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Let The Buyer Beware: Medicare Part D

Stanley Feld M.D.,FACP,MACE

The mystery of buying drugs under Medicare Part D increases each year. The plans offered become more costly and complicated.

Medicare did not cover outpatient prescription drugs until January 1, 2006, when it implemented the Medicare Part D prescription drug benefit.

Congress authorized Medicare Part D with the heading the “Medicare Prescription Drug, Improvement, and Modernization Act of 2003.”

Private insurance companies administer Medicare Part D plans for the government. The government is not allowed to negotiate drug prices with the pharmaceutical companies.

The VA healthcare system negotiates prices with the pharmaceutical companies. The prices are at least 60% lower than the Part D prices.

Multiple plans are offered with increasing premium prices and deductibles each year.

The increases in deductibles are significant. Below are the increases between 2016 and 2017. Most seniors do not pay attention to the increase in premiums, deductibles or coverage because they automatically enroll each year.

They become aware of the changes changes when they go to pay for their medication

Initial Deductible:
will be increased by $40 to $400 in 2017.

Initial Coverage Limit:
will increase from $3,310 in 2016 to $3,700 in 2017.

Out-of-Pocket Threshold:
will increase from $4,850 in 2016 to $4,950 in 2017.

Coverage Gap (donut hole):
begins once you reach your Medicare Part D plan’s initial coverage limit ($3,700 in 2017) and ends when you spend a total of $4,950 in 2017.

In 2017, Part D enrollees will receive a 60% discount on the total retail cost of their brand-name drugs purchased while in the donut hole.

Generally, not all drugs are covered at the same out of pocket cost to the beneficiary. This gives participants incentives to choose certain drugs over others. This is most often implemented—as is the case for drug coverage for those not on Medicare—through incentives to use generic drugs over brand-name drugs.

The incentive is also often implemented via a system of tiered formularies in which some brand-name drugs are less expensive than others and not subject to step therapy.

Generic drugs are less expensive than brand named drugs. Patients learned this quickly. They encouraged their physicians to provide them with a prescription for generic drugs.

When patients buy drugs with Medicare Part D the deductible price is the patients’ cash outlay. However, the Medicare Part D plan charges patients the total retail price of the drug against their donut.

For example if a 90 day supply of a generic drug is $10 and the retail price is $60 dollars, the $60 is charged against the patient’s donut to be added to future purchases.

If patients paid $10 cash already shouldn’t only $50 of the $60 be charged against the donut?

Many generics can be purchased for a cash price or using a discount drug card coupon for $10 without using Medicare Part D and incurring the $60 retail charge against a donut.

Many generics can be purchased for less using a discount drug card coupon than the cash price a senior on Medicare Part D has to pay using Medicare Part D insurance.

It is not uncommon for senior patients to reach their donut in less than a year. At that time those senior patients have to pay 100% (60% in 2017) of the retail price for a drug until they reach $4,950.

The amount is an additional cash price of $1,250.

It was difficult to figure this out before discount drug cards became available.

How do these discount drugs card work and the discount drug card companies make money?

The Middle Men are:

“1.    Cardholder – the consumer

  1. Pharmacy – the retail outlet in which the purchase is made
  2. Pharmaceutical Company – the manufacturer of the medication
  3. Adjudicator – the organization that negotiates the discounts with the drug makers
  4. Card Marketer – the organization whose brand is on the card
  5. Card Marketer Affiliate – an organization that assists the Card Marketer in distribution

 Each time a card is used there is a transaction fee applied to the purchase price. 

 That fee is split 3 or 4 ways (though perhaps not evenly) between the Pharmacy, the Adjudicator, the Card Marketer and their Affiliate.

This transaction fee comes at the Cardholder’s expense.

However, usually the negotiated discount cost of the medication far exceeds the transaction fee so the Cardholder still wins. 

For example, the retail price for a medication is $100. The prescription discount card has negotiated a 40% discount, so the cost would be $60 but there is a $10 transaction fee. So the Cardholder pays $70 instead of $100. Of the $10 transaction fee, the Pharmacy might take $2, the Adjudicator $2 and the Card Marketer $6.

The Card Marketer might pay out $1 to their marketing


Many Medicare Part D patients have figured out how to optimize their drug cost through the use of the discount drug cards.

None of these government policy manipulations are to senior recipients of Medicare Part D advantage. They all benefit the middlemen.

A simple solution is to change the Medicare Part D law so the government can negotiate the cost of drugs just as all the middlemen in the Discounted Drug Card industry are negotiating the price of drugs to the advantage of seniors.

Sometimes the discount cards yield different discounts in different pharmacies in the same zip code.

Sometimes the pharmaceutical companies figure out how to combine two medications that are just as effective when taken separately to increase the cash price to senior patients.

These companies do it with FDA approval.

I became aware of the vast price differences recently with two commonly used drugs Dutasterile (Brand name Avodart) and Tamusulosin (Flow Max). Both drugs have been on the market long enough to be sold as generic drugs.

Using the Good RX discount card these are the variation in prices for the combination drug and the drugs sold separately in one zip code.

Dutasterilde +

Tamsulosin 90

Dutasterile 90 Tamusulosin 90
Walgreens $183.00 $183.08 $113.93
Kroger $316.98 $45.61 $30.62
CVS $388.69 $84.63 $58.62
Tom Thumb $391.85 49.85 $31.85
Albertson $391.60 $52.60 $31.85
Walmart $475.10 $398.71 $55.23
Target $388.69 $388.71 $136.41

Table 1

None of the pharmacies receive an appropriate discount for the combination of Dutasterile plus Tamulosin. Only Kroger’s negotiator received an appropriate discount for the two drugs sold separately. The total price is $76.23 for 90 pills vs. $316.98 for the combination.

However, seniors have run into a problem in shopping for the best price in a neighborhood.

The government provides a bonus to physician practices that have meaningful use electronic medical records.

One criterion for a meaningful use electronic medical record is the electronically ordering prescriptions for patients.

If a patient usually used the Wal-Mart Pharmacy that telephone number would be in the record. The physician’s prescription would automatically be sent to the Wal-Mart Pharmacy. If the physician wrote for the combination for it would cost $475.10. If the physician wrote the prescription for each medication separately in would cost the patient $453.94 as opposed to cost him $76.23 at Kroger’s.

Compounding the complexity of the electric medical records unintended consequence the pharmacist would automatically fill the combination prescription using that senior’s Medicare Part D insurance. It would be much cheaper than the cash price.

The senior would pay only $146.50 for the combination but his donut would be charged the full retail price of $475.10.

The physician’s office should be aware of the difference in price between the generic combination and the generic drugs sold separately. However, that is not the physicians job.

He should be able to give the patient a paper prescription for both the combination and separate medication so the patient would be able to shop for the best price in his zip code if he was so inclined.

Clearly Medicare Part D is a mess and needs straightening out.

The discount drug cards are not the answer on top of the rising Medicare Part D premiums.

Many retired seniors are living month to month on a pension. The Medicare Part D premiums are paid with after tax dollars not pre-tax dollars.

Many seniors simply cannot afford to pay for their medication. If they do not take their medication they will develop complications of their disease.

