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The Insured Are Feeling The Strain of Health Costs : Part 2

May 14, 2008
inMedicine: Healthcare System, Patients Problems
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Stanley Feld M.D.,FACP,MACE

I could never understand why my understanding of the original Medical Savings Accounts presented by John Goodman in 1994 slowly got changed to a Health Savings Accountsounding the same but using a different formula for payment and savings.

Many consulting firms worked hard to change the structure of the original Medical Savings Account to the structure of the Health Savings Account. They also convinced congress to pass a bill permitting the structure of the HSA instead of the MSA.

To my amazement, Mr. Nussbaum Director, Group and Healthcare, North America, Watson Wyatt Worldwide explained the reason for the change clearly, saying it is unlikely that significant numbers of employers will simply drop coverage for their workers.

“The weak economy could prompt more of them to push for so-called consumer-driven plans. Such plans tend to offset lower premiums with higher annual deductibles. And when a weak economy undermines job security, he said, workers may simply have to accept reduced benefits. Even so, more companies may see themselves as having little choice but to require employees to pay even more of their health expenses.” 04insure.html?_r=3&th&emc=th&oref=slogin&oref=slogin&oref=slogin

Mr. Nussbaum dismisses Health Savings Accounts out of hand as a way that forces consumers to pay for their healthcare insurance.
 I believe the consulting firms figured out a way for the healthcare insurance industry to remain in control of the healthcare system and relieve the employer of the responsibility of paying for the healthcare insurance needs of their employees.

“And while these plans often allow employees to put pre-tax savings into special health care accounts, they typically end up forcing the worker to assume a bigger share of overall medical costs. About six million people are now enrolled in these medical plans.”

The director of a major health benefits organization (Watson-Wyatt) revealed the subtext purpose of the Health Savings Accounts. These plans seem to be evolving into plans that take the burden of payment out of the employers’ hands and into the employees’ hands with the control of the money remaining in the healthcare insurance industry’s hands. That was a neat trick. It will probably do little to Repair the Healthcare System.

The Consumer Driven Healthcare movement is an exciting movement to me because it promises to put consumers in control of their healthcare dollar and not the healthcare insurance industry.

Politics and powerful stakeholders’ agenda always seem to contaminate solutions to problems in order to protect its vested interest. The healthcare insurance industry has done and is doing just that to the consumer driven healthcare movement. I believe its goal is to destroy the consumer driven healthcare movement. The healthcare insurance industry has not been pushing HSA’s . because, I suspect because the net profit is less than traditional plans.

Health Savings Accounts do not motivate patients to save money. The healthcare insurance industry still controls the premium rates, and designs the patients’ deductibles and co-pays. The healthcare insurance industry can manipulate deductibles and deplete the HSA. If there is less money in the HSA out of pocket expenses will be higher.

The original concept of consumer driven health care was to provide the consumer with the purchasing power to control the costs of healthcare. Most other consumer driven purchases such as automobiles, computers, houses, and food control the costs using purchasing power and forcing providers to compete.

Wal-Mart and Target are really consumer extenders that drive down the costs to consumers utilizing their companies’ purchasing power. The purchase remains the consumers’ choice.

The original Medical Saving Account and my Ideal Medical Saving Account
accomplish the same using Patient Power. in a consumer driven healthcare model.

In the process it eliminates much of the non transparent 150 billion dollar skimming off the top of the healthcare insurance industry for “expenses”.. It also eliminates the control the healthcare insurance industry has on the consumer. The consumer has control over the first $6,000 and pays the first $6,000 of services. Anything he does not spend goes into his retirement fund. The money is out of play for the insurance company of other vendors.

If the consumer spends the $6,000 appropriately he gets first dollar coverage without deductibles. The consumer is by true insurance for risk. If he has a chronic disease and it is determined that certain amount of money would have to be spent to avoid complications of that disease he should be eligible for a bonus since he has saved the system a great deal of money. This is an example of the incentive I have described previously. As an example a Type 2 Diabetic should spend $4500 a year to prevent complications of his disease. If he does he keeps the remaining $1500 and gets a $2250 reward totaling $3750. This is the financial reward for losing weight, exercising, maintaining a normal blood sugar and functioning in the work place at a high level.

