloppy. The statistical results of the studies have frequently been misrepresented. Statistical trends have been interpreted as being statistical truths.

However, once a statistical trend has been reported and accepted as evidence the non- statically significant data have resulted in producing defective healthcare policy and decreasing the quality of medical treatment.

One prime example has been my opinion of the effect of the Women’s Health Initiative on women’s health. Another is the conclusion of the FDA to put a black box treatment warning in the labeling of statins.

The conclusions drawn from the clinical data for the recent black box warning are wrong. The studies are wrong because the clinical studies were designed poorly or the conclusions were not statistically significant.

There are a few simple statistical rules that must be followed for a study to prove that the conclusions are correct and a medication has a certain statistically significant effect.

The p value must be less than .05, the confidence interval must not cross 1 and the hazard ratio must be 2 or greater. It must also be a well designed study to be able to show a valid effect.

  The women’s health initiative was poorly designed. In my opinion the study design alone disqualifies the study results. 

  1.  TNT (Treating to New Targets) trial,[4] 351 of 3798 patients randomized to 80 mg of atorvastatin and 308 of 3797 randomized to 10 mg developed new-onset type 2 diabetes mellitus (T2DM) (9.24% vs 8.11%, adjusted hazard ratio [HR]: 1.10, less than 2, 95% confidence interval [CI]: 0.94-1.29, crosses 1 P = .226). Not significant.
  2.  In the IDEAL (Incremental Decrease in End Points Through Aggressive Lipid Lowering) trial,[5] 239 of 3737 patients randomized to atorvastatin 80 mg/day and 208 of 3724 patients randomized to simvastatin 20 mg/day developed new-onset T2DM (6.40% vs 5.59%, adjusted HR: 1.19, 95% CI: 0.98-1.43, P = .072). Not Significant.
  3. Across the 3 trials, there was no difference in the major cardiovascular events, which were 11.3% in patients with and 10.8% in patients without new-onset T2DM (adjusted HR: 1.02, 95% CI: 0.77-1.35, P = .69) including the SPARCL trial were not significant.  
  4. In a meta-analysis of 13 clinical trials with 91,140 participants showed no significant difference. It is my opinion that meta-analysis is worthless because of variation in each study’s design.  

I understand that the first reaction of a reader would be that it is impossible for the average person to understand the significance of this science.

There is no reason this information could not be explained to people in various formats from very advanced to cartoon simple. The explanations could be available on an Internet social network 24/7 chosen by their physicians.

I believe patients could understand the information once they were motivated to be responsible for their medical care.

I am astonished that “experts” would propagate this disinformation on topics as important as the health and well being of the population.

Hopefully a consumer driven healthcare system would compel everyone to be more careful in examining data from clinical research studies. 

 

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

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  • warhammer tau • March 21, 2012

    Thanks for this post,Good to know that there are still interesting information which you can learn browsing the net and it really helps you a lot.

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Let’s Talk About Statins

March 14, 2012
inDisinformation and the healthcare system, Medicine: Healthcare System, Patients Problems
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Stanley Feld M.D.,FACP,MACE

The New York Times did it again. Once again we are experiencing media hyperbole. The first sentence tells it all.

We’re overdosing on cholesterol-lowering statins, and the consequence could be a sharp increase in the incidence of Type 2 diabetes.

Bingo.  For years teaching physicians have worked hard trying to convince practicing physicians the virtues of statin therapy to lower the incidence of coronary artery disease by lowering LDL cholesterol (bad cholesterol).

Finally, it took hold. Practicing physicians tried for years to convince their patients to take statins to decrease the risk of heart attacks.

Over the years evidence mounted proving that normal total cholesterol value should be lower than 200 mgs% from a previous normal of 240 mg%.  The normal LDL cholesterol should be lowered to 100 mgs% from 150% mgs%.

This was not a pharmaceutical industry’s conspiracy. It was arrived at with actual statistically significant clinical data.

The New York Times goes on to say;

“This past week, the Food and Drug Administration raised questions about the side effects of these drugs and developed new labels for these medications that will now warn of the risk of diabetes and memory loss. The announcement said the risk was “small” and should not materially affect the use of these medications.”

As soon as the first sentence was read it immediately put the safety of statins in question. There was no discussion of the flawed data used to reach this conclusion.

I predict the warning that resulted from flawed data will result in the unwarranted  decrease in physicians prescribing statins and patients refusing to take statins.

“ The data are somewhat ambiguous for memory loss. But the magnitude of the problem for diabetes becomes much more apparent with careful examination of the data from large clinical trials.”

I believe the data is shabby for both increasing the incidence of diabetes and the decrease in cognitive function.