Medicare Part A and B will cost the government more and become more unsustainable.

A few simple fixes can solve the problems in Medicare Part D that policy makers and congressmen do not seem to be aware of.

Patients must be responsible for their medical care and their healthcare dollars.

It would be nice if the government would help a little with fixes in information and policies that work for senior patients.

In the meantime it is imperative to “Let the Patient Beware.”

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

All Rights Reserved © 2006 – 2017 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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The Shovel Ready EMR Project?

Stanley Feld M.D.,FACP,MACE

  The Health Information Technology for Economic and Clinical Health (HITECH) Act passed in 2009 directed 5 % of the $800 billion dollar economic stimulus package towards digitizing medical records.

This was considered one of President Obama’s shovel ready projects. This project has lots of problems and was much less than shovel ready.

It was George W. Bush, not Obama, who started the project to digitize medical records. EMRs make sense if they are directed toward improving patient care.

President Obama funded the project with his shovel ready economic stimulus package in 2009. Physicians dislike the project. Patients find little value in the project.

It is estimated that in five years 50 times more health information will be generated and digitized than today. Diagnoses, treatments, DNA, medical images and vital signs already are being analyzed and stored.

One large problem is Americans don’t own their own healthcare information.

In its present form patients find little useful information in the EMRs. Many of the EMRs do not fit the Obama administration’s criteria of meaningful use EMRs. Medical practices will experience a penalty this year.

Government punishment hardly ever works. Government providing for innovative opportunities works.

The government and the insurance industry own the information.

The big data is derived from meaningful use EMRs. The government is only interested in evaluating the quality of physicians’ care. The government would like to decide on the reimbursement of that care.

The EMR has not added value to patient care because physicians have to spend too much time concentrating on filling in required documentation. Much of the information is worthless because they cut and paste template reports that are required documentation for the government to judge. The medical record is cluttered with information that is not useful.

The cost is physicians do not have time to relate to patients.

Michael F. Raab, M.D.Sanibel, Fla writes in the WSJ

 “I recently received 147 pages of EMR which took me 30 minutes to review. I only found three lines that added new information.”

HIPAA (Health Insurance Portability and Accountability Act) requires hospitals, physicians, labs, pharmacies and other “covered entities” as well as the health plans and their “business associates” (for example, an information-technology vendor) to protect how your data. This rule applies only to paper record. It does not apply to digital records.

Most EMRs aren’t covered by HIPAA at all, and providers and vendors can do whatever they want with your information.”

Digital records are vulnerable to hackers. Health records were stolen from nearly 80 million Anthem health-plan members. The façade of privacy has been exposed.

Electronic medical records companies, and hospitals and health systems that own physician practices own the patients’ digitized healthcare records.

These entities have withheld health information from patients in order to gain an edge over competitors. It becomes difficult for patients to switch to other healthcare plans or providers without their records.

Patients are entitled to their records but they must get past vendor delays.

There is great financial value of patients’ data beyond competitive advantages to these providers. The value is in marketing research for specific demographics. The revenue comes from using health information for drug research, targeted marketing and other efforts.

Many big data companies are investing heavily to own a piece of the multi-billion-dollar monetization of health information.

 “These companies know that whoever controls health information will dominate the health-care marketplace and its vast profit pool.”

Congress has been slow to fix these problems. It needs to update health-information policy and privacy rules.

These are the four most important rules that Dr.David Brailer (the former national health information technology coordinator in the Department of Health and Human Services (2004-06)has outlined.

"1. Individuals should have unqualified ownership of their health information. Every person should be able to access his information whenever he wants, without blocking or delay.

1a. Health information should automatically follow patients wherever they get treated, unless they don’t want that to happen.

1b. Patients should be able to control which people and organizations are allowed to see their information, and whether those organizations can retain that information.

2. Individuals should be able to designate an intermediary to manage their information on their behalf. Many people would not want to handle their health information, so an “infomediary” could assist them and ensure that their information is used to advance their health status.

2a. Intermediaries could be a spouse, a hospital, a health plan, a pharmacy or even a tech company like Google, SalesForce or Yahoo.

 3. Standards for security protection should be raised so that information is protected wherever it flows.

3a. A secure medical Internet—encrypted data lines that are walled off from hackers and other threats—is needed to protect the perpetual movement of information among hospitals, physicians and other legitimate data holders.

4. Every “covered entity” that touches health data, including every app, should follow the same rules."

Congress must act now!

The goal of the EMR was to have computers that could talk to each other for instant availability of patients’ medical information to enhance care and decrease retesting.

The availability of the $30 billion dollar Obama stimulus and the lack of consumer control has led to an evolving inefficient bureaucracy and rules and regulations that have created pain for the two most important stakeholders, patients and physicians.

The EMR project was not shovel ready as President Obama promised. It has turned out to be a waste of money. Instead of improving patient care it is hurting patient care.

An effective healthcare system would provide consumers with ownership of their healthcare data, their healthcare dollars and a desire to be responsible for their health.

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

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EMRs Real Politics.

Stanley Feld M.D.,FACP,MACE


Dr. Jerome Groopman and Dr.Pamela
Hartzmen uncovered the real politics of EMRs.
 They are both on the staff of Beth
Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical

 Dr. Groopman wrote a best seller “How
Doctors Think.”

In a Wall Street
Journal article they wrote,

 The electronic medical record (EMR) is touted
as the key to containing costs, reducing errors, improving quality, and
simplifying administration: an “elegant exercise in wishful thinking

Dr. Groopman and Pamela Hartzman debunk the 2005 RAND study. The
RAND EMR study of 2005 led to President Obama’s belief that EMRs will save $81
billion dollars a year for the healthcare system.

Groopman and Hartzman show that there is little evidence to
support the president’s belief.

The RAND analysts claim that more than $350
billion would be saved on inpatient care and nearly $150 billion on outpatient
care over a 15-year period of time.

Unfortunately, data from three other studies, a cardiology
group, a Harvard group and Canadian group showed there is no savings difference
between paper records and electronic records.

Dr. Groopman claims the RAND study is self-serving to EMR software
companies that sponsored the study.


Healthcare Solutions
, the Cerner Corporation and Epic Systems of Verona, Wis. are the major EMR software companies.

 In February 2009, after years of behind-the-scenes lobbying by
Allscripts and others, legislation to promote the use of electronic records was
signed into law as part of President Obama’s economic stimulus bill.

“But today, as doctors and hospitals struggle to make new records
systems work, the clear winners are big companies like Allscripts that lobbied
for that legislation and pushed aside smaller competitors.”

At Allscripts Healthcare
solutions, annual sales have more than doubled from $548 million in 2009 to an
estimated $1.44 billion last year.

At the Cerner Corporation of Kansas City, Mo., sales rose 60 percent during that

“Current and former industry executives say that
big digital records companies like Cerner, Allscripts and Epic Systems of
Verona, Wis., have reaped enormous rewards because of the legislation they
pushed for.”

Unfortunately, many of the
EMR systems bought by large hospital systems and physician practices are not
fully functional. They do not fit the administration’s criteria of meaningful-use
EMRs. These EMRs are requiring additional hospital systems and physicians;
practices outlays of cash to make them fully functional.

