Stanley Feld M.D.,FACP,MACE

President Obama’s has created an incentive program to encourage physicians to adopt functional Electronic Medical Records.  The program’s $27 billion dollars (funded by President Obama’s Economic Stimulus package) will turn out to be a colossal failure and a waste of money.

Twenty seven billion dollars would provide $44,000 for 640,000 physicians. After the bureaucratic infrastructure is built the federal government will be lucky if one third of the money remains for bonuses to physicians.

Only 21,000 of 650,000 (3%) of physicians have applied to date.

 Complex bureaucracies and complicated regulations never save money. These bureaucracies create bigger government, inconsistent policies, more complicated regulations and inefficiencies.

The best and cheapest way to create a universally accepted and functional EMR is for the federal government to put the software in the cloud and charge physicians by the click for the use of the Ideal Medical Record.

Upgrades in software to the Ideal Medical Record will be swift , inexpensive and instantly adopted.

The federal government has done it before with an electronic billing system in the 1980’s. The incentive to physicians was to be paid in one week as opposed to the one to two months wait for payment using a paper claim.

Last week the proposed rules for defining “meaningful use” of EMRs starting in 2013 were published.

As soon as Stage 2 of President Obama’s EMR bonus program were published organized medicine complained that the rules were unrealistic and onerous.

Organized medicine is correct.  This usually happens when the bureaucracy piles one set of rules on top of another. The Stage 2 rules will discourage physicians from participating even at the threat of an undisclosed penalty.

 "Meaningful Use Workgroup Rules Regarding Meaningful Use Stage 2," from the Office of the National Coordinator for Health Information Technology requires the following in order to be eligible for the federal bonus;

Higher thresholds (in % of eligible patients, visits or orders)

• Use computerized physician order entry (CPOE) (from 30% to 60%:
• CPOE will expand from drug orders to lab and radiology orders)
• Use e prescribing (from 40% to 50%)
• Record demographics (from 50% to 80%)
• Record vital signs (from 50% to 80%)
• Record smoking status (from 50%to 80%)
• Use medication reconciliation (from 50% to 80%)

Elective to mandatory requirements

• Implement drug formulary checks
• Record existence of advance directives
• Incorporate lab results as structured data
• Generate patient lists for specific conditions
• Send patient reminders
• Provide summaries of care record
• Submit immunization data
• Submit syndromic surveillance data

New measures

• Use electronic physician notes
• Offer clinical encounter information for download
• Offer health record information for download
• Ensure patient use of online portal
• Ensure patient use of secure messaging
• Record patient preferences for communication medium
• Provide lists of care team members
• Record longitudinal care plans

Physicians can receive bonuses from Medicare of $44,000 and Medicaid of up to 63,750 for installing and using an eligible EMR system.  These payments (bonus) if you qualify are taxable as ordinary income.

There are several practical problems;

1. Most physicians and physician practices cannot afford the time it takes to find an eligible EMR they can trust.

2. An EMR that might be eligible for federal bonus could cost $70,000 per physician.

3. Physicians cannot visualize the potential payback.

4. Physicians cannot visualize the added value toward improving quality care when quality care has not been adequately defined.

5.Physicians cannot get loans from banks to finance the costs.

6.Most physicians are uncertain about the future of their practices.

Thousands of physicians (3%) are trying to meet stage 1 requirements, which went into effect January 2011.

Eligible EMRs in Stage 1 must be able to meet 15 core measures of functionality and the physician's choice of five out of 10 elective measures.

In order to meet Stage 2 requirements physicians have to spend more money to upgrade their information system to be eligible.

"Unrealistic stage 2 requirements will overly burden physicians and hamper adoption — especially for those physicians in small or solo practice."

Karen Bell, MD, chair of Certification Commission for Health Information Technology said she “does not believe any vendor's system can meet stage 2 requirements yet.”

Developing EMR technology is expensive, and vendors don't want to build complete systems when the standards probably will change in the future.

