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Obamacare Application Data Is Wrong For 2 Million Applicants Receiving Subsidies

Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Only 1.2 million of those were not eligible for subsidies.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

8 20 2014 Obamacare-Delays

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

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Why Is Obamacare A Mess?

Stanley Feld M.D.,FACP,MACE

Obamacare is a mess because the architects of Obamacare created a system that does not align all the stakeholders’ incentives.

Pre Obamacare we had a dysfunctional healthcare system because no one developed a system to improve the care of patients. When a consumer of medical care got sick he received very good treatment or the illness.

Consumers were not taught how to avoid illness. If consumers of medical care had a chronic disease they were not taught how to self-manage their chronic disease.

Medical care in the healthcare system became too expensive for employers to pay for. Consumers were the recipients of this largess. They had no responsibility or incentive for controlling their healthcare cost.

The healthcare system became more expensive because all the stakeholders except consumers tried to maximize their profit at the expense of each other.

President Obama promised to transform the healthcare system. Initially Tom Daschle was his chief. He wrote a book about healthcare after he was defeated in his bid for the Senate.

Any physician who practiced medicine knew that Tom Daschle’s ideas could not work. He had some good ideas to make healthcare delivery more efficient. The ideas were presented in an impractical way. He did not know who the customer was.

Dr. Donald Berwick was next. He tried to extend and implement some of Tom Daschle’s ideas with his own ideas.

Dr. Berwick was the co-founder the IHI (Institute for Healthcare Improvement).

Dr. Berwick has some excellent ideas. The ideas are an adaptation from the Institute of Medicine's six improvement aims for the health care system: care that is safe, effective, patient-centered, timely, efficient, and equitable.

The Institute of Medicine’s report “ Crossing The Quality Chasm” points out how to develop a new healthcare system for the 21st Century utilizing 21st century technology.

The problem is Dr. Berwick’s ideology is defective. His famous quote, “the very definition of a equitable healthcare system is the redistribution of wealth”  does not sit well with the American psyche.

There has never been a system of successful redistribution of wealth system.

Most people have experienced the deadening effect of bureaucratic systems on innovation. This is what we are experiencing right now with the Obamacare rollout.

People still cannot sign up. People are still spending hours on the telephone and not getting insurance. These are not glitches. These are system disasters.

I have long thought President Obama wants to destroy the present healthcare system so that the masses will demand a single party payer healthcare system with the government in control. Such a system will not be any different than Obamacare.

The government will still be dependent on consumers of healthcare, physicians, pharmaceutical companies, device companies and most of all insurance companies.

Insurance companies will still do the administrative services for the government at a very high price.

Obamacare has not even gotten to the problems it is going to have with the delivery of care, the access to care and the rationing of care. 

Obamacare’s business model is defective. It will be impossible to utilize the advances in technology under a system of increased government bureaucratic control.

I have previously presented a new business model. It’s possible it has not caught on for several reasons.  

1. My business model could have been presented too early in the course of  Obamacare’s demise.  

2. My business model is not politically correct.

3. My business model challenges legacy stakeholders. They do not want to give up any power.

 Legacy stakeholders are having a horrible time figuring out how to make a living under the evolving Obamacare system. Maybe by that adopting my new business model, one that aligns everyone’s incentive costs will decrease and profits for everyone will increase.

4. The presentation of my new business model could have been too complicated.

Over the next several months I am going to present my new business model.

This business model aligns all the stakeholders’ incentives except the government takeover of the healthcare system.

The government’s role should be that of a facilitator and not the director of the healthcare system.

I hope it will start making sense to people who can and want to do something to improve the healthcare system.

It will make life better for everyone.

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

The
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.

 I
believe EMRs can accomplish all of the above goals but not with their present
rollout format.

In
2009 President Obama declared that EMRs,

  “would
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.

President Obama's estimate is a little higher than that of the Rand Corp. study on the same issue.

EMR’s have
not accomplished its goals. EMRs have been a money-loser for most physicians.

I
predicted that fully functioning EMRs were too expensive for most practicing
physicians. In addition to the initial expense there are very high maintenance costs.

EMRs
bought by physicians and hospital systems in the past are not fully functional.
 Less than 20% of hospital systems and
physicians practices that have fully functional EMRs

Physicians
and hospital systems that already have EMRs will have to purchase new fully
functional EMRs.

Physicians
historically know 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.

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

It
is clear the government and healthcare insurance industry want to control the
healthcare system. The stakeholder who controls the data controls the
healthcare system.


A
recent survey from
forty-nine community practices in a large EMR 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.