I also believe the scientists at the FDA also believe the data is shabby.

FDA’s statements include;

"1. However, because statins are so widely used, there is a heightened awareness by the public when we make any safety-related labeling changes to this class of drugs."

"These changes do not in any way alter the risk-benefit calculus for this class of drugs. We continue to believe that the benefits of statins far outweigh their risks, but we do want clinicians and patients to be aware of their side effects so that they can be used in the most safe and effective manner possible."

The media has emphasized the safety label change warning patients of the possibility of getting diabetes as a result of taking statins. The fact is there are so many flaws in the studies sited that initiated the label change that the changes are unwarranted.

The FDA goes on to state,

“ We are not recommending that patients be discontinued from their statin therapy based on a small increase in blood sugar levels.”

“Rather, elevations in blood sugar levels should be treated with dietary and lifestyle management and/or adjustment or initiation of antidiabetic therapies. We do not consider this a reason to not continue or not initiate statins, particularly in the diabetic population where patients are at increased risk for major adverse cardiovascular events and statin therapy has been shown to reduce that risk.”

This disclaimer had not been emphasized in the traditional media. The Women’s Health Initiative (WHI) another flawed study did not have one statistically significant leg to the study. Yet it’s handling in the traditional media changed the course of women’s health forever. Evidence from the WHI was used as study material. The statement below assumes the conclusion of harmful effects of statins is real.

“Despite the higher hazard ratios observed in the WHI study, we do not have strong evidence suggesting that there is a gender effect for the development of this adverse effect.”

The FDA looked at the effect of statins on neurocognitive function.

“We looked at those study results; there was no difference in neurocognitive functioning observed between patients exposed to statin therapy vs those unexposed, including in executive function (attention and speed) and memory, both immediate and delayed.”

There is no evidence here.

"There were trials conducted with statins to see if they could improve cognitive functioning in patients with mild to moderate Alzheimer disease. We reviewed the results of one such study, which showed neither evidence of benefit nor harm in cognitive functioning associated with statin therapy.”

My fear is the misleading warnings being publicized in the press will change the course of therapy for patients at risk for coronary artery disease.

The science used to arrive at these warnings is shabby. It is important to understand the defects in the evidence so that society does not do to statins what it did to hormone replacement therapy for women's health.

 

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

Please send the blog to a friend

 

 

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President Obama Is Destroying His Theoretical Basis For Obamacare In Order To Win Re- election.

January 4, 2012
inDisinformation and the healthcare system, Medicare, Medicine: Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D., FACP,MACE

I have been speaking to many people about the hazards of Obamacare.

Many well-educated people do not understand the defects in President Obama’s Healthcare Reform law and its potential unintended consequences.

Unfortunately, many congressmen and senators do not understand the consequences of the law either.

Rather than President Obama’s Healthcare Reform law making the medical care system better it is destined to make it worse.

I have explained the reasons for these unintended consequences in past blogs.

Most people have difficulty understanding details of the law because it is poorly covered in the press in our sound bite society.

Only a small percentage of people need medical care at any one time.  To those not needing medical care the healthcare system under President Obama’s law has changed little except for higher healthcare premiums and deductibles.   

The 35-55 year olds are the group that must become aware of the changes that will result from the law. When they will need medical care our healthcare system will likely be decimated. 

Everyone is in agreement that our federal, state and local governments are bankrupt.  Everyone understands our federal government has borrowed and spent the money we should have saved to fund our future healthcare needs.

Additionally, entitlements and administrative inefficiency, waste and fraud will have intensified the problems of overspending.

Paul Krugman believes deficit spending is immaterial. He continues to insist that John Maynard Keynes was right even though he lack evidence for his conclusion. Deficit spending is immaterial until there is no one around to lend the government money.

President Obama keeps saying he is going to decrease healthcare costs with his law. His conclusion is theoretical. His conclusion defies his own government’s CBO and various experts.

President Obama’s conclusions also demonstrate his lack of understanding of the complicated defects that have accumulated over many years of adjusting to defective healthcare policy. 

Increasing bureaucratic structure and government control is at the root of the problems in the healthcare system. Increasing this structure is not the solution to the healthcare system.

President Obama is now backing off some of the draconian aspects of contaminating the theoretical basis of his Healthcare Reform Act.

The Obama administration’s surprise announcement Friday that it planned to give states broad leeway to pick the benefits offered under the federal health care law offers yet another example of a gradualist approach to carrying out its signal domestic policy achievement.

