Stanley Feld M.D.,FACP, MACE

Below is a comment made to my son, Brad Feld, on his blog, when he asked everyone following his blog to join his dad’s Posse.

Kinky Friedman is running for governor in Texas. We have our own Arnold Schwarzenegger and Jessie Ventura combined. Kinky Freidman is the Texas Jewish Cowboy Country Music Star and Author.

Denise ——- wrote

Dear Denise

You are now an official member of the Stanley Feld M.D. ,FACP, MACE Repairing the Healthcare System Posse. Enclosed is an official membership card. Your letter to Kinky is great. You hit the nail on the head. You are talking about transparency of prices. You are also talking about leveling the playing field for all patients, insured and the uninsured.
I think Kinky Friedman will listen. He might not know what to do. Through my Posse,I plan to tell him and every other elected official what needs to be done to Repair the Healthcare System

We need about 10,000 Texans sending Kinky this kind letter detailing their experience. If he responded appropriately he could get elected in Texas as Jessie and Arnold got elected in their States. I sent him your letter and a detailed explanation of the letter’s importance. His public relations people have not yet answered.

Wouldn’t it be fabulous if two people from Texas could start creating the Tipping Point that would Repair the Healthcare System.

I would like to request that you send this note to your entire email list and invite them to visit my blog and subscribe. They, too, need to be members of the Posse and learn what to do to Repair the Healthcare System. The time has passed when we can leave it to someone else to fix things for us. If the politicians want to be our surrogates, they should know what the we want them to do to earn our vote.

Stanley

A few days ago I received an email comment about my successful 43 years of marriage.  I answered the email in the comment section. However, I feel the answer deserves publishing in the main body of the blog. The answer can serve to illustrate the development of problems in the healthcare system and the Demise of the Patient-Patient Relationship.

Stanley

,

Wanted to let you know that I have been reading your blog from the start, keep up the good work! On a personal note, happy 43rd to you and Mrs. Feld. Whatever your secrets to a long and happy marriage, we should try and bottle that, we could all use some. Also, Happy Father’s Day!

Alan

Alan

Thanks for the comment.

The key to our successful marriage is mutual respect, mutual trust, and love.

Stanley

One can also look to this answer as a definition of the therapeutic effect of the Physician-Patient relationship. The therapeutic effect is a positive physician-patient relationship. In my opinion, the patient-physician relationship has been destroyed by the attempts of policy makers to fix the healthcare system. The actions catering to the facilitator stakeholders have only made the this relationship vanish.

Price controls do not work in any industry in my view. Intelligent people always seem to figure out how to get around price controls.

In medicine, the price controls imposed by Medicare in the early 1980’s, led to physicians seeing more patients in a less of time. Physician offices started to rely on physician extenders to relate to the patients as well leverage the physicians intellectual property. Physicians were forced to distant themselves from this important therapeutic effect. One of the most important healing factors in medicine, in my opinion, is a positive relationship with the patient. If physicians have no time to relate to the patient this all important effect erodes.

As a result of Medicare price controls, price shifting was occurring. The private insurance industry was happy because more money flowed through the system resulting in more profit. However, the insurance carrier started to delay payment and in many cases reduce payment to the physicians. Physicians did not notice the reduction in payment. Their financial information systems were not very efficient or effective.

Physicians noticed they were working harder, seeing more patients and taking home less money.

When they realized their fees were cut by the insurance companies, they were very angry at the insurance industry. The physicians’, then, billed the patient many months after the service was performed. Patients’ became angry at physicians and at the insurance companies. Physicians were angrier at insurance companies because patients became angry at the physicians. Employers were angry at the insurance companies and the physicians. Everyone is mistrusted, and everyone disrespects each other. The demise of the physician-patient relationship. In fact the demise of any relationship.

Hospital stayed very quiet as they steadily raised their rates. Hospital pricing is a topic of a future blog. The hospitals did not experience the firestorm the physician community experienced. The rate of increase of hospital rates were higher than physicians’ or insurance companies’. However, the hospitals had an advantage. Only 5% of patients are hospitalized. Ninety five percent(95%) of potential hospitalized patients have no idea of the fees charged in the hospital. In fact, at least 60% of physicians do not know what the hospitals charge. One has to be pretty sick to be put into the hospital in these days. If you leave the hospital with all the scary media news about hospital acquired infections, medication errors as well as such things as amputating the incorrect arm, the former hospitalized patient is grateful to be alive. They do not have the energy to complain. They simply pay the bill, if they can. If they can not they are usually more stressed by the hospital system pursuing the payment. This collection drill also stress the hospital system and is costly. The remaining 90% of us, thank god, so not experience hospitalization. We are able remain detached from the fees the hospital is charging and choose to ignore the problem.