City-based Pain Clinic of Northwest FL filed a purported class action lawsuit
on Dec. 20, 2012 against Chicago-based Allscripts (NASDAQ: MDRX).

“The purported class action
lawsuit says that about 5,000 small group physicians were sold an EMR called
MyWay from 2009 until late last year, when the company stopped supporting the

“The company was also hit with
a federal shareholder class action securities fraud lawsuit in the Northern
Illinois District last year over allegations that it misled investors about the
performance of its EHR programs.”

 The MyWay EMR cost about $40,000
per physician. ThePain Clinic of Northwest Florida claims it was misled by
Allscripts Healthcare Solution.  The
Clinic stated that MyWay has “shortcoming
and inherent defects,”  

complaint says Allscripts was unable to obtain “meaningful use” bonus status
for MyWay because of the problems with the program. The lawsuit claims that

 “Allscripts has been unjustly enriched by
retaining the money paid by MyWay purchasers and users without delivering an
EHR software product that performs as it was intended to work,”

 These costs are always
passed on to the consumer
. Drs. Groopman and Hartzman  go on to say,

president and his health-care team have yet to address these difficult and
pressing issues.

 Our culture adores technology, so it is not
surprising that the electronic medical record has been touted as the first
important step in curing the ills of our health-care system.

this notion is an overly simplistic and unsubstantiated part of the solution.

It is important to note Drs. Groopman and Hartzman’s total
and refreshing frankness.

“We both voted
for President Obam
a, in part because of his pragmatic approach to problems,
belief in empirical data, and openness to changing his mind when those data
contradict his initial approach to a problem”.

We need the
president to apply
scientific rigor to fix our
health-care system rather than rely on elegant exercises in wishful thinking.”

Please note that Drs. Groopman and Hartzman said it not

a new study The RAND Corp has backed off on its 2005 study earlier this year
and withdrew its estimate of saving to the healthcare system of $81 billion
dollars annually.

In the
RAND Corp’s view, the disappointing performance of health IT to date can be
largely attributed to several factors:


  1.  “Sluggish
    adoption of health IT systems
  2.   Coupled
    with the choice of systems that are neither interoperable nor easy to use;
  3.   The
    failure of health care providers and institutions to reengineer care processes
    to reap the full benefits of health IT.
  4.  We
    believe that the original promise of health IT can be met if the systems are
    redesigned to address these flaws by creating more-standardized systems that
    are easier to use,
  5.  EMR are
    truly interoperable,
  6.  Afford patients more access to and control
    over their health data.
  7.  Providers must do their part by reengineering
    care processes to take full advantage of efficiencies offered by health IT, in
    the context of redesigned payment models that favor value over volume.”


It should not be a blame game.

General Electric sponsored this new RAND study.  It is important to note that GE is a major
Allscripts competitor.

There is true value in the EMRs to patient care. However the
focus of the marketing and development is on the wrong customer.

The RAND still does not get it. Perhaps
it does not want to get it.

EMRs should be for the benefit of physicians and their
patients. It must be at a price physicians can afford to pay. It should not be
for the benefit of the government, the healthcare insurance industry and
hospital systems.

It should be a tool to
continually educate physicians and patients. It should not be a tool used by
secondary stakeholders to penalize physicians and patients.

Patients and physicians control My Ideal Electronic Medical
Record. It should be seriously considered to achieve the maximum benefit of EMRs’

I believe it would be of value to interested readers to go
to this link.

 Those articles will
not only describe the problems with EMRs, problems which I have predicted and are
now recognized. These articles will also outline real  solutions to having universal adoption of

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

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What Happened to the “Physician/ Patient Relationship?”

Stanley Feld M.D.,FACP,MACE

The only way America’s healthcare system will be repaired is by
revitalizing the Physician/ Patient Relationship.

Veterans complaining about the VA Hospital System in my last
blog brought
on a flurry of negative comments about practicing physicians not
connecting with their  Medicare and
commercial insurance patients in the private sector.

The chief complaint is that physicians are not connecting to
their patients or their patients’ illness. I have heard enough stories to
believe it is true.

A 44-year-old male with
private healthcare insurance sent one such complaint to me.

His acute illnesses history was compatible with acute prostatitis.

He needed a new physician because his previous primary care physician
had taken a sabbatical leave.

He called for help in finding a physician to his friends on
Facebook, Twitter and Link In. The consensus was the physician he describes

The physician did multiple tests, several of which I did not
think were necessary, along with a cursory physical examination. The physician
thought the patient had prostatitis and prescribed Cipro for one month. A
follow-up examination was not scheduled.

The last paragraph in the patient’s note to me was,.

By the way, my doctor's office called to let me know the
lab results are in and they are mailing them to me. The doctor told the front
desk person to send me a letter, which I'll get in a day or two. According to
the front desk person, in the letter he says that my labs look good, and that I
need to work on getting my lipids up. Apparently he included a link to a
website that I can learn more about lipids. Pretty great patient care, eh…

This is horrifying to me. The patient will probably do well.
However there is no contact or concern about the patient’s outcome in this
interaction. There was no physician patient relationship formed for a patient
who is looking for a primary care physician.

I would be very upset if this interaction happened to me.  I would be more upset if I then receive a bill
for $800 for the visit.

This patient does not know what the bill will be because the
office said it will bill his insurance company.

The evidence of the loss of the Patient-Physician Relationship of delivering medical care did not happen overnight.

A reader Dr. Dale Fuller sent me this commentary. He walks us through the
evolution of the destruction of the Doctor- Patient relationship.

Dr. Fuller’s view is similar to the view I have discussed in this
blog on multiple occasions. I believe it is important to publish his thought in
its entirety.


 "Whatever Happened to
the “Doctor- Patient Relationship?”


Dale Fuller M.D.

Lately, I
find myself thinking about this question more and more.  I think the first time I heard the term,
“doctor-patient relationship” was back during Harry Truman’s administration,
when there was an effort led by the Democrats to create a National Health
Insurance Program.

Medicine” the opposition cried, and “The end of the doctor patient
relationship!   I wasn‘t even a student
in college back then, and in the absence of more information, I saw the
doctor-patient relationship in the context of my experience with the doctor who
looked after me on those rare occasions when I needed to see him,

Dr. T.D.
Jones, who was a very kind man.  He was a
small town doctor, and the only doctor in my hometown as well as a good many
other towns around it during World War II.

I kind of
understood the term “socialized medicine” in the context of the then-new
National Health Service being launched in Great Britain. 

Truman and
company lost the battle for NHI back then.

The next big
“Socialized Medicine initiative arrived in 1960 
“Socialized   during the Republican administration of Dwight

Robert Kerr, of Oklahoma and Rep. Wilbur Mills of Arkansas, both Democrats
introduced the Kerr-Mills act, the “Medical Assistance for Aged Act 1960-1965”
(benefiting primarily the elderly on Old Age and Survivors’ Assistance).

was passed in 1960, again over cries that it would destroy the doctor-patient
relationship.  But this time the cries
were neither so loud, nor as successful. 
By this time I am a newly minted MD, and my awareness of the total
meaning of the term is still mostly intuitive.