 Obamacare mandates what must be covered under the Federal Health Care Law

• Ambulatory patient services, like doctor’s visits

• Emergency services

• Hospitalization

• Maternity and newborn care

• Mental health and substance abuse services

• Prescription drugs

• Rehabilitative and habilitative services, and specialized social and medical services for people with conditions like autism and cerebral palsy

• Laboratory services

• Preventive and wellness services and chronic disease management

• Pediatric services, including oral and vision care

 

President Obama is choosing to avoid some crucial choices until well after the 2012 elections. Critics accuse the administration of political expediency. The Obama administration insists the decisions have been based on sound policy judgments.

I hope the public is not stupid enough to believe President Obama’s ploy. The public has been duped in the past. I think it is  waking up.

 In passing a good deal of the decision-making to states, the administration has guaranteed that Americans will continue to face a patchwork of state regulations that make coverage uneven and inefficient.

People in Utah and Wyoming, for example, are likely to have more limited access to expensive services now mandated in states like Massachusetts and Maryland. And consumer advocates worry that some states will limit benefits too strictly.

President Obama has taken the guts out of his law just as he previously discontinued the insurance mandate to large organizations in 2011.

 “I think what Congress had in mind was creating a uniform national level of benefits that would be available to everybody,”

President Obama is playing another trick play on the states and the American people. The net result will be more uncertainty, more unintended consequences and more deficit spending.

Let us not be fooled again. Let us wake up!

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

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Where Is The Healthcare Money Going?

November 27, 2011
inDisinformation and the healthcare system, Physician's Problems, Politicians,Healthcare and Vested Interests
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Stanley Feld M.D.,FACP, MACE

In reviewing Ezekiel Emanuel’s New York Times article I thought of an interesting question. In Dr. Emanuel’s view it is not worth having tort reform or healthcare care insurance reform. He claims these reforms are an insignificant burden to the cost of the healthcare system.

I have demonstrated that the evidence for tort reform and reform of the healthcare insurance industry proves him wrong.

The question then is where is the $2.5 trillion dollars the U.S. healthcare system spends going?

President Obama and Dr. Emanuel think it is going to physicians. President Obama’s idea to control healthcare costs is to reduce physician reimbursement.

Physicians have the weakest expression of its vested interests among all the stakeholders because of lack of effective leadership. 

Simple arithmetic reveals that reducing physician reimbursement will yield an insignificant reduction in healthcare costs.

Never the less on January 1st Medicare is going to decrease physicians’ reimbursement by 27%. This decrease is the result of the application of the government’s Sustainable Growth Rate (SGR).

The Sustainable Growth Rate (SGR) is a complicated and defective formula intended to contain the overall growth of Medicare spending for physicians’ services.  The intent was to keep physicians’ reimbursement in line with the nation’s ability to pay for that medical care.  The SGR formula uses the gross domestic product per capita in a complicated and inaccurate way. 

In 2008 the Bureau of Labor statistics published a report that there were 661,400 physicians in the United States.

 The report’s findings are summarized in the table below.

 

Projections data from the National Employment Matrix

  

Occupational Title

SOC Code

Employment, 2008

Projected 
Employment, 2018

Change,
2008-18

Detailed Statistics

 

Number

Percent

 

Physicians and surgeons

29-1060

661,400

805,500

144,100

22

[PDF]

[XLS]

 

    NOTE: Data in this table are rounded. See the discussion of the employment projections table in the Handbook introductory chapter onOccupational Information Included in the Handbook.

 

Let us assume that 161,400 of the 661,400 physicians in the U.S. work in private medical related industries such as the healthcare insurance industry, the pharmaceutical industry, the physician executive industry and government services.  These physicians are not involved in direct patient care and do not generate direct patient costs to the healthcare system.

 The number of non direct patient care physicians is probably higher (185,192 in other non practice positions and 476,208 in direct patient care). My assumption uses 500,000 physicians involved in direct patient care for all types of insurance to inflate physicians’ reimbursement. 

The Bureau of Labor report states,

 Physicians and surgeons held about 661,400 jobs in 2008; approximately 12 percent were self-employed. About 53 percent of wage–and-salary physicians and surgeons worked in offices of physicians, and 19 percent were employed by hospitals.  .

 

Let us also assume that physicians’ overhead is 50% of total collections. Therefore physicians’ take home salary is 50% of collections. Fifty percent is a fairly accurate assessment whether the physicians are self employed or hospital system employed.  

 “According to the Medical Group Management Association's Physician Compensation and Production Survey, median total compensation for physicians varied by their type of practice. In 2008, physicians practicing primary care had total median annual compensation of $186,044, and physicians practicing in specialties earned total median annual compensation of $339,738.”

 If we round off the salaries to $190,000 for Primary Care Physicians and $340,000 for Specialists and round off the number of Primary Care Physicians to 300,000 (actually 375,000) and 200,000 in Specialties (actually 125,000) and do the math, physicians’ salary comprise only 5% of the total $2.5 trillion dollars spent in the healthcare system.