The therapeutic effectiveness of the physician patient relationship deteriorated rapidly during this period of anger toward physicians. Patients expressed some of this anger by suing the physician.

Malpractice suits increased markedly. Media coverage of medical errors did not help. The fact that some of the media coverage was disinformation was immaterial. The excessive law suits served to increase the price of care. Premium cost had to be passed on somehow. The government should have taken action at that time, but did not do anything. The government should have set or define liability limits as well as rules to discourage frivolous law suits. Limits on liability would have acted as a deterrent to plaintiff attorneys who saw easy money.

The physician extender market was escalating. The insurance industry saw an opportunity to devalue physicians. They categorized physicians, nurse practitioners, and physician assistants as Healthcare Providers thus implying an equality of value and therefore an equality of fees.

The mounting distortions resulted in physicians adjusting to the distortions. They ordered more physician visits and more procedures. The increase in malpractice suits lead to more defensive medicine. The result was more testing and more expensive treatment to avoid a malpractice suits.  The increase in the delivery of medical care led to higher Medicare payments and private sector payments as well. As a result the total gross Medicare and private sector payment obligations increased markedly over the next few years.

The major take home point of these examples is that price controls do not work. Price controls simply distort a free market system even further.

Everyone was in pain. The patients, physicians, government, and employers are all suffering. The insurance industry was prospering, but they feared they were losing their customer, the employer and can not keep up with their crazy insurance billing and payment practices. The lawyers were prospering at the expense of cost effective medical care (defensive medicine). The major stakeholders, the patients and the physicians were suffering because of the quality of care, the cost of care and the access to care. Interesting enough the facilitator stakeholders were starting to suffer as well.

What came next was even a sharper blow than previous blows to the effectiveness of our healthcare system.

Stanley Feld M.D.,FACP,MACE

The following email was recieved. I feel it is important to post this email on the main page because some of you might not read the comments. I thank Walt for his comment.

First we need Patient Power and Political Power will follow!

Dr. Feld,  I believe you’re on the right path.  By getting a posse rounded up and engaged in the hunt for a solution through sharing of information, insights, and observations of constraints, we may be able to get the political ‘help’ needed to effect change.  Are you working with Newt’s group here in Atlanta (http://www.healthtransformation.net)?

Walt

Dear Walt

I know Newt and he knows me. I have presented my ideas on Disease Management to Newt when he was speaker of the house. His response was this is a "BIG IDEA" .

He was then at a Human Resource and Information Technology meeting at Delta Airlines a few years later, after he left congress, where I gave a presentation. He loved my presentation and summarized it for an hour. He then invited me to visit him at his office in Washington. We went over the presentation in great detail. It was still a BIG IDEA in his mind. He told me he has quoted me often. However, I have never had followup from him nor have never been able to make contact with him since.

I have sent him the blog information. However, I suspect he has a fortress of  people creating blockades between him and the ordinary people like me, and they do not know me.  This information has probably never gotten on his screen.

If you know him please direct him to the site. He is a nice guy. I am convinced the concepts I am presenting will excite him. He theoretically understands the problem about the dysfunction of the healthcare system in my view. 

I am trying to get to the main stakeholders, the patients and future patients, in mass to appeal to people like Newt.  Newt could help greatly if he became engaged in my effort.

However, it is going to take "People Power" to turn this boat around, and not simply talking about turning it around. Coming from one person, the "BIG IDEAS" that will be presented in this blog will have little impact, unless people understand the problem and act. Anyone involved personally in the healthcare system or has a relative involved has felt the pain of the dysfunction. I am convinced we have the power to fix it and align everyones incentives.  One can not be passive anymore and simply make judgements to disconnected sound bites.