During the
administration of Lyndon Johnson, came the Social Security Amendments of 1965,
which brought us Medicare and Medicaid. 

When I
entered practice in 1968, Medicare and Medicaid were just getting under way, so
I never experienced what it was like to practice in the absence of the law.

In March of
2010, President Obama signed into law The Patient Protection and Affordable
Care Act, and we are now living through the incremental steps preceding that
law becoming fully in effect in 2014.

The various
legislative initiatives have, to be sure, impacted the doctor-patient
relationship in many ways, as the opponents predicted, but it appears to me
that we have been hearing less and less about that relationship as the years
have passed. 

I think it
might just be that the relationship we are discussing may be threatened by a
number of other forces other than the laws described above, but before I
attempt to list those forces, I want to spend a little time setting the stage
to describe just what the doctor-patient might and might not mean.

Goold and
, in an article published in 1999 (1) called the doctor-patient
relationship “a keystone of care: the medium in which data are gathered,
diagnoses and plans are made compliance is accomplished, and healing, patient
activation, and support are provided.”

They say that
the medical interview is the major medium of health care, and that more than
82% of diagnoses are made by history alone.

The three
functions of a medical interview are the gathering of information (both through
history and physical examination) developing and maintaining a therapeutic
relationship, and communicating information.

In the eyes
of the law, physicians also have a fiduciary responsibility toward their
patients. Physicians are bound to act in their patients’ interests even when
those interests may conflict with their own.

In that
physicians are often directly involved with events and conditions that are
life-altering for their patients and families, at birth, during severe illness,
healing or death, it can also be said that in being a physician, and providing
health care, doctors are engaging in a moral enterprise.

There was a
time when the unwritten social contract laid out above, simply existed as an
understanding between patients and doctors.

In the early
1940’s the arrival on the scene of what became the Blue Cross and Blue Shield
program, initially serving the employees of the Dallas, Texas Independent
School District began to interpose a third party, the insurance company,
working through the employers, in the social contract that was the Doctor-Patient relationship.

that interposition was pretty innocuous, with the insurance plan simply paying
the bills of the doctor as they were presented. The phrase, “usual and
customary” arose to define the fees involved that the insurance company paid.
Unusual fees or fees exceeding customary levels became subject to challenge,
requiring justification if they were to be paid.

Over time, a
database of fees that really were usual and customary began to become a better
and better tool to define where the usual kind of fee stopped and the unusual
kind of fee was recognized.

when it came along, introduced the federal government as a payer, and
relatively soon thereafter, the health care bureaucracy began to grow and
insert itself between doctors and patients to an increasing degree.

Since this
was in the “Pre-Medicare era” the number of patients involved was relatively
small, and so the impact on the doctor patient relationship was still somewhat

The arrival of Medicare and Medicaid served to
illustrate that the old “camel entering the tent” analogy was beginning to come

while the organizations were formed to administer the programs, “usual and
customary” was still the order of the day where payments were concerned, and
the social contract still functioned much as it had always done.

At the
request of the Department of Defense, organized medicine (AMA) created a set of
relative value scales in an attempt to standardize professional fees. The set
of codes was called “Current Procedural Terminology (CPT codes)” (first
introduced in 1966).

The charges
were to be based upon a blend of time required, professional skill involved,
and liability risk.

The compendium
of procedures have grown over the years, the principles remain essentially the

In a fit of
zeal, the Federal Trade Commission inserted itself and accused professional
societies of “price fixing” via the CPT codes.

eventually ensued, and money passed from the societies that were sued to the
FTC, and life, after the “nolo contendere pleas’ went on as usual.

The reason
for this was that the societies were not well enough funded to defend their
position vs. the FTC, even though they might have won their cases.

though, as might be expected, the government began to insert itself more and
more into the transaction between doctors and patients, generally, drawing upon
the reality that it was paying, directly or indirectly, for more than 50% of
the care given in the US.

and rules have proliferated, respecting what can and cannot be done for
patients who are beneficiaries of federal programs. 

Another force
was also becoming more vocal in making statements and policy regarding what
could and could not be done for patients.

This force
began with the passage of the Health Maintenance Act of 1973.  This act enabled a vast acceleration of the
whole concept of managed care. 

Insurance Companies citing the growing demand for, and cost of medical care to
employers, found a ready market among employers for their “products” to serve
as “benefits” for their employees. 

and hospitals, fearing that they might be left out of the managed care programs,
made haste to “join” this program or that program, seeking access to the
populations of patients enrolled in the programs by the insurance companies
selling coverage to employers. 

The fear was
that exclusive arrangement with insurance companies would eliminate whole
populations of patients from providers who had not “signed up”.

This meant
that the traditional bilateral social contract between doctors and patients
essentially had come to an end of sorts.

Patients’ expectations
were that service and behavior of the doctor they were allowed to see remained
pretty much the same except for a small by important fact.

employees covered by managed care were required to see the doctors who
participated in the program, and to use the hospitals the programs had
agreements with.

penalties awaited those patients who sought their care “out of plan”, for
whatever reason. 

Now patients
and doctors both have someone else “calling the tune” when it comes to the
delivery of healthcare.

Each time the
“plan” purchased by the employer changed, for whatever reason, there could be a
change in the physicians and hospitals available to the patient. 

This brings
us to a key element of the doctor-patient relationship. A key element is
continuity of care.

Continuity of
brings with it an opportunity develop relationships in which doctors and
patients really know and trust one another. This relationship allows physicians
to recognize changes in patients and recognize the early onset of disease.

Neither the physicians’ understanding nor the
patients’ trust cannot be rebuilt immediately between two individuals each year
who are basically strangers to one another.

 Doctor of days past, the trusted counselor, often
friend and confidant, is no longer exists. 
Now, patients are simply seeing another person in an office. Both
parties are at sea when it comes to knowing what they need to know about one
another to allow the encounter to produce the necessary result within the time

Time, like
continuity, is also a vanishing element in the doctor-patient
relationship.  Fewer and fewer
practitioners have the time, amidst the pressures of “patient throughput” to
really engage in patients’ needs.

must gather and record data, establish a diagnosis, and create a treatment plan
of quality.

documentation has to be complete in order to get paid by the government or the
healthcare insurance carrier.

Doctors must also
explain his treatment plan in such a way that they are assured of patients’
compliance with the treatment proposed in the time available to doctors.

As a result
of decreasing reimbursement and increasing overhead the time necessary for
patient education is insufficient. Patients do not understand the significance
of the therapy. The result is a lack of compliance.

problem is that the “third party payers” rather than the patients approves of any
tests and procedures that doctors believe are needed to strengthen the

The result is
a further erosion of patients trust in the doctor.

The time for
a consultation is short. Tests and procedures are now increasingly used to
substitute for the gathering of data to make the diagnosis.

Tests and
procedure escalate the costs of medical care.

gathering by history and physical examination is time consuming. If a history
and physical examination is properly done it can yield the diagnosis of patients’
problems about 80% of the time.

doctor-patient relationship is indeed fading into the past. The third party carriers
and the federal government have, in their zeal to contain cost, pretty much
seen to that.