A Family Practice Group of 4 physicians in Georgia recently spent $75,000 per physician upgrading the practice's EMR in order to meet meaningful use stage 1 requirements. Five years ago they spent $200,000 to launch their original EMR.

Fulfilling stage 2 requirements will probably cost at least another $75,000 per physician to continue qualifying for federal bonuses.

This Family Practice is chasing its own tail. It is working at the whim of a bureaucracy whose job it is to write regulations and not think of the consequences to practicing physicians.

Wouldn’t it be easier for the federal government to install its approved software in the cloud, upgrade it as necessary and charge physicians by the click?

Wasting $27 on bureaucratic regulations is a complicated mistake that is destined to fail.

$27 billion dollars could be better spent on direct patient care and the implementation of my ideal Electronic Medical Record   

Stanley Feld M.D.,FACP,MACE

President Obama’s Healthcare Reform Act was passed in both houses of congress one year ago. Democrats had a large majority in both houses. Last week Democrats throughout the country held events celebrating President Obama’s Healthcare Reform Acts anniversary. Either Nancy Pelosi is blind to public opinion or thinks the public is stupid.

 The public is realizing what bad a law Obamacare is turning out to be. We have not even gotten into the truly bad effects of the law yet. The law’s truly bad effects are timed to take effect in 2013 after the 2012 elections. Meanwhile, the costly and wasteful bureaucratic infrastructure is being put in place.

1. Many seniors have lost Medicare Advantage plans as Obamacare is starting to put restrictions on the plans and the healthcare insurance industry is dropping out of providing Medicare Advantage coverage.
2. Millions of other Americans have been forced to find new healthcare insurance options.
3. Healthcare insurance options are decreasing as a result of President Obama’s Healthcare Reform law.
4. Healthcare insurance premiums are increasing rapidly.
5. Employers are discontinuing healthcare coverage or at least increasing employee contributions.
6. States have warned that the law's Medicaid provisions could bankrupt their treasuries,
7. Medicare insurance premiums and deductibles have risen in 2011. A rise in premiums in 2012 was announced today. The Social Security Administration also announced that there will be no cost of living increase for Social Security recipients in 2012.  As Medicare premiums increase without a cost of living increase, Medicare recipients will receive smaller Social Security checks.
8. The new House of Representative has voted to repeal the entire act. They have succeeded in repealing the part of the law dealing with 1099 reporting.
9. Some courts have ruled against the constitutionality of President Obama’s Healthcare Reform Act. The final judgment resides with the Supreme Court.

10. A 3.8% surtax on the sale of homes, and unearned income becomes effective January 1,2013.

11.  “I can make a firm pledge.  Under my plan, no family making less than $250,000 a year will see any form of tax increase.  Not your income tax, not your payroll tax, not your capital gains taxes, not any of your taxes,” 
President Obama, September 12, 2008

12. States are requesting waivers from President Obama’s Healthcare Reform Act.

13. President Obama has already granted temporary waivers to over 2,000 favored unions and businesses.

14.  Even the Washington Post said Mrs. Pelosi's recent claims that the law has created jobs and will cut the deficit are "false or exaggerated."

An ongoing tracking poll by the Kaiser Foundation found a significant erosion of public support for President Obama’s Healthcare Reform Act. President Obama’s Healthcare Reform Act was not popular when it was jammed through congress by a partisan Democratic majority. It is less popular now.

1. 2010: 35% of respondents said they and their family would be "better off" as a result of Obamacare .
2. 2011: 26% feel they will be better off as a result of President Obama’s Healthcare Reform Act.
3. 2010: 28% believed their quality of care would be better under ObamaCare.
4. 2011: 20% believe their quality of care would be better under ObamaCare.
5. 2010: 31% believed the cost of their care would be better because of the passage of Obamacare.
6. 2011: 23% now believe President Obama’s promises. Only 2% believe healthcare insurance premiums have been going down. 50% believe premiums have gone up.
7.  More people say family income and medical care has been "negatively affected" by ObamaCare than those who say their family has benefitted.