Healthcare insurance should be available to everyone regardless of pre-existing illness. It should be paid with pre-tax dollars regardless of the payer. It should be community rated and not individually rated.
Who pays for the premium? It could employer, the government with subsides, or the patient himself. All would pay with pre-tax dollars. All consumers would be automatically eligible without penalty. Monies not spent or monies for performance would accrue in a tax free retirement account until withdrawn.
Medicare and Medicaid entitlement programs would be eliminated. The government could get out of the way after making the rules and providing effective subsidy programs. The government would guarantee and enforce the requirements for real price transparency from insurance carriers, hospitals, physicians and drug companies.

The New York Times article simply confuses the issue. It does not clarifying anything. It presents war stories that we have no way to cure.

Let us stop complaining. Let us start demanding positive constructive action from our local, state, and national government.

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

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The Insured Are Feeling The Strain of Health Costs : Part 1

May 11, 2008
inMedicine: Healthcare System, Patients Problems
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Stanley Feld M.D.,FACP,MACE

The United States economy is slowing down. Many employers provide healthcare coverage to their employees. As healthcare premiums rise employers are providing less coverage than previously in order to reduce their costs for providing the healthcare coverage. Employees are beginning to realize their healthcare insurance is not very inclusive and their out of pocket costs are high. In fact, many the out of pocket expenses are unaffordable. The result is a tendency to not seek necessary medical care. The avoidance of medical care leads to more serious and costly illness.

I have warned my readers about this problem earlier. I have received comments such as “The cost of healthcare does not concern me. I have a very good healthcare insurance policy through my employer. The inability to obtain healthcare insurance is the other guys’ problem and not mine.”

The other guys’ problem eventually becomes your problem either through higher taxes or other burdens on society. Individuals with healthcare insurance can not assume they have adequate coverage. The inadequate healthcare coverage is discovered when they become ill.

A basic economic fact is consumer spending defines the market place. Consumer spending also defines the economic well being of our society. An informed consumer can make or break a business. In Dallas, the new concept restaurant capital of the world, we see this market phenomenon daily. This week’s hot restaurant is next week’s dud because the consumer does not show up.

“The economic slowdown has swelled the ranks of people without health insurance. But now it is also threatening millions of people who have insurance but find that the coverage is too limited or that they cannot afford their own share of medical costs.”

Many of the 158 million people covered by employer health insurance are struggling to meet medical expenses that are much higher than they used to be — often because of some combination of higher premiums, less extensive coverage, and bigger out-of-pocket deductibles and co-payments.
Our presidential candidates provide sound bite babble in the “so called” healthcare debate. The “debate” has nothing to do with the solution to our healthcare problems. Some politicians claim people are too dumb to take care of themselves. They claim the government needs to provide single party payer system for citizens healthcare needs.

The government is having a difficult time providing insurance for our senior citizens through Medicare. In fact Medicare is scheduled to be bankrupt before 2020. I cannot imagine how the government will insure the entire population.

The government should be figuring out rules that level the playing field for all stakeholders. All the stakeholders vest interests must be aligned. The basic principle should be the patient is first.

REED ABELSON and MILT FREUDENHEIM of the New York Times listed examples of the increased burden to consumers as healthcare premiums increase. The article does not present solutions. It simply confuses the consumer and intensifies the consumer feelings of impotence toward fixing the healthcare system.

Alan Shimel’s blog makes the problem clear from a consumer’s and executive decision maker’s point of view.

“My wife had minor surgery in September. It was ambulatory surgery where she went in the morning and went home that afternoon/evening. Even though we have full PPO coverage and it was participating doctors, hospital, etc. my out-of-pocket costs after insurance were almost $3000! The surgeon received a whopping $472 from the insurance company for the operation and the hospital billed like 17k! When I called the hospital they said they did not expect to get paid that much, but had to bill it so they could get as much as they could. I than had to negotiate what I would pay out of pocket beyond that. I also had to pay the anesthesia, the prescriptions, etc”.