I believe the media has failed us. They have not provided real information in systematically connected way. I also believe connecting people in a systematic way with the same vested interest, protecting our health, and fixing the healthcare system is the power of RSS and the blogosphere. 

If you can help, it will be greatly appreciated

Stanley Feld M.D.,MACE

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Stanley Feld MD,FACP,MACE

Healthcare System vs. Medical Care System

A very impressive and thoughtful blog Procurement Central said today “I highly recommend Dr. Stanley Feld’s blog for those interested in a deep dive on this important area.”

I very much appreciate the recognition from Procurement Central.

My goal is to get every thinking person that is affected or will be affected by the healthcare system working toward the solution of the healthcare systems problems. Every stakeholder is involved. In order to understand the solution one needs to take a “deep dive” into the factors that created the problem. Only then can one buy into the solution that will align every stakeholder’s incentives. It must be remembered that the “Patient is First”. Please do not think of my blog as a “deep dive”. This can scare you away because you might not have the time for. I have gotten this reaction from a person in organized medicine that runs the socioeconomic department of that organization. I imagine the same thing happens in insurance companies’ managers, and with government officials’, hospital systems officials’ and physicians’ office administrators. Everyone is very busy going to meetings.

Please think of my blog as an intellectual exercise that can be transformed into action. Everyone has a responsibility to understand what needs to be done for your health and well being in the future.

You will notice I always use the term healthcare system and not medical care system. Physicians’ deliver medical care. Medical care is excellent for acute illness and for correcting the complications of chronic disease. In my opinion, and the Institute of Medicine as well, we are not very good at preventing the complications of chronic disease. However, physicians all over the country are trying to learn. The distortions in the healthcare system have to be corrected in order to improve our excellent medical care delivery system. If the repair of the healthcare system is done correctly, the repair will reduce price of care, cure the problems of access to care, and correct the 45 million uninsured problem.

Lighten up

Both my wife Cecelia Feld a world class artist (www.Studio 7310.com) and my son Brad Feld (Feld Thoughts) have told me to lighten up a little. So here goes.

Father’s Day was great. We stayed at Brad and Amy’s house over the weekend. You need to understand that Brad was my tech support person from the time he was 13 years old until the time he was 30 years old. In 1977, he bought the first of the Apple II computers with his Bar Mitzvah money. I had to make an additional $1500 contribution for all the accessories we, absolutely, had to have. It was clearly the best investment I ever made. I not only received tech support for 17 years free, but Brad has blossomed into an information technology wizard. In the last 10 years it has been difficult to get tech support from my son. We have joked about it often. His standard answer has been, “he did not know how to do what I needed help with”. Incidentally, I never believed him but pretended to not get the message.

This Father’s Day was special. Brad is rooting for me and my blog. We sat for 1 hour going over details on how to improve my blog presentations. As some of you might know Brad is a master blogger with a huge audience. Amy found the following cartoon while reading the New Yorker during our tech support session. The cartoon is a riot!

The caption reads " For Father’s Day, I’m giving my dad an hour of free tech support."

Email

Dear Stanley:

A new comment has been submitted to your weblog "Repairing the Healthcare System," on the post "Do Complications of Chronic Disease really absorb Eighty Percent (80%) of the Healthcare Dollar?."

Stanley,
Great post.
Here’s my question.
Can the market be allowed to solve the problem? What if the cost scale for insurance was weighted based on the amount of preventative health steps one took?
What happens then?

Eric
The answer is the market can solve the problem! The government can not! The patient is the primary stakeholder and should make the market decision. However, they need to know what decisions to make and how to make them. There is enough information on the web presently to use as a resource if appropriately selected. I have given you a few clues to the solution already. I will put all the steps together as we get go along. The goal and purpose of the blog is to teach patients and futures patients what to do to fix the system. I hope the blog will also teach all the others stakeholders what to do, and how to stop spinning their wheels.

I need to have as many patients, future patients and physicians subscribe so that they understand the problem how we got here, and then understand the action they need to take toward the solution. Please encourage everyone you know to subscribe.

Thanks for your email Eric

Stanley Feld MD,FACP,MACE

Stanley

Feld MD,FACP,MACE

I received the following email a few days ago.

Could you please provide a reference that supports the 80% statistic ("Fixing the complication absorbs 80% of the healthcare dollar")?  I am not questioning this number, but I would like to read more about it.  Thanks!