The reality
is that the destruction of the doctor-patient relationship costs more in the
long run.

The federal government, in its enthusiasm to
make a positive impact on the quality of care patients receive, has mandated
the use of electronic medical records.

The EMR in
its own way have also served to diminish the doctor-patient relationship.

In many
doctors’ offices, the focal point in the room is a computer with data entry.
The keyboard and the screen have almost the full attention of the doctor, who,
without looking at the patient, asks the questions and types the responses.

The patient is lucky if the doctor makes eye
contact with him/her for a brief interval a couple of times during the visit,
thus further diminishing the possibility that trust can be built in the

The quality
of the encounter can, in the opinion of various policy makers and consultants,
be measured and changed in the same way that manufacturing processes can be
impacted by applying the principles taught by Deming and others.

Maybe it can,
but it has yet to be demonstrated. 
Processes peripheral to the interaction of patient and doctor, may be
made better, but there is little evidence that the same approach can bring back
anything like the doctor patient relationship we used to know."

The three basic goals of Obamacare are
to create an affordable healthcare system with access to care of high quality.

A complicated and complex
bureaucracy that is over regulation will be very difficult to enforce.

It will penalize physicians’
judgment as it tries to decrease reimbursement. It will restrict patients’
access to medical care. It will reduce freedom choice.

Obamacare will not enhance the
Patient Physician Relationships that are so vital to a successful therapeutic

A healthcare system that places
consumers in control of their healthcare dollars and provides incentives to
consumers to be responsible for their health and healthcare will encourage
physicians to save money and rejuvenate the Physician Patient Relationship for
improved therapeutic outcome at an affordable cost.

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

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The False Promise of Electronic Medical Records (EMR)

Stanley Feld M.D. FACP,MACE

promise of the Electronic Medical Record (EMR) is fading for physicians and
patients. The EMR was supposed to reduce the cost of medical care, improve
quality of care, improve physician communications, reduce duplicate testing and
improve efficiency of care.

2009 President Obama declared that EMRs,

save some $80 billion a year,
safeguard against medical errors, reduce
malpractice lawsuits, and greatly facilitate both preventive care and ongoing
therapy of the chronically ill.”

EMR’s have
done none of the above. EMRs have been a money-loser for most physicians.

had predicted that fully functioning EMRs were too expensive for most
practicing physicians.
EMRs bought in the past were not fully functional.
Therefore physicians would have to purchase new fully functional EMRs.

understand that all data collected, whether accurate or not, has been used
against them in the past.
They are hesitant to provide more data at their own
expense that compromise the privacy of their patients and potentially harm their
own reputation.

would be happy to participate in the project if the EMR improved their ability
to serve their patients without a potential penalty.

suspect there is another agenda underlying President Obama’s insistence on the
adoption of EMRs.

is clear the government and healthcare insurance industry want to control the
healthcare system.
As the payers they do not want the physician/patient
relationship to control the healthcare system.  

recent survey from
forty-nine community practices in a large EHR pilot study
by the Massachusetts
eHealth Collaborative studied the projected five-year financial returns on
investment to physicians’ practices. It was published in Health Affairs.

survey concluded,

We found that the average
physician would lose $43,743
over five years; just 27 percent of practices
would have achieved a positive return on investment; and only an additional
14 percent of practices would have come out ahead had they received the
$44,000 federal meaningful-use incentive

Only a few practices would
have had EMR’s that qualified for the Obama administrations meaningful –use
incentives. The Obama administration’s criteria for meaningful-use are too
strict and complex for EMR software that physicians can afford.

More amazing is that the
only way for a practice to have a positive cash return on investment for their
EMR is to game the healthcare system using their EMR. The resulting cost of
medical care would rise.

 “The largest difference between practices with
a positive return on investment and those with a negative return was the extent
to which they used their EHRs to increase revenue, primarily by seeing more
patients per day or by improved billing that resulted in fewer rejected claims
and more accurate coding.”

This does not constitute an improvement in medical care. It also
contradicts the idealistic advantages of the electronic medical record.

The survey concludes that current meaningful-use incentives
alone may not ensure a positive return on investment from EMR adoption.

The authors suggest,

that provide additional support, such as expanding the regional extension
center program, could help ensure that practices make the changes required to
realize a positive return on investment from EHRs.”

 The government and
healthcare insurance industry’s goal is to reduce physicians’ reimbursement for
those physicians that do not meet Obamacare’s imposed criteria for quality
medical care. These criteria will be set by IPAB.

Many physicians in practice object to converting medical care
into a commodity. Medical care is a very personal and complex interaction.

I have said previously that about 50% of the therapeutic index
(therapeutic effect) is determined by the patient physician relationship.

 "We need to move to EHR forward for a number of reasons,
but if I am a small practice I am going to really think about a few
things," she says. "One is how to decrease the cost of adoption and
the cost of the system itself.

“ To the
extent you can reduce the upfront cost that is going to help bring down the
amount you have to figure out how to make up elsewhere. Increasingly there are
new models taking this into account for small practices to decrease the big
upfront costs."

There are two basic problems, cost and the real purpose of EMRs.
Both can be remedied.

The costs of an EMR to a medical practice can be remedied
easily.  My ideal electronic medical
record could reside in the cloud. It would be available at no cost to physicians.
The patient data would be fully secured and only used by patients and their

Physicians would pay for its use by the click. The EMRs would be
maintained and updated for free.

The EMRs could only be used for physician education purposes and
not for penalizing physicians.

If there is a terrible physician in the community a way needs to
be found to deal with that physician within his community. This is where
consumer driven evaluation would work.

Lost in this discussion is the real politics of EMRs.

 Jerome Groopman and Pamela Hartzmen

electronic medical record (EMR) is touted as the key to containing costs,
reducing errors, improving quality, and simplifying administration: an “elegant
exercise in wishful thinking

Dr. Groopman and Pamela Hartzman debunk the 2005 RAND study that
led to this belief by President Obama. They show that there is little evidence
to support the president’s belief.

Dr. Groopman claims the RAND study is self serving to software
companies that sponsored the study.

Healthcare Solutions
 ,  the Cerner Corporation  and Epic Systems of Verona, Wis. are the major EMR software companies.

In February 2009, after years of behind-the-scenes lobbying by
Allscripts and others,
legislation to promote the use of electronic records was
signed into law as part of President Obama’s economic stimulus bill.

“But today, as doctors and hospitals struggle to make new records
systems work, the clear winners are big companies like Allscripts that lobbied
for that legislation and pushed aside smaller competitors.”

At Allscripts healthcare solutions,
annual sales have more than doubled from $548 million in 2009 to an estimated
$1.44 billion last year, partly reflecting daring acquisitions made on the bet
that the legislation would be a boon for the industry.

At the Cerner Corporation of Kansas City, Mo., sales rose 60 percent during that
period. With money pouring in, top executives are enjoying Wall Street-style

Current and former industry executives say that
big digital records companies like Cerner, Allscripts and Epic Systems of
Verona, Wis., have reaped enormous rewards
because of the legislation they
pushed for

The weird thing is many of
these EMR systems bought by large hospital systems are not fully functional
(meaningful-use). The EMRs are requiring additional hospital system outlays of
cash to make them fully functional.