The
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 survey’s authors suggest,

“Policies
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 to
those physicians that do not meet Obamacare’s imposed criteria for quality
medical care. The controversial Independent Physician Advisory Board (IPAB)
will set these criteria.

Many physicians in practice object to converting medical care
into a commodity. Medical care is a very personal and complex interaction not
taken into account by the rigid criteria.

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

 "We need to move to EHR 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 issues, the cost of a fully functional EMR and
the real purpose of EMRs. I believe both can be remedied.

The costs of an EMR to a medical practice can be paid for by the
click. The data would be fully secured. The data would be available only to
patients and their physicians.

Physicians would pay for the EMR by the click. The EMRs would be
maintained and updated for free in the cloud.

The EMRs could not be used for penalizing physicians. It would
be used for educating patients and physicians thereby improving the quality of
care.

If there is a bad physician in the community, a way needs to be
found to deal with that physician within his community. All medicine is local.

This is where a consumer driven healthcare system with public
critique of physicians would be an effective deterrent to bad physicians.

The current healthcare system is defective. It has to be
changed. Obamacare is making the business plan worse.

America cannot afford it becoming worse.

 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

The
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.

In
2009 President Obama declared that EMRs,

  would
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.

I
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.

Physicians
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.

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

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

It
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.  

A
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.

The
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,

“Policies
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.

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
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 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.

 Allscripts
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
paydays.

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
me.

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

”We
need the president to apply
scientific
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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Big Data Is A Major Problem For The Healthcare System.

Stanley Feld M.D.,FACP,MACE

President
Obama is blinded by his ideology. His healthcare policy goal is to eventually
have a single party payer system. Medical care will be commoditized with
treatment decisions made by the central government.

It
is a charade that his health insurance exchanges will lead to affordable
private insurance. It is misguided to believe that a non-elected central
committee (IPAB) will be tolerated to make treatment decisions for the
population.

The
larger pretense is that President Obama is building an inexpensive bureaucracy.
Last week he again stated that government overhead for Medicare and Medicaid is
very low. He again declared that the overhead expense is only 2½ percent.

It
cost two and one half percent for the central government to outsource administrative
services to the healthcare insurance industry. The healthcare insurance
industry, in turn, charges the government 18-40% to administer the programs.

Everyone
knows most everything government run is inefficient. President Obama is
enlarging the scope of government in all areas at a time when government is too
large and inefficient. The government’s income is $1 trillion dollars less than
its expenses per year since he has been President.

President
Obama thinks if he spends enough money he will spend his way out off the jam.

President
Obama believes one way to become more efficient is to gather more data. He can
then figure out which hospital systems and physicians are inefficient and
penalize them.

This
philosophy has two potential pitfalls. If the data is faulty the conclusions
are wrong. The second pitfall is that penalties do not encourage cooperation
and meaningful improvements. 

Decision-making in
healthcare can be painfully slow, as any physician will tell you
.
Hospital systems and
physicians are being spurred on in part because healthcare is beginning to deal
with a shift in reimbursement toward one that rewards quality and disincentives
inefficiency and waste.

One problem is that quality is not clearly
defined and is sometime false. The government must reexamine its premises.

Most hospitals and health systems have lots of
data that might improve outcomes and cut waste.

The
problem is getting that data, which is often unstructured, into a format that
allows clinicians to make decisions faster and in a more coordinated fashion.

All
of the innovation is happening without input from physicians. It is being done
to decrease the cost of the hospitals. One thought would be to get rid of a few
excess salaried, $750,000 a year hospital administrators and $2,000,0000 plus
healthcare insurance company administrators which would go a long way to reduce
the cost of healthcare coverage.

Instead
the government is looking to penalize physicians
. Physicians are the providers
that deliver medical care.

There
is software being developed that deals with real time processing of clinical
data. The software can communicate those data to networked physicians instantly
and help physicians deliver more timely care.

Many
hospital systems are trying to install these real time systems. Unfortunately,
many hospital administrators do not understand its power as a teaching tool to
increase the efficiency and effectiveness of medical care.

 The hospital systems’ only interest is in the
financial result and the question of whether the huge investment is worth the
capital expenditure.

Some
physician group practices, independent of hospital systems, are incorporating
these software systems into their electronic medical records. These groups recognize the potential
importance of having instantaneous predictive data.

Most
physicians do not have an EMR and only 7% of physicians have a fully
functioning EMR.

In
the monograph from “Pathways to Data Analytics” two things were very apparent. It
looks like the healthcare insurance industry controls the committee and its
plans is to continue to control the healthcare dollars and hope to control the
healthcare data.