The Math:

 $190,000 per year per primary care physician x 300,000 physicians= $57,000,000,000 ($57 billion dollars for primary care physicians).

 340,000 per year per specialists x 200,000 specialists= $68,000,000,000 ( $68 billions dollars a year for specialists).

 $57 billion + $68 billion= $125 billion per year for the costs of physicians salary for direct patient care.

 $125 billion (125,000,000,000)/ $2.5 ($2,500,000,000,000) trillion per year = 5%

 If you double the physicians’ collections to include physicians’ overhead costs ,  physicians receive 10% of total dollars spent on healthcare system.

Improvements can be achieved in decreasing physicians’ overhead by having more integrated healthcare systems. Presently, most communities do a fair job.

Integrated electronic medical records could achieve a further decrease in the 5% of the total healthcare cost spend by physicians for overhead.

The government is spending billions of dollars on building bureaucracies, creating regulations, developing a IRS physicians fraud squad and creating committees trying to reduce 5% of the healthcare costs.

President Obama is approaching the problem of escalating healthcare system costs using the wrong premises. It will result in increasing healthcare system costs. Obamacare already has increased the costs of the healthcare system even though it is not fully implemented.

 "IF REALITY DOESN'T match your expectations, perhaps it's time to re-examine your premises."

 

Where is the other 90% of the healthcare system costs going?

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

Please send the blog to a friend 

 

 

 

 

 

 

  • physical therapist salary • December 13, 2011

    By some weird arithmetic, the more life stuffs itself into the valley, the more spaces it creates for further life.

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Disinformation Compliments Of The New York Times

November 13, 2011
inDisinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

 If you want to have an accurate opinion you should have accurate facts.

 Lately, the New York Times has been publishing opinion articles, in the name of truth, by experts who give opinions based on inaccurate facts.

The danger is that government policy based on those opinions is wrong and will lead to unintended consequences.

 Ezekiel Emanuel M.D. published such an article in his weekly opinionator blog on November 3rd,2011.   

I will review the facts used by Dr. Emanuel to form his opinion.

“Everyone — conservative and liberal — agrees that $2.6 trillion a year is too much to spend on health care, and that we have to cut costs. But they don’t agree on who is to blame or what is to be done.”

I agree.

 He proposes an artificial threshold of significant costs saving in order to form a policy.

 “ A useful threshold for savings is 1 percent of costs, which comes to $26 billion a year. Anything less is simply not meaningful.”

This number is random. It permits him to dismiss problems that cost the healthcare system less than $26 billion dollars a year.

 Health care spending in the United States typically increases by about $100 billion per year. Cutting a billion here or there from something that large is undetectable is meaningless. In health care, you have to be talking about tens of billions of dollars before you are talking about real money.

 He defines the divide between conservatives’ and liberals’ opinions.

He states that conservatives are concerned about the cost of tort reform. Liberals are concerned about the profits of the healthcare insurance industry and drug industry.  Using the wrong data to prove his point he concludes that these issues are simply a distraction from the real efforts of controlling healthcare costs.

 Nothing could be further from the truth.

Today, I will concentrate on examining his evidence against the need for tort reform.

 “ Conservatives favorite fix is to reform medical malpractice by limiting noneconomic damages, statutes of limitation and lawyers’ fees. In its favor is the fact that doctors’ fear of medical malpractice lawsuits is legitimate.

According to a recent study in the New England Journal of Medicine, about 7.4 percent of doctors get sued each year. By age 65, even those in “low risk specialties” like pediatrics and dermatology face a 75 percent chance of being sued.

His argument continues by saying,

 It’s no wonder doctors order M.R.I.’s for routine headaches and monthly ultrasounds for normal pregnancies, despite these procedures not being required or recommended by professional guidelines.

His second argument against tort reform is the Congressional Budget Office 2009 scoring of the cost impact of tort reform.

“In 2009, the Congressional Budget Office did a comprehensive assessment of the potential cost savings from medical malpractice reforms.

Its conclusions: A package that included a $250,000 cap on noneconomic damages, a $500,000 cap on punitive damages and a one-year statute of limitations for claims by adults would save about $11 billion a year — 40 percent from reduced malpractice premiums and the rest in the form of fewer defensive procedures like M.R.I.’s.

 Dr. Emanuel concluded that $11 billion dollars a year savings is insignificant because it is a cost saving below $26 billion dollars a year. He contends tort reform is a distraction from real efforts to control healthcare costs and should be ignored. The CBO scoring information has lead Dr. Emanuel to an inaccurate opinion.