The main issue in the healthcare debate is perfectly described in Alan Shimel’s next paragraph.

“Here at StillSecure we had to switch providers again this year because United Health Care wanted another 15 to 20% raise in premiums. In fact that is about normal for health insurance, way above the cost of living and inflation. We pay a good chunk of our employees’ insurance premiums, but even so the 20% or so that we have the employee pick up gets bigger and bigger. Plus the insurance company covers less and less. This squeeze is frankly baffling. How can you pay more and get less.”

The problem is understood easily. The healthcare insurance industry is determining the premium as well as the access to care. The higher the premiums and the greater the restrictions on medical services the higher the healthcare insurance industry’s profit.

In the last few years employers have tried to get out of the business of providing healthcare to employees.
To my amazement, Mr. Nussbaum Director, Group and Healthcare, North America, Watson Wyatt Worldwide and other consultants say it is unlikely that significant numbers of employers will simply drop coverage for their workers.

“The weak economy could prompt more of them to push for so-called consumer-driven plans. Such plans tend to offset lower premiums with higher annual deductibles. And when a weak economy undermines job security, he said, workers may simply have to accept reduced benefits. Even so, more companies may see themselves as having little choice but to require employees to pay even more of their health expenses.”

Mr. Nussbaum dismisses Health Savings Accounts out of hand as a way to force the consumer to pay for their healthcare insurance.

It now becomes clear why many healthcare policy consultants for the healthcare insurance industry have bastardized the original Medical Savings Account and morphed it into the Health Savings Account. It looks like another example of telling the consumer you are providing something good but perhaps in reality providing an advantage to the healthcare insurance industry and the employers but providing something bad for the consumer.

I will discuss this point in greater detail next time.

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

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Is The Healthcare System Too Complicated To Fix? My Answer Is No!!

May 7, 2008
inMedicine: Healthcare System
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Stanley Feld M.D.,FACP,MACE

Many feel the healthcare system is so complex and dysfunctional that it is going to be impossible to repair. I have faith in the American system and the American people. I believe people are going to stand up soon and say enough is enough. We are going to force the government to help us help ourselves.

Winston Churchill said “You can always count on Americans to do the right thing – after they’ve tried everything else.”

I also believe American public is getting close to the point of demanding our elected officials make the correct rules to let us help ourselves.

Freedom of speech and freedom of the press has helped us solve many problems we have encountered in the history of America. The freedom to be creative and innovative drives us forward despite the complexity of any issue.

In healthcare we have all the technology and infrastructure necessary to do it right. I believe the internet and social networking will create the infrastructure for creating a competitive environment among the various secondary stakeholders.

Stakeholder vested interests naturally try to protect their products and services often to the determent of the general good. I am not criticizing the pursuit of a stakeholders’ vested interest. .

However, I am criticizing our elected officials’ resistance to make rules that will align everyone’s vested interest.

If a product or service is out of touch with the needs of the people it must not be permitted to survive. Obsolete companies have remade themselves with new products in order to survive. Companies not adjusting to the changing consumer demand simply must be permitted to disappear.

The healthcare system has many challenges. Eighteen percent of our gross national product (GNP) is spent in healthcare. Each year this percentage increases. Despite the increase in healthcare expenditures, access to physicians’ services is decreasing. Physician reimbursement is also decreasing.

Where is all of the money going if not to the physicians? Why do patients feel they are not receiving timely and appropriate care? Why is there an ever increasing shortage of primary care physicians while medical schools are producing more physicians yearly?

I have covered the answers to these questions previously. However, the politicians and the stakeholders in the healthcare system have not made any progress toward an answer to these questions or a solution to the problems. The problems of increasing cost, decreased access, affordable care, and avoidance of the complications of chronic disease have not been addressed in any logical way by any of our presidential candidates or candidates running for other offices.