There are many articles in the literature to support the 80% rule. Our focus is on Diabetes Mellitus a disease that cost society about $150 billion dollars.

The best recent reference is published in a story in the LA Times on June 19, 2006 entitled “Medicare Looks to Boost Seniors’ Use of Preventive Care.”

Mark B. McClellan Medicare administrator said in an interview “If you take a big step back and look at Medicare spending, 90%-plus of what we are spending is going for the complications of chronic disease.” He goes on to say “We can get healthier beneficiaries and lot lower costs related to complications if we can get more prevention.”

Medicare’s budget is $336 billion dollars a year. In some diseases, you can reduce the complication rate by 50% or more as shown by the DCCT (Diabetes Control and Complications Trial) NEJM 1993.

If we spend 90% of the healthcare dollar on complications of disease for persons over 65, and we can reduce the complication rate by 30% rather than the 50% or the theoretical 100%, the cost saving would be $90 billion. If we could reduce the complication rate by 50%, the savings to the Medicare system would be $168 billion. Then Medicare would not have to solve their increasing cost of care problem by reducing payment to physicians yearly, and restricting patient access to care.

Since Medicare is the payer of last resort, physicians have finally gotten the governments attention about the “Power of Prevention”. The 2007 Medicare handbook will focus on preventive care. Medicare will finally start paying for preventive care.

Complications of chronic diseases take a long time to develop. It has been estimated that Diabetes mellitus takes 8 years to discover from the time of onset of disease and the onset of complications even longer. Many times a high blood sugar is discovered when the patient is in the Cardiac Intensive Care Unit after having a heart attack. Coronary artery disease is the most common complication of Type 2 Diabetes Mellitus. If the blood sugar was controlled by intensive self management this complication could have been reduced 30-100% depending on the control of the blood sugar. There are many other complications in other chronic diseases states that the “Power of Prevention” will stop.

The private insurance industry has been very slow to pay for prevention of chronic complications. I imagine the thinking is “we pay for some things that are broken”. If something becomes broken, we will pay but raise the insurance premium or not offer the employers insurance next year. If you are self employed, simply getting older and at greater risk for disease might make it impossible to buy insurance.

How do we motivate the private insurance industry to pay for a future event that will not happen on their watch? A clue is that every State has a State Insurance Board that licenses the insurance company to sell insurance in that State. We, the people, have to do is educate our politicans, policy makers and State Insurance Boards and demand coverage for chronic disease from the insurance company in order for them to sell health insurance in our state.

There are many other things we, the people, will have to demand. We will get to them in time.

The LA Times article goes on to state that “some of the results have been disappointing to Medicare officials. 2% of eligible seniors have taken advantage of the physical examinations that are paid for. “Only 54% of male beneficiaries get Prostate Specific Antigen, or PSA blood test- prostate cancer screenings that are free."

Why is that? The presentation of the information is confusing to the elderly. The patients are afraid to be checked for fear of discovering an unknown illness. Patients do not understand the Power of Prevention. Patients lack economic incentives to participate in prevention.  Chronic disease management is not a strong card in the Primary Care physicians’ deck as I have stated previously. However, we, the medical profession, are trying very hard to improve the Quality of Care for Chronic Disease.

I will cover my opinions for the reasons for all of the above and more in future blogs.

The article is worth reading completely.    

Stanley Feld M.D., FACP,MACE

I received the follow email a few days ago.

Stanley,

These episodes are very good. To whom are they written? Public at large, I suppose. I am waiting for the final scenario in which you pronounce the solution!

Anonymous

Unfortunately, the solution is not a sound bite! It can not be pronounced. The solution must to be understood in the context of the problems evolution. My goal is to activate the public. The people need to demand control over their insurance dollar as part of the solution.

I believe strongly in individual responsibility and individual freedom. Individual responsibility and individual choice will be the driving force to the Repair of the Healthcare System. An activated public willing to put some skin in the game, and pressure on the politicians, hospitals, and insurance companies will fix the system. I need a large number of people to bang pots and make some noise that is focused toward a proper solution. No one will be interested in doing this until they know what has happen to their most valuable resource, the healthcare system, over the past 30 years. I suggest one reread the Preamble and the Introduction to the blog for hints about the solution.