Nevertheless, President Obama, Harry Reid, and Nancy Pelosi continue to praise President Obama’s Healthcare Reform Act as a "a milestone in the history of this country." 

The trio might be right. It is turning out to be a disastrous milestone in the history of the country as many and I have previously predicted. 

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

Stanley Feld M.D.,FACP,MACE

I thought America was a free country. Last week, Judge Rosemary Collyer ruled that seniors have a legal obligation to accept government health benefits (Medicare Part A) or they will lose their Social Security benefits. What happened to freedom of choice?

What does Medicare Part A have to do with Social Security? Americans pay a separate payroll taxes for each. If Americans choose not to accept Medicare Part A, why should they lose their Social Security benefits?

Americans should have the freedom to choose to accept or reject an entitlement for which they paid. Americans who rejected Medicare Part A would not get their Medicare Part A prepayment back. .

Americans pay a separate tax for the Social Security retirement benefits. Why should the government be able to eliminate the Social Security benefit when someone gives up his Medicare benefit?

It looks like another one of President Obama trick plays. This judgment would help him in the implementation of his healthcare reform act. Obamacare’s goal is eliminate to Americans’ freedom of choice.

President Obama’s lawyers have not only tricked the American people by eliminating their freedom to choice, they tricked the judge who does not understand the long term consequences of her judgment. Two years ago, she made the opposite judgment.

Judge Collyer’s judgment has not been widely covered in the traditional media. Its significance has not been discussed. It is a significant victory for President Obama’s healthcare reform act. I presume Judge Collyer’s judgment has gotten limited coverage because President Obama did not want seniors and others to realize the significance of the judgment.

President Clinton promulgated the so-called POMS rules. The POMS is a primary source of information used by Social Security employees to process claims for Social Security benefits.

The rules stated that seniors who withdraw from Medicare Part A must forfeit their Social Security benefits.

Few people are aware of President Clinton’s POMS rules. Three years ago, a group of senior citizens sued the government about this rule. The seniors wanted to be allowed to opt out of Medicare Part A without losing their Social Security benefits.

Their logic was impeccable.

1. They paid their Medicare taxes separately from their Social Security taxes all their working lives.

2. Both Social Security and Medicare are separate benefits.

3. They are not asking for their Medicare payments to be returned.

4. They want to buy private insurance with their own money.

5. They do not want to lose their Social Security benefits. Social Security is a separate benefit.

Two years ago, Judge Collyer supported the seniors’ position and rejected President Obama’s argument. His argument was;

1. Plaintiffs were fortunate to receive Medicare Part A coverage.

2. Plaintiffs suffered no harm from Medicare Part A coverage and therefore lacked standing in the case.

3. President Clinton’s POMS are part of a government handbook.

4. The POMS never went through a formal rule-making process.

She also refused the Administration’s request to dismiss the suit, noting, "neither the statute nor the regulation specifies that Plaintiffs must withdraw from Social Security and repay retirement benefits in order to withdraw from Medicare."

Last week something caused the Washington D.C. judge to revisit and reverse her decision. Her logic is very shaky.

She said:

1. The Medicare statute provides that only individuals who are "entitled" to Social Security are "entitled" to Medicare Part A.

2. Therefore it follows,” the only way to avoid entitlement to Medicare Part A at age 65 is to forego the source of that entitlement, i.e., Social Security Retirement benefits."

This is not syllogistic reasoning. It is not logical. In order to obtain Medicare you have to be eligible for Social Security. This concept is reasonable.

If one does not accept Medicare one cannot receive Social Security benefits is disconnected and arbitrary. If this judgment stands it will set the precedent forcing Americans to have a duty to accept all entitlements the government rules necessary or suffer a penalty. Americans will have lost an important freedom.