Increasingly, a
data-driven approach to healthcare is necessary.

The complexity of clinical care requires it, says Glenn Crotty
Jr., MD, FACP, executive vice president and chief operating officer at CaMC.

 “We’re moving from an
individual practitioner cottage industry to a team-based process now . . .. [Medical
care] is beyond the capacity of any one individual to be expert enough to do
that. So we have to do it in a team.”

A team requires information. The changing dynamics of healthcare
spending and reimbursements also require data to navigate.

“Our analytics are not just for finance, which traditionally is
what hospitals invested in,” says St. Luke’s Chief Quality Officer Donna Sabol
, MSN, RN. “When you look at how [hospital] payment is changing [to] a value-based
equation, you have to have good analytics for finance and for quality.”

Absent from the report is the patient and his/her responsibility
to the therapeutic unit. Until some policy maker understands the role of
patients to the therapeutic unit they will get nowhere in improving the
healthcare system.

A glaring example is the money spent by hospital systems to
improve the discharge process to avoid re-hospitalization within the 30 days
post discharge.

Obamacare has instituted the rule November1,2012 that if a
patient is re-hospitalized within 30 days of the initial hospitalization the
hospital system will not get paid.

I can think of 5 ways hospital systems can get around this rule
without suffering the penalty. 

None-the-less the hospital systems are buying software to study
and automate the process to avoid re-hospitalization using its clinical data in
real time.

 The Seton Hospital System in Austin Texas
might have figured it partially out.

It started what it calls an extensivist
program. It is acting as an extension of its physicians care to help avoid re-hospitalization
and use the best data it can collect.

Its is helping clinicians identify patients who
would benefit most from extra attention following discharge. The program
started with congestive heart failure patient



"A
lot of it is about enabling decision-making," Ryan Leslie says

"It's taking the whole universe of
information we have and cutting out what's extraneous and giving clinicians the
information they need to make decisions."


Ryan Leslie is vice
president of analytics and health economics at Seton Healthcare system.  He is taking
unstructured clinical information and connecting that with billing or
administrative information and social demographic information.

He says,  "you start connecting all those things
together and you get a more complete picture of the patient as a person, rather
than as a recipient of a bill," he says. "That's been the exciting
thing recently. You realize that a patients' success or failure may not have to
do with the care plan details or the clinical attributes of the patient as much
as the social attributes
."

Physicians
outside the hospital work with a team of social workers, nurses, and others to
visit patient homes and figure out what's keeping a patient from effectively
following treatment protocols that will likely keep them out of the hospital.

The software
helps determine, based on a host of combined data, which patients are most
likely to be re-hospitalized within 30 days. Targeting the patients is like
looking into a crystal ball. The hospital system cannot afford to service all
the patients with congestive heart failure. The program is in its early stages.
If successful the plan is to expand it to diabetes and other chronic diseases.

This will
happen well beyond November 2012 and January 1,2014. This hospital system
finally realized that it can and must be an extension of its physicians’ care
and not a competitor for patient care.

Missing is the
patients responsibility and incentive in not being readmitted to the hospital.
This can only be accomplished when consumers not only have a desire to be
healthy they have a financial interest to stay healthy.

This can be
accomplished in a consumer driven healthcare system where the patients are responsible
for their health and own their healthcare dollars. The easiest way to get there
is using my ideal medical savings accounts.

 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
model.

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.

Slide16
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.

 
Slide24

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

 
Slide19

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

 
Slide18

 

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.

Slide20

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
place.

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.

Slide21

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.

Slide22

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.  

 
Slide23

The way President Obama is going about
developing a universally functioning electronic medical record is foolish and
costly
.
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
functional.

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.

 
Slide17

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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America Is An Innovative And Exciting Nation

Stanley Feld M.D.,FACP,MACE

I had several wonderful intellectual experiences last weekend. These experiences served to confirm my thinking that intelligent Americans are less interested in politics, rhetoric and empty promises and more interested in innovative solutions to all the ills that our bureaucratic political processes have brought upon us.

Todd Siler, Phd

My first stop was a visit with Todd Siler, Phd. Todd is a famous American multimedia artist, author, educator, and inventor. He is equally well known for his art and for his work in creativity research.

Todd’s analytic skills and creativity are uncanny.

The following quote is from one of his web sites,

 In 1890, the psychologist and philosopher, William James, described “Cerebralists” as “those who combine the sensual and spiritual, the physical and intellectual” in their creations. “

Clearly, we’ve lost sight of the broader meaning and reality of this practice. 