These costs are passed on to
the consumer.

The president
and his health-care team have yet to address these difficult and pressing
issues. Our culture adores technology,
so it is not surprising that the
electronic medical record has been touted as the first important step in curing
the ills of our health-care system. But it is an overly simplistic and
unsubstantiated part of the solution.

It is important to note Drs. Groopman and Hartzman total and
refreshing frankness.

We both voted for President Obama, in part because of his
pragmatic approach to problems, belief in empirical data, and openness to
changing his mind when those data contradict his initial approach to a problem.
We need the president to apply
scientific rigor to fix our
health-care system rather than rely on elegant exercises in wishful thinking.

Please note that Drs. Groopman and Hartzman said it not

I have said this many times in the past. The same statement
applies to the Obamacare in its entirety.

need the president to apply
rigor to fix our health-care system rather than rely on elegant exercises in
wishful thinking.”

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

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The Promise Of Health Information Technology (HIT) Through Electronic Medical Records (EMR) Is Not Fulfilled


 In 2005 the
RAND corporation published a
study stating the HIT through EMR can save the
Healthcare System $81 billion dollars a year in a short period of time.

2012 HIT and EMR have not come close to fulfilling the RAND study’s prediction.

deployed effectively can deliver that promise.

In 2009 the administration’s
stimulus package put aside $19 billion dollars in the first two years and an
extra $50 billion dollars over the next five years to stimulate and subsidize
the adoption of Electronic Medical Records (EMR) to further development of
Health Information Technology (HIT).

The RAND corporation’s 2005 study predicted
a healthcare cost savings of $81 billion dollars a year.

The RAND corporation’s study was
wrong. In the interim healthcare costs have risen $800 billion dollars

our view, the disappointing performance of health IT to date can be largely
to several factors: sluggish adoption of health IT systems, coupled
with the choice of systems that are neither interoperable nor easy to use; and
the failure of health care providers and institutions to reengineer care
processes to reap the full benefits of health IT.”

Many EMR software development companies have
reaped handsome benefits from the administration’s largess. These software
companies have a strategic defect in common.

These companies are trying to transform the
processes used in the practice of medicine into a process that permits the
government to commoditize the quality of medical care. 

If successful the government believes it
could then “judge quality of care”
and “pay for performance” accordingly.

The goal to ensure success should be aimed at
teaching physicians how to improve the quality of medical care rather than
judging physicians’ care.

The RAND corporation’s new suggestions are
repeating the same mistakes that have failed.

 “We believe that the original promise of
health IT can be met if the systems are redesigned
to address these flaws by
creating more-standardized systems that are easier to use, are truly
interoperable, and afford patients more access to and control over their health

must do their part by reengineering care processes to take full advantage of
efficiencies offered by health IT, in the context of redesigned payment models
that favor value over volume.”

In the meantime annual health care expenditures in the United
States have grown by $800 billion. 

The new RAND study blamed the underperformance on several

 “Including: sluggish adoption of HIT systems, along with
balky systems that are hard to use and aren't interoperable; and a failure by
providers and hospitals to adjust care processes to better benefit from
HIT. “

The RAND corporation is looking at the EMR problem
from 30,000 feet. On the ground many private practices and hospital systems had
previously installed information systems that cost them dearly and eroded those
providers’ net revenue.

Money is the main
impediment especially when reimbursement for physicians and hospital systems is
decreasing. Presently, physician groups and hospital systems are struggling to
remain solvent. This is partly from decreased reimbursement and partly from the
cost of ineffective non-functional information systems.

A new capital expenditure
of $65,000 dollars per physicians and $200 to $500 million dollars for hospital
systems is unrealistic even with the government’s partial subsidy. The cost
increases when maintenance fees are added.

 Many hospitals simply do not have the capital
to buy systems that can cost $20 million to $200 million, especially when so
many are struggling to remain solvent. Hospitals also worry about high
maintenance costs, an uncertain payoff on their investment, a lack of staff
with adequate technical expertise and resistance from doctors.

 In 2009 only 1.5 percent of
3000 hospitals had a comprehensive and fully functional electronic medical records
system “ comply with meaningful use criteria.”

The meaning of meaningful
use is all major clinical units in a hospital must perform 24 functions deemed
important by a panel of experts.

The EMR should incorporate
data points. It should include physicians’ and nurses’ notes in data point

The EMR must have the ability
to order laboratory and radiological tests.

It must include clinical
guidelines defining criteria for treating various conditions. It should contain
alerts to avoid dangerous drug interactions and 20 other functions.

It is cookbook medicine all
over again. The goal is to eliminate physician judgment.

On January 1,2013 only 11
percent of the hospitals had even a basic EMR system in at least one major clinical
unit that performed 8 of the 24 functions.

Physicians have been slow to cooperate. Intuitively they
know that a functional EMR might collect data that will be used against them,

The question is will the data improve medical outcomes,
result in less medical complications and less morbidity and mortality? Will it
increase or decrease physicians work hours or increase or decrease physicians’ net

“Pamela McNutt, senior vice president/CIO at Dallas-based Methodist
Health System, says HIT advocates were a little naïve early in the

"There was a bit of over-simplistic thought that if we just purchased
and installed some software that suddenly everyone would start connecting and
talking and it is premature," McNutt says. "Even people who have met
high levels and are ready to meet Meaningful Use Stage 2 still have to work to
get efficiencies."

says the whole idea of "efficiencies" in HIT is undefined.

have to talk about what are the efficiencies we are looking for," she

data to judge performance should not be the goal.  Judging performance does not necessarily increase

EMR should improve the physician-patient relationship. It should be for the
patients’ benefit. It should not be for data collection to commoditize medical

ideal EMR should be constructed through the eyes of practicing physicians and
not through the eyes of bureaucrats and computer software companies. 

should be an EMR that is interoperable and compatible with physicians and
patients needs not the administration’s needs.

EMR should be cloud based.

should be secure and protect patients’ privacy. 

should not result in a capital expenditure by physicians or hospital systems.

would pay by the transaction.

should not provide a financial burden to physicians and hospital systems.

could be updated and maintained at no cost to providers.

would turn an expense into a profit center for the government.

Why can’t the
administration’s healthcare policy makers figure this out?

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

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Business Model For Medical Care 2020. The Ideal Future State

Stanley Feld M.D.,FACP,MACE


Please click on all the links to study
the references to each spoke. It will help you visualize the power of the business

The ideal future state business
model for the healthcare system must include the execution of ideas in the specific spokes outlined below.. These spokes
will serve to align all of the stakeholders’ interests.

The business model must
contain appropriate rules for a consumer driven healthcare system, an ideal
electronic medial record, and an ideal medical savings account.

The ideal medical saving
accounts can work optimally when there is significant tort reform and patients
take full responsibility for their health and healthcare dollars.

Consumer education is critical to the business
model of the future. Educational modules can be available to consumers 24/7 via
the Internet. These educational modules must be an extension of consumers
physicians’ care in order to be effective. The education can become available
using a series of social networks.