The CBO did not score all the necessary data to arrive at the accurate cost savings from tort reform.  

 

 “A full accounting of medical malpractice reforms shows the benefits would be $242 billion a year.”

 

The CBO assessment is a gross underestimate of the potential cost savings. President Obama and the Democrats provided the CBO with scoring data. The data given was intended to give cover to congressional Democrats who say malpractice-liability costs are trifling.

The truth is a full accounting reveals that more than 10 percent of America's health expenditures per year are spend on tort liability and defensive medicine.

The percentage of healthcare costs is even greater when the Massachusetts Medical Society survey is taken into account. The amount spent for defensive medicine can be extrapolated to actual costs from this survey.  

I have written a series of blogs analyzing the impact Massachusetts Medical Society’s survey. The extrapolated costs turn out to be about $700 billion dollars a year. The real cost of defensive medicine is somewhere between $242 and $700 billion dollars a year.

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2009/04/president-obama-if-you-really-want-to-reduce-healthcare-costs-effectively-reform-the-medical-malpractice-tort-system-part-2.html

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2009/04/president-obama-if-you-really-want-to-reduce-healthcare-costs-effectively-reform-the-medical-malpractice-tort-system-part.html

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2009/04/president-obama-if-you-really-want-to-reduce-healthcare-costs-effectively-reform-the-medical-malpractice-tort-system-par.html

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2009/04/president-obama-if-you-really-want-to-reduce-healthcare-costs-effectively-reform-the-medical-malpractice-tort-system-part-2.html

 In 2008 damage awards alone for medical malpractice claims reached $5.9 billion dollars.  The total of medical tort costs was $16 billion for legal costs, underwriting costs and administrative expenses. From 1986 the average jury award was $100,000. In 2006 the average award increased to $637,000. No one knows what the award value is for cases settled out of court.

Each year, 25% of practicing physicians are sued. 90% of physician sued are found innocent. The average defense cost is $100,000. This cost is not included in the CBO scoring

The fear of lawsuits causes most doctors to practice "defensive medicine" as the interviews of Massachusetts physicians points out.  The result is unnecessary testing, referrals, and procedures to protect themselves from allegations of medical negligence.  

A recent survey of doctors published in the Journal of the American Medical Association found that 93% of physicians admit to practicing defensive medicine. A 2008 survey by the Massachusetts Medical Society found that about 25 % of medical procedures are defensive in nature.

This waste results in increased healthcare insurance premiums. The premium increases result in an increase of at least 3 million uninsured people per year. When these uninsured people get sick they avoid going to a physician. This results in a decrease in  work productivity. It is estimated that the annual decrease in productivity is more than $40 billion dollars a year.

In states where tort reform has been instituted by placing caps on so-called non-economic damages, the malpractice costs have decreased 39%. This drop in costs is a result of decreased malpractice suits. The decrease is economically bad for the plaintiff attorneys. Annual malpractice premiums have gone down at least 13%. In fact, the medical malpractice business for plaintiff attorneys has about dried up in Texas.

As a result of tort reform in Texas, more than 16,500 physicians have moved to the state from non-tort reform states. More than 430,000 additional Texas have healthcare insurance as a result of the tort reforms according to the Perryman group.

  Senate Majority Leader Harry Reid, a Nevada Democrat, claims: "The whole premise of a medical malpractice 'crisis' is unfounded." Harry Reid listens to Dr. Ezekiel Emanuel’s opinion.

The influence of the disinformation is terrifying. Inaccurate opinions by influential people will never lead to a functional, affordable healthcare system.

 The disinformation concerning healthcare insurance company profits and drug company profits will be discussed shortly.

The New York Times needs a fact checker.

In my view it is irresponsible of President Obama and his advisors to distort the truth with disinformation.

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

Please send the blog to a friend 

 

 

 

 

 

 

 

 

 

 

  • Private Investigator NYC • November 22, 2011

    Reading a long and full of information article like this one are still one of the best way to improve knowledge.

  • EMR • November 27, 2011

    I dont think anyone really knows all of the information, bills, side notes and loop holes in these bills. No one really knows the whole story.

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RomneyCare and Jobs

October 12, 2011
inDisinformation and the healthcare system, Innovations in Healthcare, Medicine: Healthcare System, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

Everyone except Mitt Romney agrees RomneyCare was used as a model for President Obama’s healthcare reform act. Mitt Romney insists that on the first day of his Presidency he will repeal Obamacare. He contends that healthcare reform should be a state problem. Each state should choose what is right for itself.

RomneyCare was enacted in 2006. It was implemented it in 2007. It offered insurance subsidies for low-income individuals, expanded Medicaid coverage and created an individual mandate to obtain insurance. Pay-or-play requirements for employers were imposed on employers. It created a state insurance exchange through which many of the newly insured Massachusetts residents obtained coverage.