Unfortunately, the healthcare system is almost beyond repair. When it collapses everyone will suffer. However, the people who will suffer most will be the patients and the medical profession, the system most important stakeholders.

This blog is an attempt to get patients and physicians motivated to step out and demand the proper solution. A patch that will benefit facilitator stakeholders will not do. Patches have been tried in the past and have failed. I plan to outline what patients, future patients and physicians need to do with explicit instructions down the line.

However, I need a posse’. You can help by emailing my site address www.stanleyfeldmdmace.typepad.com to all the people you know and ask them to subscribe. I want to get people (physicians, patients, and future patients to read the blog, and buy into the solution. Our most precious possession is our health. We need to protect it. Barriers of Repair to the Healthcare System have developed, because all of the major stakeholders had to adjust to changes in the healthcare system in the past. All the stakeholders are good people just trying to make a living. However, their adjustments have led to a misalignment of incentives and further dysfunction.

Politicians look at numbers and public opinion. I call it the “Fax machine phenomenon”. One day no one had a fax machine and by the end of the month everyone had a fax machine.

Since all the stakeholders are in pain because of the dysfunction in the healthcare system, I am writing to everyone that could be affected by the system. Remember, I said no one ever ask the practicing physician or practicing patient how to fix the system.

I know your question is on the mind of many others reading the blog. Many want the solution so they can be the judge. As judge you can accept or reject the proposed solution without necessarily understanding the facts behind the solution. Most people understand we are the victim of a broken healthcare system. The usual comment made when I express my goal to fix the system is “Good Luck”. There is a lack of engagement by the only people who can really fix the system, the people affected presently and in the future by the system.

This can only happen if the people understand how the system got into this pickle. Only then will they become actively engaged in getting us out of the pickle. I will try to develop the story quickly so we can concentrate on the solution. I believe in any problem you must know how you got there in the first place. Only then can you know where to go. I also believe that people have tremendous power; they simply need leadership, inspiration and hope.

The blogosphere can democratize ideas to a great number of people and produce constructive action. I would appreciate if you would help.

Please send a blind copy to everyone in your email address book who would be interested in becoming engaged in the solution. .

Thanks for you kind praise. I hope you will help.

Stanley

Stanley Feld M.D.,FACP,MACE
www.stanleyfeldmdmace.typepad.com

Stanley Feld M.D.,FACP,MACE

I love it! These are the type of comments I wanted to stimulate. My comment is below the quoted article.

Stan

That is according to a phone survey in which American and Canadian adults were asked about their health. Less than a month ago, other researchers reported middle-aged, white Americans are much sicker than their British counterparts.
“We’re really falling behind other nations,” said Dr. Steffie Woolhandler, a co-author of the Canadian study.
Canada’s national health insurance program is at least part of the reason for the differences found in the study, Woolhandler said. Universal coverage makes it easier for more Canadians to get disease-preventing health services, she said.
James Smith, a Rand Corp. researcher who co-authored the American-English study, disagreed. His research found that England’s national health insurance program did not explain the difference in disease rates, because even Americans with insurance were in worse health.
Woolhandler said her findings were different in at least one important respect: In the Canadian study, insured Americans and Canadians had about the same rates of disease. The uninsured Americans made the overall U.S. figures worse, she said.
The study, released Tuesday, is being published in the American Journal of Public Health. It is based on a telephone survey of about 3,500 Canadians and 5,200 U.S. residents, all 18 or older, in 2002-2003.
The results are based on what those surveyed said about their health. The researchers in the American-English study surveyed participants and also examined people and conducted lab tests on them.

I just finished a book call Fooled by Randomness by Nassim Nicholas Talas

It is a book on how to judge stock trading statistics. The subtitle is “The Hidden Role of Chance in Life and in the Markets . Telephone surveys have a gigantic selection bias. The selection bias does not flatten out with large sampling. The conclusions if forceful enough or impact full enough become the eventually become the truth in decision making. However, the evidence in this article, in reality, is observational and not randomly controlled scientific evidence.

This data would be classified at Level 4 data. It suggests a difference in health but does not prove a thing. How many Hispanics and Blacks were in the American survey as opposed to the Canadian survey? Is the survey reproducible with the same number of participants, and a controlled mix of patients? These are just a couple of the many questions that must be answered.