Chronic disease self-management education can
be achieved by the use of interactive online teaching programs. Patients can be
linked to share their disease experience through private social networks.

Most believe that the healthcare system must
have greater integration of care. This integration of care can be done
virtually through a series of private integrated networks.

Effective integration can be achieved without
disruption of the entire healthcare system. Obamacare has been disruptive to
the entire healthcare system.

Obamacare is forced integration by the
government will be slow, costly and unsuccessful.

Physicians must be compensated for the presently
uncompensated time necessary to execute each one of the spokes of the wheel.

Each spoke is necessary to convert the
healthcare system into a system that once more makes the physician patient
relationship paramount.

The future business plan removes control of the
healthcare system from the government. It permits the patient to have the freedom
to choose his own healthcare course.   

Tort reform is vital to the 2020 business model.
It will decrease costly over-testing to avoid frivolous malpractice suits.
There are many ways to set up a tort reform system that truly protects patients
from real harm while eliminating over-testing. It limits the malpractice
litigation system. Punitive damages must be lowered. Losers in lawsuits must
pay all fees. These two provisions will decrease lawyers’ incentive to sue.


Consumer driven healthcare will create a system
that promotes personal responsibility by the consumers’ for their health and
health care dollars.


The major spoke necessary to successfully
accomplish a consumer driven healthcare system is my ideal medical saving



The ideal medical savings accounts would
provide the financial incentive for consumers to drive the healthcare system.
It would dis-intermediate the healthcare insurance industry’s grasp on first
dollar coverage and profits. The insurance industry would realize that its
profit margin would increase under this system.

In order for consumers to be in a position to
lower the cost of healthcare they must be taught to understand how to self
manage their disease and be responsible for the decisions they make in their
choices for medical care.


In order to decrease patients’ dependency on
the government and increase  being
responsible for themselves, a system of education using information technology
as an extension of their physicians’ care has to be developed and put into

Social networking is in its infancy at present.
It must be developed and used as an educational tool between physicians, patients
and physicians, and patients and patients.

All the social networking must be an extension of
the physicians’ medical care
to their patients. Social networking must be
developed to enhance and promote the physician/patient relationship because
this relationship is critical, at its core, to successful medical treatment.

Social networking and information technology
can extend physician educational resources for patient care.


Systems of care for the self-management of chronic
disease as an extension of their physicians care
have already been developed.
The unsuccessful chronic disease self-management systems are the programs that
are not an extension of physicians’ care. The reason these third party systems
are unsuccessful is because they undermine the patient physician relationship.

President Obama has done pilot studies using
those third party self-management companies to prove that chronic disease
self-management systems work. They have all failed to reduce the cost of care.

Therefore the administration has reached the
conclusions that self-management of chronic disease does not work. Nothing
could be further from the truth. The government simply does not understand the
magic of the physician-patient relationship.


In order to decrease the cost of medical care,
medical care must be integrated. At present, primary care physicians recommend
specialists. The primary care physicians know whether the specialists are doing
a good job by the specialists’ treatment results with their patients.

Most of the time physicians do not know their
specialists’ fees. These fees must be totally transparent to primary care
physicians and their patients. The primary care physicians can then be in a
position to help their patients choose appropriate specialists.

It will also reduce the specialists’ prices
because they will be forced to become competitive by the patients in a consumer
driven system.

Hospital fees must also be transparent. One of
the reasons I am opposed to hospital systems hiring physicians and paying them
a salary is the hospital systems would then be able to develop a monopoly in a
town or area of town. This would permit the hospital system to raise prices
without informing patients or physicians.

Hospital systems could erase physicians’ choices
and hindered patients from having the freedom to choose a hospital or
specialist of their choice with their primary care physicians. It devalues the
patient physician relationship.  


The way President Obama is going about
developing a universally functioning electronic medical record is foolish and
Most physicians cannot afford a fully functional electronic medical
record. This fact is being used to drive physicians into being employees of
hospital systems. The problem is hospital systems are paying hundreds of
millions of dollars for electronic medical records that are not fully

Many of these records are hard to use and
provide inflexible data. The inflexible data leads to healthcare policy
decisions that are wrong. The data is also used to commoditize medical care.

Commoditized medical care is not the best quality
of medical care.  

If the government is so smart it should develop
a fully functional electronic medical record and provide it to all hospital
systems and practices for free.

The EMR should be put in the cloud. Providers
should be charged by the click. The government can service and upgrade the EMR
in one place and improve the quality of data collected. The data should be used
for educational purposes only and be owned by the patients and physicians. It
should not be used for punitive purposes. The inaccurate data is now used for
punitive purposes. The result has been a lack of physician cooperation.


The healthcare journey to an ideal future state
must begin in an orderly way. The principle goal is to be consumer centric. It
must be consumer driven and force the secondary stakeholders to be transparent
and competitive.

This journey will wring the excess costs out of the healthcare
system. It will create a democratic system affordable to all.

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

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Health Policy Wonks Confused By Physicians Resistance To Adopting Electronic Medical Records (EMRs).

Stanley Feld M.D.,FACP,MACE


Electronic Medical Records (EMRs) for physicians’ offices and hospital systems could be great for patients’ care and physicians’ education. Remember, patients and physicians are the primary stakeholders in the healthcare system.

If the deployment of EMRs were directed toward the benefit of patients and physicians, they would be more readily adopted. If they were used to teach physicians how to be better doctors and patients to be more educated about their disease physicians would accept EMR’s more readily.

Instead, the fully functional EMR is designed to be punitive to physicians and patients. 

President Obama’s motives are obvious to me. He wants to have total control over the healthcare system. Obamacare will be punitive to physicians, hospital systems and patients when fully implemented. The fully functional EMR will be a principle tool.

The government has tried to spin the news about EMR adoption.

 “The most recent CDC data would seem encouraging for EMR adoption. It claims EMR use has finally been adopted by 50% of physicians and hospital systems.”

Actually less than 11% of physicians and hospital systems have adopted fully functional EMRs. The fully functional EMR is so vital to President Obama and his Healthcare Reform Act and government control over the healthcare system.

If the VA systems’ EMR and the Kaiser systems’ EMR were excluded, the percentage is lower than 11%. The administrations of the VA system and the Kaiser system have full control over how medical care is delivered in their system.

Their computer system’s purpose is to direct physicians’ care and tell them what they can and cannot do.

A  “fully functional EMRs mean the payers’ (government or healthcare insurance company) can have full control over the physician’s work-flow.  A fully functional EMR along with 68,000 ICD-10 codes (vs. 18,000 codes in ICD-9) and adoption of the 5010 billing system would put the government in full control of patient care.

I do not think physicians and hospital systems have fully thought out President Obama’s fully functional EMR.

They know from their installation of non-functional EMRs that EMRs are disruptive to workflow at first. They know EMRs do not increase their quality of care and have not decreased the cost of their care.

 A major reason for non-adoption is physicians and hospital systems cannot afford the $60,000 per physician for a fully functional EMR plus the annual maintenance and services fees.

The government is using a carrot and stick to get physicians to adopt the fully functioning EMR.

The stick is the threat of decreasing physician reimbursement if they do not adopt the EMR.