It sounds like Obamacare.

 In Massachusetts 98% of its citizens have healthcare insurance coverage. Massachusetts has also experienced a large increase in health insurance premiums. The healthcare insurance costs have nearly doubled in Massachusetts.  There is increasing political pressure and public opinion opposing the increasing budget deficit resulting from RomneyCare.

President Obama has bailed out Massachusetts twice to the tune of 8 billion dollars.

        The results of a study “Health Care Reform and the Health Care Workforce — The Massachusetts Experience” was published in the New England Journal of Medicine on September 22, 2011 by  Douglas O. Staiger, Ph.D., David I. Auerbach, Ph.D., and Peter I. Buerhaus, Ph.D., R.N.

 

 The study looked at job growth in the healthcare sector in Massachusetts since the implementation of RomneyCare.

My impression in 2007 was that Massachusetts would experience an increase in healthcare costs, an increase in budget deficits and a decrease in availability of medical care.

I also knew there would be an increase in administrative costs and administrative jobs. Anytime a new bureaucracy is begun there is an increase in hiring bureaucrats. Many times bureaucrats’ income is higher than physician’s income.  

 The study showed there was an increase in job growth in the healthcare sector. The increase in hiring was 5.5% greater than job growth in the rest of the United States’ healthcare sector.

  Romney care and jobs 1

 “Had health care employment in Massachusetts grown at the same rate as in the rest of the country, approximately 18,000 fewer people would have been employed in health care by 2010.”

 It turns out that most of these healthcare related jobs were not related to the delivery of medical care by physicians or healthcare providers.

  Romneycare 2

 From 2005–2006 to 2008–2009, employment per capita in administrative occupations grew by 18.4% in Massachusetts, as compared with 8.0% in the rest of the country (P=0.015).

 This data clearly confirms my bias. The data shows a pattern that should be obvious to all.

Unfortunately, none of the differences in percentage in each category are statistically significant. In order for a comparison to be statistically significant the p value must be less than .05. A p value of 0.015 is greater than .05. It is not statistically significant.

Two weeks ago I had an email exchange with a reader about the importance of accurate data. Data is scientific and complicated. It increases the complexity of the healthcare system.

The reader wrote,

 “With the advent of HIT products such as EHR’s, registries and “smart” hardware, it is now much easier to access data that can be used to drive improved outcomes.  Most EHR’s can provide population level data that can be used to view the level of care presently rendered and to track changes in outcomes as new processes and hardware are adopted.

It will be necessary in the near future for providers to develop their skills in using data to modify processes at their site so that the patient outcomes are significantly better.  New payment models based upon quality of care will require this.  Successful employment of these techniques will be rewarding for all involved—patients, providers and payers.

 Have a great weekend.”

I replied,

“If data is not accurate and the results are not statistically significant, the conclusions, decisions and policy on the basis of the data are not going to be good.

 I have seen business data and healthcare policy data that has been poor, inaccurate and not statistically significant pose as accurate scientific data. This data has led to faulty business and health care policy decisions. “

Physicians have been paranoid about the collection of data evaluating their performance. Both valid and invalid data have been used to penalize them. Data collections should be used as a learning experience not as a punitive weapon to reduce reimbursement.”

 Toyota has done it in its factory auto production. My reader continues

 “This approach to providing quality in services and products has been used for many years outside of healthcare.  Toyota developed a unique approach based principally on plan-do-check-act (PDCA) and teamwork that resulted in a superior product that enabled them to be the standard of quality in production for many years.”  

 It is time the physicians adopt this model. Unfortunately it will not happen until the competing learning systems (experiential, [physicians learning] and complicated [data collection]) are managed effectively and stakeholders’ incentives are aligned.

 It is time the healthcare system started to use accurate data. Accurate data can extend the legacy experience of physicians. Only then will the healthcare system start aligning incentives. 

 Some healthcare providers are starting to adopt data driven models such as PDCA. I believe adoption can only be driven by trust among stakeholders. Patients are first and they must assume responsibility to drive the system.

 The only way they will do that is if they have a financial incentive to drive the system.

I will try to describe a framework necessary for consumers of healthcare to drive the healthcare system. Successful employment of these techniques will be rewarding for all involved—patients, providers and payers.

 

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

 

 

 

  • Michelle • October 19, 2011

    If people really want quality insurance, it is available and affordable. They just need to make it a priority in their budget and call health insurance reps to find them the best deals that fit them.

  • Darwin • November 9, 2011

    I don’t understand why you say 0.015 > 0.05. It is not.