“Plaintiffs attorney, Kent Masterson Brown, warns: "Anyone concerned with what will happen when the bureaucrats start writing the thousands of pages of rules that will govern" ObamaCare need only look at this ruling. "Nothing will be optional."

This judgment will help President Obama in the Supreme Court fight for his mandate requiring Americans to purchase healthcare insurance. It will be a deterrent for business to create innovative and cheaper forms of healthcare insurance. It will eliminate healthcare insurers from the marketplace. It will lead the way to the “Public Option.”

There will be no need for a “Public Option.” Americans will have no other option than to accept government healthcare coverage.

President Obama’s next step would be to require all physicians to accept the government rules. The government will dictate to physicians who they can see and how they can treat them.

If physicians do not accept the mandate, they will lose their license to practice medicine.

President Obama’s goal is not about saving money or providing choices. His goal is to force all Americans into the same healthcare coverage program. A program the government controls completely.

I hope, for freedoms sake, President Obama does not get away with this trick play.

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

Stanley Feld M.D.,FACP,MACE

The larger the bureaucracy the more inefficient a system becomes. Several things can happen in the decision making process.

1. The decision making process can become opaque rather than transparent.

2. Decisions are made by a committee by consensus.

3. Consensus committee decisions might not sharply define the original goals.

4. Blame for errors gets dissipated.

5. Decisions are only as good as the information that is gathered.

6. Changing a wrong decision can be difficult and costly.

President Obama’s healthcare reform law is creating 256 new agencies to gather information and recommend decisions for other agencies to write regulations.

The following decision is being made by an agency in Washington state. It is not only the wrong decision, but is a decision that will set back the care of Type 2 Diabetes Mellitus 15 or 20 years. It is a decision being made using the wrong information.

Ironically, the chairperson of the agency (the Health Technology
Assessment Group) is being promoted to head President Obama’s Patient-Centered Outcomes Research Institute as a reward for her good work in the state.

The Health Technology Assessment group’s actions are one of many warning signs for future tragedies of government controlled healthcare.

The subsidized, mandated and overregulated insurance model is imploding in Massachusetts yet the Secretary of Health and Welfare in Massachusetts last week announced it was a success.

In 2006, the state of Washington created the Health Technology Assessment group. The group scrutinizes the cost-effectiveness of various surgeries and treatments. Last week the panel presented its conclusions on lack of value of home glucose monitoring (HGM) for diabetic children under 18.

The board is targeting a fundamental standard of diabetes care. Home glucose monitoring has been well established as a cornerstone of diabetes care for three decades. The agency is wasting its time scrutinizing home glucose monitoring’s cost effectiveness. It has made a decision to eliminate the state’s insurance coverage on the basis of the wrong information. HMG is cost effective because its use decreases long term complications of diabetes.

The issue of cost effectiveness of a test deserves far more scrutiny. “ObamaCare” and the economic stimulus package have devoted billions of dollars to comparative effectiveness research.

President Obama has so often said; "The idea is to pit Treatment X against Treatment Y and find out "what works and what doesn’t." In theory, it sounds great. The Health Technology Assessment in Washington State is an example of how comparative effectiveness will work in the real world, as the political system tries to find ways to restrict or limit treatment to control entitlement spending with little regard for long term outcomes.

I have many ideas on how to control entitlement spending. Eliminating HMG is not one of them.

What is revealing is last November, Ms. Hole-Curry and others debated whether patients were the institute’s "primary constituents."

I believe these bureaucrats believe the budget deficit is their prime constituent. The Health Technology Assessment board is looking to decrease costs short term. Remember the oil filter advertisement, “Pay now or pay more later.”

In 1993, the Diabetes Control and Complication Trial (DCCT) showed that normalizing the blood sugar decreased the incidence of complications of diabetes. The complications of diabetes account for 80% of the cost of diabetes care. It takes 10 to 20 years to develop diabetes complications after the onset of the disease. Complications can be reduced at least 50% with glucose control.