Cerebralism encompasses all forms and expressions of art. Through art, we can connect and transform everything (information, knowledge, ideas, experiences), to create new meanings and purposes for everything. Art makes life meaningful. It inspires wonder, while challenging the limits of our vision and imagination."

Please click on to Todd’s imaginative art. http://www.toddsilerart.com/index.html

In our rapidly changing world, where it seems, to many, confusing and scary Todd’s message is brilliant and enlightening. His course “Think Like A Genius” is enabling. It enables people to think expansively through art and science to develop strategies and actions that are innovative. He promotes mutual respect, trust and love.

One of Todd’s trademark symbols is;

  Todd siler png

It would serve everyone well to “Think Like a Genius” rather than think selfishly and try to take advantage of others.

http://www.thinklikeagenius.com/

 

My wife and I met Todd three years ago through an introduction from my son Brad (both MIT graduates). Since then Todd and I have been in constant communication via Skype. Last week was special.

Thanks, Todd.

Nextera Healthcare

My next visit was to Nextera Healthcare. Nextera Healthcare is a new model for delivering healthcare. It follows many of the principles embodied in my ideal medical savings account model.  It delivers compassionate care at an affordable cost.

Nextera Healthcare combines the compassionate practice of medicine with advanced information technology. My impression is that the founders have fire in their belly for delivering the best medical care for their patients.

I will explain more about Nextera Healthcare in the near future.  

The reason I am so high on Nextera Healthcare is that it closely fits a model of healthcare delivery that I believe will work. It will increase the quality of medical care and decrease the cost of healthcare. 

Nextera Healthcare has the potential to permit the patient to be responsible for managing their health and their healthcare dollars.

Nextera Healthcare has the potential to reduce healthcare cost to individuals, employer sponsored self insured plans, associations and even the government while permitting consumers to make their own healthcare decisions.

http://www.nexterahealthcare.com/

TechStars

Next I stopped in at the TechStars fancy new dungeon. TechStars was co-founded by my son Brad Feld and David Cohen in Boulder, Colorado in 2007. It has been a very successful start up accelerator.

TechStars has expanded to Boston, New York, Seattle, and San Antonio. TechStars also has a number of affiliates in many cities in the U.S. and throughout the world.

Bloomberg TV has a special about TechStars concepts in 2011. TechStars business model is compelling to me.

I show up at TechStars Boulder’s office every year with permission from Brad and David. The goal is see if the 10 selected companies can explain their company’s business model to me is a way that I can understand.

It is a fascinating experience for me to see how these start-up companies hone their product and their story for Demo Day. Each company is mentored for three months to develop their model and hone their presentation.

On Demo Day Brad and David invite venture capitalist from all over the country to listen to these technology start-ups’ story and have the opportunity to invest in them.

The success rate for investment has been very high each year and at every site.

Last Thursday was the second day of the new session in Boulder. It was the first Demo Day practice session.

The first practice sessions blew my mind. I think the kids are getting smarter, more articulate and more creative each year.  Someone told me it was harder to get into TechStars than it was to get into Harvard Business School.

 

http://youtu.be/pLIVBTmg3Gg

 

GoldLab’s 3rd Annual Symposium “Time: Tempus Fugit”  

The purpose of the trip was to attended GoldLab’s 3rd Annual Symposium “Time: Tempus Fugit” at the Colorado University as an invited guest.

Dr. Larry Gold is a legendary Biotechnology guru. His mission for these Symposia is to synthesize the confluence of science and humanity. His goal is to stimulate the thinking of bench scientists, practicing physicians and social scientists to understand progress and thinking in each discipline.

Once the participants are stimulated they are encouraged to focus on actionable solutions to the complex problems society faces through each discipline’s lens.

“This was a symposium that truly, truly, truly engaged all four organs of the participants — the head, the heart, the gut and the hoo-ha organ (ah-ha) organ. Larry Gold’s  Symposium  “Time: Tempus Fugit” did so it in grand style.’

It was certainly an invigorating weekend for me. The levels of intellect and the abilities to “Think Like a Genius” are very high.

I am certain the younger generation is not going to let President Obama get away with his “Obamacare” and other government controlling baloney he is pushing.

The challenge is going to be how to get their attention now and not later when the disintermediating task will be much harder.

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

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  • Fitness Info

    I constantly spent my half an hour to read this blog’s posts everyday along with a mug of coffee.

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New Statin Therapy Warnings and Its Science

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

    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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Spokes 5 and 6- Future State Of Healthcare Business Model

Stanley Feld M.D.,FACP,MACE

Spokes 5 and 6 of future state business model for the healthcare system’s survival must be understood as one unit.  Chronic Disease Management and Education As An Extension Of The Physicians Care are two simple concepts.