People are not stupid when they have enough accurate information. The challenge to our healthcare system is to provide accurate and transparent information. The patient can then make a wise choice. We must work our way through all the noise presented daily.

People also become very smart when they have some skin in the game. My goal is to teach physicians and patients how to demand both so that the facilitator stakeholders feel they have to produce to satisfy the will of the major stakeholders, the patients and the physicians.

Stanley Feld M.D.,FACP,MACE

Stanley Feld M.D. FACP, MACE

Canada has been very proud of its government directed single party payer Healthcare System. Everyone in Canada automatically has health care coverage. The system in Canada has been compared to the American Healthcare System. The impression through the media has been that Canada’s System is what an effective healthcare system should be However, last year, the Canadian Supreme Court ruled that people of Canada should be entitled to buy private health insurance. Prior to the Supreme Court decision, a choice of private insurance was forbidden.

The headline in The National Post of Canada on Saturday June 3, 2006 read,

“51% say private care OK”.

The Supreme Court decision has brought the argument about the purchase of private healthcare insurance into public debate. A percentage of the population has been dissatisfied with the Medicare system for a long time. However, no one talked about it. In theChaoulli decision, the Supreme Court declared Quebec’s ban on private health insurance is unconstitutional.

A survey of 3,000 Canadians brought out some incredible opposing opinions. Fifty-one per cent of respondents identify with the statement “If we are unhappy with the service we receive from Medicare, we should have the right to spend our
own money to buy health care outside the public Medicare system.”

49% believe that “when it comes to health care, everyone should be equal and no one should be allowed to spend their own money to get better services.”

An overwhelming majority of respondents believe the government should focus on making the public system better so no
one feels any need to pay for private health care. This is a clear indication that there are endogenous defects in the single party payer government directed healthcare system in Canada.

The identical sentiments are prevalent in England. The Hillary Clinton “Healthcare Reform initiative”
advocated a single party payer system similar to the Canadian system. The advantages of both the Canadian system and British system were widely quoted at that time.

Why is our system and their system creating such discomfort among patients and physicians? One is supposedly a private system (United States Healthcare System) and one is a government run system (Canada). The answer is obvious to me. Each of them limits access to care.

A system that is truly market driven, and lets the patients exercise control over their choice of care would be a system that would work. If the patients were responsible for their care and had control of their own healthcare dollars the defects in the system would be their responsibility.

The answer is found in examples in the retail arena. Wal-Mart and Target have done so well because they sell quality products at a transparently affordable price. If the quality decreases or the price is too high, people will switch to a different vendor. Why has Target done better in the clothing area than Wal-Mart? Target has better quality and style at about the same price! Target figured out how to get a competitive advantage. Wal-Mart is presently redoing the clothing section of its business to compete.

People are not stupid. They know when their freedom of choice and access is restricted. When freedom is restricted the people react; hopefully our politicians respond. If things get bad enough, people will elect different representatives.

Stanley Feld MD,FACP,MACE
Part 3

In the late 1950’s and early 1960 pace of medical bench research and clinical research accelerated. The government invested heavily in an effort to increase medical knowledge. Medical schools expanded. The medical schools increase medical student and Phd. enrollment. Medical schools became medical research factories. The era has been referred to by some as the Golden Era in Medical Research

The medical knowledge base was growing at the rate of 10% per year. The growth of medical knowledge resulted in a growth of subspecialties in medicine and surgery. There simply was too new much medical information growing at a very rapid rate. The rate of growth of medical information and procedures were too much for a generalist to master.

These advances improved the quality of medical care for acute illness. It expanded our ability to “fix things that were broken.” We were able to save patients from death in a very skilled way. The survival rate for cancer improved markedly. Specialties such as Oncology, Pulmonology, Endocrinology, Cardiology, Gastroenterology to name a few grew rapidly. In turn, the cost of this specialized care produced accelerating cost of medical care. Patients stayed alive longer. Diseases were cured or stabilized. Our ability to help people medically was much more effective than after WWII.

By early 1980, Medicare’s burdens for medical costs were out of control as the population aged and treatment were improved. The government said: “ Stop! We can not pay the fees we have been paying. We have to have cost reductions and controls“

This generated to the next problem for the health care system.