The American Association of Clinical Endocrinologists’(AACE) system of intensive diabetes self- management teaches patients how to control their blood sugars. The system teaches patients how to adjust medications based on HGM readings.

Home glucose monitoring is a major tool used by patients to control their blood sugars.

It is ridiculous for an agency to discuss the efficacy of home glucose monitoring. By discontinuing payment for home glucose monitoring the group shows a disregard for medical science and its ability to prevent the complication of this devastating disease.

The 11-member Health Technology Assessment does not include an endocrinologist or any other physician with relevant clinical experience whose expertise is in diabetes.

“More to the point, as shown by the arbitrary Washington state method, political comparative effectiveness is not about informing choices. It is really about taking away options.”

Washington’s Health Technology Assessment makes the decisions about state-subsidized health care for 750,000 people including Medicaid beneficiaries, public employees, and prisoners.

The Health Technology Assessment program targets therapies that it thinks may be wasteful or unnecessary, and then in nearly all cases it proceeds to ban or restrict state payment for those treatments.

Since 2006, the Assessment program has eliminated coverage for or imposed restrictive conditions on drug-coated cardiac stents, knee replacements for osteoarthritis, ultrasounds for pregnant women, infusion pumps for chronic pain medication, lumbar fusion back surgery and hip resurfacing arthroplasty to name a few.

The Health Technology Assessment program is the prototype for ObamaCare’s many comparative effectiveness programs. No one is discussing the healthcare insurance industry abuse, bureaucratic waste, or decreasing access to care.

President Obama has already hired Ms. Hole-Curr, head of the Health Technology Assessment program to head his comparative effectiveness program

President Obama’s healthcare reform act will create de facto criteria for procedures through his comparative effectiveness program. The result will be to dictate all the choices about how doctors are allowed to treat patients.

This is not “evidence based medicine.” Anyone can believe prove anything if they evaluate the wrong information. If the government’s imperative is to save money, new and effective tests and treatments will be rationed to the detriment of patient care.

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

Stanley Feld M.D.,FACP,MACE

Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee announced on March 8,2011 that “The Senate will never vote to confirm Dr. Donald Berwick as CMS administrator.” Dr. Don Berwick is currently serving through a temporary one year appointment made by President Obama while congress was in recess last summer.

Mr. Bacus did not call for confirmation hearings before the recess because of fears that Dr. Berwick’s views would be too controversial for him to be confirmed. He and President Obama feared the Senate and the American people would reject Dr. Berwick’s nomination.

Last week 42 Republican Senators sent a letter to President Barack Obama requesting that he withdraw Berwick from consideration. The Republican Senators said they would not vote for Dr. Berwick under any circumstances.

Senator Bacus said the “Republicans won”. He said alternative nominees to the post are "up to the president."

President Obama has announced, after receiving the Republican Senators letter, his support of Dr. Berwick’s nomination. President Obama declared Dr. Berwick is the most qualified candidate to lead CMS. Dr. Don Berwick told reporters that he “was grateful for the White House support.”

The 42 no votes would block confirmation because 60 votes are needed. Dr. Berwick was asked if he has met with any of those Republican senators to address their concerns about him. He said he would “meet with anyone in Congress who wants better healthcare.”

His answer implies Senate Republicans do not want better healthcare. It also implies that Republican Senators have no interest in meeting with him and that he knows the answers and they do not.

Republican Senators have expressed many concerns. One concern stems from Dr. Berwick’s praise of the British single-payer system which is failing and the sense President Obama’s healthcare reform act is heading toward a single party payer system.

The concerns are deeper than these. There has been little coverage of the Republican Senators’ letter to President Obama in the traditional media.

The Republican Senators wrote; “Withdrawing Dr. Berwick’s nomination would be a positive first step in rebuilding the trust of the American people.”

The letter says; “CMS is in charge of both Medicare and Medicaid, and will oversee most of the implementation of the recently-enacted health law.”