 

Slide22

 

Slide21

 

Patient education is a crucial element in the care of patients whether the disease is acute or chronic. Systems must be set up so that education is an extension of the physician’s care in order to be effective.

Education is less effective if it is not personalized and unrelated to the patient’s physician.

Both concepts have been devalued by President Obama’s healthcare reform plan. The chronic disease management concept has been devalued with the administration’s pilot studies showing that chronic disease management programs do not decrease the quality of care or cost of care.

The pilot studies were conducted by freestanding clinics. The education was not an extension of the patient’s physician care. Medical care is a personalized endeavor that requires a personal relationship between patients and physicians.

At its core the quality of medical care is enhanced by a strong physician patient relationship. This relationship is critical to a successful patient outcome and decreases in the cost of medical care.

An analogous educational event happened to me in my junior year in high school.

I was on the high school baseball team. Baseball practice started in February. It rained and snowed a lot in New York City in February. If it rained we would practice in the gym. We couldn’t have baseball practice outside one day.

On that day the gym was taken. The baseball team was sent to the study hall the last period of the day. My year before geometry teacher was in charge of that particular study hall.

I was an excellent high school student. I never missed a question on a geometry test.

I loved my geometry teacher. It was easy for me to understand everything she taught.  This was an example of a positive teacher student relationship.

I was taking trigonometry that spring term. The chairman of the math department was my teacher.

I had a poor relationship with that teacher. He was not enthusiastic about trigonometry.

He was detached from his students and their needs. He had no interest in relating to us.

I could not understand a thing he taught.  I figured I could tolerate him.  I thought I had to ability to learn the course directly from the textbook.

To my surprise I could not understand any of the concepts in trigonometry when I was studying at home. I was resigned to the fact that I was going to fail trigonometry.

My geometry teacher saw me in the study hall. She came up to me an asked me how I was doing. I told her I was going to fail trigonometry.

I could not stand Dr. B and I could not retain anything he taught. I also found it impossible to teach myself trigonometry from the text.

She asked me what period I had lunch and which period I had trigonometry. I had lunch the 5th period and trig the 6th period.

She said she taught trigonometry the 5th period and she could transfer me into her class and into 6th period lunch. She was also a student advisor.

Her words were as if a weight was lifted from my back. She said there was one problem. The departmental first quarter test in trigonometry was being given tomorrow. If you do not know anything you will fail. I said I understood.

After dinner I went into my room to study for the test. I started on page one of the text. Everything I read stuck. All of a sudden trigonometry was understandable and every trigonometry problem was easy to solve. All my anxiety about trigonometry melted away.

The next day I took the departmental test in my new 5th period trigonometry classroom. I got 100% on the trigonometry test. I received an A+ in trigonometry at the end of the semester and 100% on the New York Regent examination. I did not miss a trigonometry question the whole term.

This lesson stuck with me throughout my medical career. A positive physician patient relationship is just as powerful as the positive teacher student relationship. Both enable patients and students to reach their potential.

Obamacare is interfering and methodically destroying the ability to form a positive patient physician relationship.

The regulations are punitive. Patient care is becoming depersonalized and commoditized.

I predict Obamacare is going to make the medical outcomes worse and the cost of healthcare higher.

After 30 years of practicing Clinical Endocrinology I am convinced that the therapeutic effect of the patient physician relationship is a major factor contributing to the healing process.

Chronic disease management does not work unless the patient physician relationship is intact.

President Obama has proven this with his pilot studies in chronic disease management.

President Obama has not proven that chronic disease management as an extension of physicians care does not work.

Combined with a positive patient-physician relationship, chronic disease management with education as an extension of the physicians care can work.  Patients can be motivated to maintain control of their disease. Patients controlling their disease will decrease the complications, morbidity and mortality of the chronic disease.

The result will be a decrease in the cost of healthcare.

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

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  • Education Management Software

    Do yourself a favor and learn them while you’re young. They have a lot of practical applications, including remembering people’s names.

  • Practice Management Software

    A lot of what you say is absolutely correct. It’s no use longing for the better “old” days ’cause there was no such thing. It was precisely becuase there was a problem with healthcare, that Obamacare became a reality. Yes, the doctor-patient relationship is sacred, but at whose expense? If the patient has no respect for the associated costs, takes little, if any, responsibility for his/her healthcare, the burden falls elsewhere. Despite our increasing standards of living, healthcare cost increases has seen no abatement. I see Obamacare as an attempt to do something about this. We do not have unlimited resources, even though healthcare is a basic human right.

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