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President Obama Sneaks In Another Tax Increase: Means Testing for Medicare Part D

October 9, 2011
inDisinformation and the healthcare system, Medicine: Healthcare System, Patients Problems, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust
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 Stanley Feld M.D.,FACP,MACE

 

I must interrupt the development of my theme, “Managing Complexity In Order To Repair The Healthcare System,” to bring you this special announcement.

Starting in 2011, Part D enrollees whose incomes exceed $85,000 (for individual tax returns) or $170,000 (for joint tax returns) will begin paying more for Medicare Part D (Drug Prescription Benefit Plan). These “super rich?” seniors will be paying up to 60% more for Medicare Part D per person.

Some really rich seniors who receive a total income from all sources, including retirement benefit, social security, capital gains and dividend will pay the government up to an additional 500% more than their Medicare part D premium costs.

The government should fix the Medicare Part D program by negotiating the drug costs with drug companies directly as they do in the Veterans Administration. The healthcare insurance companies lobbied hard for this concession.

President Obama has chosen to tax seniors for the outrageously constructed drug benefit rather than putting seniors first.

President Obama slipped the means testing regulation for Part D into last years budget. Means testing went into effect on January 1,2011. I missed the regulation and its implementation completely.

Congress and the mainstream media also missed this rather historic regulation. Some would say the regulation was in plain sight but congress did not bothered to see it.

It was also astonishing to slip this into law when President Obama specifically promised he would not change Medicare benefits for any seniors. 

President Obama cannot be trusted.

It reminds me of President Reagan’s famous line. “I am from the government and I am here to help you.” 

President Obama’s plans to collect more than $8 billion a year from “wealthy seniors” for Medicare Part D drug prescription benefit by “means testing” seniors for all sources of income.

Major Democratic members of the House and Senate have been opposed to means testing for Medicare Part D. President Bush tried to get congress to pass means testing for Part D in 2006. It was quickly rejected by the Democratic controlled congress.

The Democrats arguments were consistent with liberal dogma.

“Social Security and Medicare are participatory programs, designed for all Americans—rich and poor alike. You work hard, kick a portion of your income into these two retirement funds, and are guaranteed a payout in your golden years. This gives these programs broad popular support—they are not welfare for the poor, they are guaranteed retirement benefits for all.”

“Liberals fumed. Means-testing of entitlement programs would send us down a dreaded "slippery slope," they argued. Soon Medicare, and then Social Security, would lose their broad-based popular support, and be merely costly welfare programs! Both Obama and then-Sen. Hillary Clinton voted against a Republican proposal to means-test Part D last year.”

President Obama’s regulation has not gotten very much media attention.  Liberals declare the goal is to preserve Medicare's status. Wealthy seniors (earning retirement income from all sources of over $85,000 per year) did not recognize the increase in 2011. The tax is deducted from their electronically paid Social Security benefit.

This tax was another President Obama trick play.

Pete Stark must be fuming about the means testing. It contradicts his liberal philosophy.

“Requiring some seniors to pay more for Medicare is a red herring from Republicans who want nothing more than to end Medicare as we know it,” said Rep. Pete Stark, ranking Democrat on the Ways and Means Health Subcommittee. “Upper-income seniors paid more into Medicare when they worked. Applying a new surcharge is essentially double taxation and should be rejected.”

Charlie Rangel’s reaction to means testing for Part D was expressed in 2006.

“The beauty of Medicare is that we’re all in it together, whether you are rich or poor, healthy or sick,” commented Rep. Charles B. Rangel, senior Democrat on the Committee on Ways and Means. “Charging certain people more is the first step toward destroying Medicare’s universality and turning it into a welfare program.”

Nancy Pelosi’s take on means testing for Part D in 2006 was harsh.

“It is simply unacceptable that nearly 2 million Medicare premiums will double beginning this January,” House Democratic Leader Nancy Pelosi said. “Seniors, who are already struggling to make ends meet, should not pay the price for failed Republican policies. With further premium increases slated in the future for even more beneficiaries, we must act immediately to protect America’s seniors.”

The Part D premium increases, known as means testing, are based on the same income thresholds as Medicare Part B means testing.

2011 Income thresholds are as follows:

2011 Income Thresholds (single)

Joint per person

Less than $85,000

Less than

$170,000

$85,000 – $107,000

$170,000

to $214,000

$107,000 – $160,000

$214,00

to $320,000

$160,000 – $214,000

$320,00

to $428,000

$214,000 or more

$428,000

or more

2011 Part D Additional Premium (monthly)

$0

$12

$31.10

$50.10

$69.10

2011 Part B Premiums

(monthly)

$115.40

$161.50

$230.70

$299.90

$369.10

Part D plan members will continue to pay their regular premium to their Part D plan, but the income-related adjustments shown above will be paid to Medicare. It will be deducted from their monthly Social Security check.