Why? The solution to the Repair of the Healthcare System for each stakeholder varies with the differences in each stakeholder’s vested interest.

The primary stakeholders (patients and physicians) should be in control of the healthcare system. Patients should be responsible for their own care and their own healthcare dollar. Consumers should be subsided if they qualify for subsidy. The criteria for qualifying for subsidy must be clear and realistic.

Consumers with “adequate” healthcare insurance are not motivated to change behavior. Obesity, alcohol intake, and lack of exercise are increasing daily. Obesity is a major risk factor in precipitating chronic disease. The complications of chronic diseases are responsible for the expenditures of 90% of the healthcare dollars spent. This culture must be changed to make progress.

America food industries in pursuit of their vested interest do little to help fight the obesity epidemic. (See War on Obesity Part 1-7) The Fast food industry has not done anything to decrease the incidence of obesity. They have offered not so low calorie “salads” as a loss leader in order to look good in the eyes of the consumer. Cheap fast food containing an abundance of salt and fat contribute to the obesity epidemic and the high incidence of hypertension and diabetes mellitus.

Restaurants at all level serve large high calorie portions in order to raise prices while giving customers their money worth. When a company (TGI Fridays) tries to reduce the size of the portion while decreasing the price their volume of sales decreases.

The media has no interest in a public service campaign to discourage obesity. In having a successful public serviced campaign the media would lose a large share of their advertising revenue. The “open 24 hours” campaigns and the 99 cent meals are large revenue generators for the media. Two for the price of one fast food offers by all companies is endless.

The Supermarket industry is not interested in my War on Obesity because the “taste” of fatty food loaded with salt and sugar “taste” better than the non fat non salt non sugar food. Next time in the Supermarket notice the shelf space for cookies, soda pop, prepared foods and other fattening items.

The prepared foods in Supermarkets are not as healthy as advertised. They are convenient by loaded with fat and calories.

As a society, we have fallen for the organic food hype. The food costs a little more but it is healthy for you. Who said? Much organic food is loaded with calories and salt and promotes obesity.

National physicians’ organizations ( AMA,AAFP,ACP ect) have not helped its physician members’ help their patients stay healthy. Organized medicine has a terrific opportunity to step up and promote good health, fitness, and healthy habits community to community in a serious way. I’ll bet organized medicine could get physician volunteers from every community with a well organized and integrated public relations program. It would have to be sustained and awareness would have to be created at the political level, the social level, the educational level, and the corporate level to create the cultural change needed in society.

The environmental organizations are doing it and are becoming successful. Much of Corporate America wants to be known as a “Green Company” today in order to win the favor of the consumer.

Why hasn’t organized medicine stepped up to the plate? I know it could cite initiatives but how many have been transformational? Physicians want to keep their patients healthy. Organized medicine should help physicians with public service campaigns incorporating the grass roots physicians in order to change the culture of America’s health habits and health.

It would be a wonderful service for patients and physicians. It would also go a long way to reducing the costs of the healthcare system by reducing the incidence of chronic diseases and its complications.

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

  • Jennifer • May 7, 2008

    Great blog. I really like your perspective. Curious what you think of patient advocacy groups? Are they helpful? Are for-profit groups viable or is it better offered through non-profits?
    Thanks.

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Why Bother?

May 4, 2008
inMedicine: Healthcare System
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Stanley Feld M.D.,FACP,MACE

MICHAEL POLLAN wrote an inspiring article about climate change in the April 20, 2008 issue of the New York Times Magazine section.

I have substituted the word healthcare system in my minds eye every time he mentioned climate change. Mr. Pollan is describing exactly what has to be done for the healthcare. His major point is every individual has to get involved. The individual has to be aware of the issues and then act in his self interest and do his small part. The parts will add up to the necessary change.

Why bother? That really is the big question facing us as individuals hoping to do something about climate change, (healthcare) and it’s not an easy one to answer.