The Republican Senators letter lists the reasons for their request in a civil way.

1.“Don Berwick is a contentious choice to head an agency with a budget larger than the Defense Department’s and implement the vast majority of the $2.6 trillion health law.

2. “ The White House’s handling of this nomination – failing to respond to repeated requests for information and circumventing the Senate through a recess appointment – has made Dr. Berwick’s confirmation next to impossible,”

3.  “In the spirit of cooperation, the President should withdraw his nomination and choose a different candidate who has the support and confidence of the American people.”

4. “Both Congress and more than 100 million Americans that will be affected by this partisan health care reform plan need to know who is minding the store at CMS.

5. There are just too many questions about what Dr. Berwick and CMS are doing or will do with the unprecedented power they have been given to reshape our health care system,”

6.  “The President should start with a clean slate and send the Senate a nominee who is willing to answer our questions and seek our bipartisan support as he or she leads CMS in implementing the new health care law.”

7. “ The occupant of this important position, which affects the health care of so many Americans on a daily basis, requires an individual with the appropriate experience and management ability. Our seniors and those who rely on Medicaid deserve no less.”

The letter questions Dr. Berwick’s experience and management ability to handle large organizations. There has not been evidence presented to the congress verifying that Dr. Berwick has experience in running large organizations with multiple competing vested interests.

The healthcare system is dysfunctional. Only a consumer driven healthcare system with consumers in charge of their healthcare dollars will repair the healthcare system. Consumers must have access to appropriate information and appropriate incentives to make wise health decisions. This is the only way to control the costs of the healthcare system. A complex bureaucracy will not do this.

Mistrust of President Obama is rampant among Americans. President Obama must regain the trust of the American people and stop his trick plays.

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

Stanley Feld M.D.,FACP,MACE

Last year’s “Doctor Fix” was passed the last week congress was in session in 2010. This was after the medical profession was held in suspense for 9 months.

The “Doctor Fix” was supposedly the result of President Obama making a deal with the AMA for the AMA’s support. He was going to pass a real “Doctor Fix” in 2011 by repairing the defective sustainable growth rate formula (SGR). Nothing has been done about this by President Obama in 2011. The cumulative physician reimbursement reduction of 25% was suspended until January 2012.

Physicians face a 29.5% Medicare Pay Cut in January 2012. Four and one half percent was added to last year’s cumulative physicians reimbursement reduction. The reduction was calculated into the CBO’s cost score for President Obama’s Healthcare Reform Act.

Last week an official with the Centers for Medicare and Medicaid Services unveiled the 29.5% rate reduction for 2012 in a recent letter to the Medicare Payment Advisory Commission. This will become another distraction for physicians and the media as President Obama stalls for time.

“Leaders of the American Medical Association and other medical societies have warned that such a huge pay cut would force physicians to turn away not only seniors but also military families whose TRICARE coverage is based on Medicare rates.”

President Obama is stalling for the development and implementation of Accountable Care Organizations. His goal is to deal with big hospital systems, clinics, and not 600,000 individual physicians.

President Obama is ignoring the fact that Accountable Care Organizations (ACOs) are difficult to organize and impossible to execute efficiently and effectively. ACOs will fail for the reasons I have outlined previously.

It will end up costing the federal government more rather than less than the present system does. Hospital systems are excited because they think they will own the physicians and make a killing on Accountable Care Organizations. They think they will own physicians intellectual property. They cannot be more mistaken. They can expect a lot of fighting and grief.

At the same time, President Obama is dispiriting the physician workforce with his duplicity. He is increasing physician mistrust for government control over medicine.

President Obama’s proposed budget for fiscal 2012 calls for delaying the next cut from January 1, 2012, until January 1, 2014, freezing rates in the meantime.

Why doesn’t he fix the SGR? It is a screwy way to do business.

The healthcare system needs to be repaired. President Obama is going about it the wrong way.

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