These additional charges are sure to catch some seniors’ off-guard. Some who might be subject to the additional charges are those who own a business, those who are earning farm or investment income, seniors who are taking installments from their 401(k), or those selling a home for a profit.

“This potentially historic change (and others like it) will slide right through, and serve as a model for further means-testing of entitlement programs”.  

What bothers me most is that there was no public discussion or political debate on the issue that I recall. President Obama simply hid the increased senior tax in his budget. He has often promised to make the drug plan more affordable.

President Obama’s means testing regulation is really an assault on the retired middle class seniors of modest retirement income.

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

 

 

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The Healthcare System and Managing Complexity

October 5, 2011
inDisinformation 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, MACE

 Many readers were confused by my last four blogs, It Is Easy To Forget, How To Manage Complexity, Aligning Incentives Is A Must In Creating An Efficient Healthcare System and How Home Depot Learned To Manage Complexity.

I have received comments like, What does this have to do with the healthcare system? Who cares about Mechanism Design? What does the healthcare system have to do with Pareto efficiency?

One person wrote; “Dr. Feld, I do not get it. None of this relates to the healthcare system.”

All of these blogs relate to the dysfunction in the healthcare system. The healthcare system has a larger “Blind Spot” than many large corporations in America. 

My brother and I have been discussing his analysis of the Blind Spot in corporate America in detail. The subtitle of his book is “A Leader’s Guide To IT-Enabled Business Transformation.”

It dawned on me that his transformation model could be applied to the healthcare system. Everyone knows the healthcare system has to be fixed but no one knows what to do.

President Obama and Dr. Don Berwick are making the dysfunction worse as they impose their complicated ideas on the healthcare system.

A reader wrote in response to my Home Depot article,

 

“Yeah, this is good stuff–consumer oriented.  Obama & those ox#70 professors he listens to don't get this at all.” 

I often get comments that the Healthcare System is impossible to repair. It is too complex.

Medicine is going through a transformation. There is conflict between vested interests and between learning systems.

1. Stakeholders are fighting to protect their vested interests. The fight has intensified as a result of the transformation. The conflicts must be resolved.

2. Physicians continually learn through the experience of daily medical practice. The experience gained increases physicians’ medical judgment. This learning system is important for the physician-patient relationship. It promotes the confidence patients should have in their physicians.

 As a result of the dysfunction in the system physicians are abandoning their medical judgment in the pursuit of defensive medicine and patients are losing confidence in their physician’s judgment.

Data should be accurate and informative for patients and physicians to improve care. Instead the data collected has been punitive to both patients and physicians.

3. Advances in medical science and medical technology represent complicated learning systems. New advanced techniques are developed in surgery, medicine, genetics and therapeutics.

Information technology offers a chance to enhance experiential learning but has not been deployed properly. Instead it has led to disinformation and increased stakeholder mistrust.

Healthcare insurance companies, hospital systems, and the government have installed complicated data collecting information systems to gather insight into the cost and quality of medical care.

In the past, much of the data has not reflected the true value of the care of physicians. The data has been used to the disadvantage of patients and physicians.

4. No one has understood the patterns of behavior that have resulted from these conflicting learning systems and vested interests. No one has figured out how to manage the complexity generated by these interactions in the healthcare system.

The Home Depot example of learning to manage complexity can be applied to the healthcare system.

The physician is the store manager. The patient is the customer.  All the rest of the stakeholders should be the supporting cast.

Once everyone gets it, a sensible conversation can begin. Only then can the healthcare system be on its way to achieving Pareto efficiency.

Readers should think about their recent healthcare system encounters. I would guess many have walked away with an unpleasant feeling toward the healthcare system whether it was the encounter with the insurance company, hospital, government, pharmacy, or physician.

 Navigating the healthcare system has become an unpleasant chore.

It is also unpleasant for all the stakeholders. Yet none of the stakeholders see their Blind Spot.

These unpleasant and inefficient activities are created by the complexity of the healthcare system. This complexity can be broken down into components parts. Only then can the complexity of the healthcare system be managed. 

The most important asset all of us own is our health. Every effective effort must be made by the healthcare system to maintain our health. We as individuals must be responsible for maintaining our health.  Individual responsibility can be achieved.  When it is everyone will win.

Central control of our healthcare system with government imposition of rules and regulations to control patients’ freedom and physicians’ medical judgments will not work.

   

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

 

 

 

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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.

  1. Experience
  2. Complicated-scientific
  3. 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 21st 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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