Al Gore’s “Inconvenient Truth” is scary, if true. Let us assume global warming is true for this argument. Al Gore’s suggestion to me as an individual seemed bizarre. I am happy to say it was also depressing to Michael Pollan, a person I admire.


“ No, the really dark moment came during the closing credits of Inconvenient Truth, when we are asked to change our light bulbs. That’s when it got really depressing. The immense disproportion between the magnitude of the problem Gore had described and the puniness of what he was asking us to do about it was enough to sink your heart.”

In thinking about it in terms of healthcare and general behavior we as individuals can make a big difference. People are social beings. They need other people. If we can create a trend we can make a difference even if others choose not to follow.

“ But the drop-in-the-bucket issue is not the only problem lurking behind the “why bother” question. Let’s say I do bother, big time. I turn my life upside-down, start biking to work, plant a big garden, turn down the thermostat so low I need sweater, forsake the clothes dryer for a laundry line across the yard, trade in the station wagon for a hybrid, get off the beef, go completely local (with my food purchases).”

If no one else did the same the only impact you would have is for yourself and your self interest. You would save money and improve you wellness. I was terrified to read about tilapia fish farms in Indonesia. How can we allow our government to allow its import? We have no idea of the conditions in Chilean fish farm where “Chilean Sea Bass” comes from. Restaurants make Chilean Bass sound romantic, sexy and expensive. However the details of these fish harvests are chilling.

If we the people change and do little things to improve our health the payback is beyond personal virtue. If everyone does the same the change in society will be enormous.

“ A sense of personal virtue, you might suggest, somewhat sheepishly. But what good is that when virtue itself is quickly becoming a term of derision? There are so many stories we can tell ourselves to justify doing nothing, but perhaps the most insidious is that, whatever we do manage to do, it will be too little too late.”

This is nonsense as science is beginning to show us. Nonetheless, we tell ourselves all kinds of stories to justify our weight, our food intake and our lack of exercise. We can make a difference in our health and healthcare cost if we are determined to change our behavior. Small changes in society’s trend setting can help change behavior for the better.

“ So do you still want to talk about planting your own gardens? I do. Yet it is no less accurate or hardheaded to say that laws and money cannot do enough, either; that it will also take profound changes in the way we live.”

We have seen money and laws cater to vested interests and not societal interests as they should. Individual actions add up. The most profitable center in a hospital is the Bariatric Surgery Center. Hospitals are reformatting themselves to all have Bariatric Centers. They would go out of business if we conquered obesity. This victory can only happen on an individual basis.

“Whatever we can do as individuals to change the way we live at this suddenly very late date does seem utterly inadequate to the challenge.”

So why bother? We should bother because we have a responsibility to ourselves and our children and grandchildren. We have a responsibility to repair the healthcare system before the ability to deliver the greatest healthcare on the planet implodes. We, the people, have to drive the change and make the politicians respond. Politicians are responding to the secondary vested interests.

“ The Big Problem is nothing more or less than the sum total of countless little everyday choices, most of them made by us (consumer spending represents 70 percent of our economy), and most of the rest of them made in the name of our needs and desires and preferences.”

This is the reason we need to own our healthcare dollar. We have to be motivated to drive the change.

“For us to wait for legislation or technology to solve the problem of how we’re living our lives suggests we’re not really serious about changing — something our politicians cannot fail to notice. They will not move until we do. Indeed, to look to leaders and experts, to laws and money and grand schemes, to save us from our predicament represents precisely the sort of thinking — passive, delegated, and dependent for solutions on specialists — that helped get us into this mess in the first place. It’s hard to believe that the same sort of thinking could now get us out of it.”

Michael Pollan hit the nail on the head. Whether it is climate change or healthcare we need to be responsible to ourselves. The inspiration lies in his next example.

“Sometimes you have to act as if acting will make a difference, even when you can’t prove that it will. That, after all, was precisely what happened in Communist Czechoslovakia and Poland, when a handful of individuals like Vaclav Havel and Adam Michnik resolved that they would simply conduct their lives “as if” they lived in a free society. That improbable bet created a tiny space of liberty that, in time, expanded to take in, and then help take down, the whole of the Eastern bloc.”