“Important! For 2015 and later, Medicare eligible professionals, eligible hospitals, and CAHs that do not successfully demonstrate meaningful use will have a payment adjustment in their Medicare reimbursement. 

The carrot is President Obama’s $19 billion dollar  meaningful use incentive program. His meaningful use incentive program will not come close to paying for a functioning EMR.

Eligible professionals can receive up to $44,000 over five years under the Medicare EHR Incentive Program. There's an additional incentive for eligible professionals who provide services in a Health Professional Shortage Area (HSPA).

Eighty-eight hundred dollars a year for 5 years will not hack it when you have to pay at least $60,000 upfront. The only way it will work is if the government had the ability to take away a physician’s license to practice medicine if they did not comply with the government’s wishes.

President Obama included funding for this program in his economic stimulus package (trick play) and not toward the cost of Obamacare.  

Why? If deployed the meaningful use incentive program is a key element in its ability to control physicians’ behavior and judgment. It will restrict also patients’ access to care.

 Jonathan Bush, the Founder-CEO of AthenaHealth (a major EMR supplier)  said,

 “It’s healthcare information technology’s version of cash-for-clunkers,” and because it is actually all about control.”

 “The goal of EMRs is to wrestle control of healthcare away from the doctor-patient relationship into the hands of third parties who can then implement their policies by simply removing a button or an option in the EMR.”

 If a treatment option is not available in the computer program physicians can’t select it.  If the appeal process is difficult and time consuming the tendency for physicians is to not fight the system.

Patients will only be able to get the healthcare that they “qualify” for according to a bureaucracy and a non-elected committee. (IPAB)

Physicians will become the instrument of government rationing of care by the use of a fully functioning EMR.

It will eliminate physicians’ need to think. It will destroy the physician patient relationship. It will increase the cost of running the practice and in turn the cost of medical care.

The ideal fully functioning EMR should be provided free to physicians and hospital systems. The software should be cloud based with physicians having the option to own the data or keep it stored privately in their offices.

It should be a teaching tool for physicians and not a tool that threatens punitive actions if physicians do not get the coding right.

Most physicians might not have consciously thought out the threat to their clinical judgment and the physician patient relationships. They nevertheless subconsciously feel something is wrong.

Once President Obama understands this reasoning he might understand the resistance of the medical community.

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

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The Fourth Spoke In the Business Model For A Successful Healthcare System

Stanley Feld M.D.,FACP,MACE

The fourth spoke of a successful healthcare system’s business model is my Ideal Electronic Medical Record (EMR). I have been speaking about the Ideal Electronic Medical Record since 2006.


I have been an advocate of EMRs since 1992. An appropriately designed user friendly EMR would improve workflow efficiency, increase physicians ability to communicate with patients, hospitals and other physicians and reduce costs. Presently it costs physicians $7 to pull a chart.

There have been many EMRs built by many technology companies in the last 20 years. The price of an EMR has ranged from $ 5,000 to $120,000 per physician. The practice disruption to install a new system has been unbelievable.

Hospital system costs to install EMRs have ranged from $500,000 to $5 billion dollars.

In 2007 the deficiencies in Kaiser’s EMR were exposed to the chagrin of the Kaiser board of directors.  

“Kaiser: Critical Need To Cut Rising Costs”

$7 billion in losses if no action taken, HMO report says”. Kaiser has invested $3 billion in data system created by Epic Systems Corp. Kaiser’s project supervisor e-mailed 180,000 employees detailing his frustration with Kaiser’s Electronic Health Record System, which he considers inefficient and unreliable. The project supervisor brought his concerns to the Kaiser HMO’s board. He said the information was not taken seriously “because of conflicts among top executives.” Doesn’t this sound typical of the hierarchical bureaucratic systems we live in?  

The creation of a fully functioning electronic medical record is extremely complicated. Physician practices and hospitals have different needs.

If hospital administrators are choosing a company to build the EMR invariably the software company builds the EMR for the payer (hospital). The hospital is their customer.

The physicians on staff are not their customers. Patients and physicians are their real customers but they are not considered the customer. The EMR should be built for patients’ benefit. It should be built to improve the patient physician relationship.

The EMR must be designed so that it does not interfere with the physicians' workflow and improves physicians’ care of patients.

The only way this is going to happen is if consumers are responsible for their health and healthcare dollars. Consumers will then drive their physicians to obtain a fully functional EMR.

Little progress has been made in getting large numbers of hospitals and physicians to install EMRs. There are many reasons for this dilemma The principle reason is cost.

As the government and the healthcare insurance industry decrease reimbursement to hospitals and physicians, hospitals and physicians are hesitant to make large capital investments for EMRs.

As of 2010 only 12% of US hospital have installed at least basic EMRs. Only 2-3% might qualify for having fully functional EMRs. A fully functional EMR has to meet 23 to 25 of government imposed criteria. In 2012 these criteria define “meaningful use” developed by President Obama’s healthcare administrators.

The "minimal use criteria" will become more complex by 2014. This means the cost of upgrading an EMR will increase. Converting from ICD-9 to ICD-10 will add to the upgrading costs.

The government bureaucracy has added another gigantic hairball in the middle of the patient physician relationship.  

Government bureaucrats looking at the healthcare system believe in fully functioning EMRs. Some hospital and physicians in small practice cannot afford the prices of EMRs despite the $27 billion dollar subsidy President Obama included in his Economic Recovery Act.

The $64,000 dollar maximum per physician subsidy, if they qualify, is less than the cost of the functioning EMR cost. The millions of dollars in hospital subsidy don’t match the billions of dollars in costs, service, upgrades and maintenance needed by hospitals for a functioning EMR.

No one in President Obama’s ever expanding government healthcare bureaucracy ever thought of putting an Ideal Electronic Medical Record in the cloud and charging the physicians and hospital 1 penny per click per month.

This formatting of the Ideal EMR would align the incentives of the government, hospitals, physicians’ practices and patient care.

There would be a universal EMR with automatic upgrades, maintenance and service.

Organizations that have spent a lot of money would move over to the system because they would avoid service contracts, maintenance fees and the cost of upgrades.

All the software the government felt was necessary to make the Ideal EMR completely functional would be in the system. New regulations necessitating added software would be incorporated into this Ideal Electronic Medical Record.

Practice Fusion is a new website that provides an electronic medical record for free to physicians. It is sponsored by ad revenue.



This website might have struck gold. It has grown from 10,000 users to 50,000 users in the last two years. It has meaningful use criteria embedded in the software program.    

The You Tube and its accompanying You Tubes explains the system. It is easy to set up. It is free and seems secure. I still have some questions. However Practice Fusion might be right on target.

Remember, online banking did not take off until it was free.  

 Practice Fusion might be the disintermediator of the electronic medical records industry in healthcare just as ITunes was the disintermediator for the music industry.

Whoever said physicians are not computer literate was wrong. The only way the healthcare system is going to be fixed is if patients and physicians take the initiative without government and its bureaucratic complexity or interference.

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

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  • Medical Alarm

    I like very much your way of presentation.. I got more useful information on this blog.. Thanks to sharing the useful information….

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