We have a government for the people by the people. We have tremendous power to influence our government. Our health is our most important asset. It is our responsibility to demand the infrastructure to help us maintain our health.

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

  • Dave Greenstein • May 6, 2008

    The Dalai Lama relayed a quote to me once that resonated and I’ve lived by ever since “be what you want the world to be”. I’m not even buddhist 😉

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Chicago, Chicago, It’s a Wonderful Town!

April 30, 2008
inLife's Experiences, Medicine: Healthcare System
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Stanley Feld M.D.,FACP,MACE

Springtime in Chicago can be totally unpredictable. One day it’s hot and sunny and the next day it’s cold and rainy.

Last weekend was a father and son bonding weekend for Daniel and me. Daniel is the younger of my two sons. Brad is 42 years old and Daniel is 39. I try to have a weekend alone with each boy every year with nothing scheduled except what Dad figures out.

Daniel and I had two full days in Chicago counting Friday afternoon and Sunday morning. I started to think about what we were going to do on Wednesday. Thanks to the weather O’Hare was closed down for three hours so we landed late right in the middle of Friday afternoon traffic. The late arrival slowed my plans down a little but we adjusted. The weekend is not about going to different cities; it is about being with each other.

We spoke non stop in the one hour taxi ride into downtown. I even got the taxi driver to contribute to my plans for the weekend. Daniel and I were energized and hit the streets right after we checked in.

Our first stop was Millennium Park.Frank Gehry created an extra ordinary space over an ordinary parking lot next to the Chicago Art Institute. This magnificent open space is enjoyed by many people from 6am to 11 pm daily. In our ever increasing commoditized society, it feels good to know someone out there is thinking about us as human beings with sensitivities, emotions and feelings that need nurturing.

The park is a huge quiet space in the middle of a noisy and potentially anxiety provoking city. The visual stimuli of the space are invigorating.

Next, we walked down Michigan Avenue (the magnificent mile). It has not lost it glitter for me. We stopped into the Atlas art gallery to participate in an art opening at 6pm showing of JalinePol’s work. Daniel and I had a great time at the opening.

At 7 pm it was time for dinner. Traditionally, Daniel and I eat once a weekend in a steak house reproducing his college days. I chose Sullivan’s. I talked Daniel into sharing a steak. The concept of sharing is important because it cuts the calories in half. Cecelia and I always do it.

After dinner it was on to on Rush Street. I had a fantasy from the past of a great jazz concert in a perfect venue. It turned out they were all clip joints today. We passed and took a taxi to the hotel to watch the end of the Dallas Mavericks game. We finally won a game.

It was warm and muggy after the rain. The next morning it was cold, dry and windy. We worked out at the hotel fitness center rather than jog along Lake Michigan. Then were off to the Historic District Architecture Tour conducted by the Chicago Architecture Foundation. This is a great tour. The Architecture tour of the Chicago River did not start until May 1. It is a great tour as well.

Next we went to “Art Chicago” and “Next” in the Chicago Merchandise Mart. We took the EL
for the experience of riding on an elevated train. The ticket machine was a little tricky. However we figured it out with the help of an attendant.

“Art Chicago” was an endless visual journey of contemporary art presented by art galleries from all over the world. This was another great but tiring experience. Daniel had to sit down and close his eyes as I had to finish Aisle 5 and 6.

Even though our feet were going to fall off we had to go to the Art Institute of Chicago. I wanted to see the Ed Ruscha show.

We arrived at the hotel at 4.30 pm. We passed out for about an hour nap, dusted ourselves off and hit the road again. Now we were off to the Italian Village Restaurant. I had never heard of it before and was afraid it was going to be tacky. It is an eighty year old Chicago institution with fair food, dynamite ambiance and more people I could imagine in this size restaurant space.

We left the restaurant at eight o’clock and had ten minutes before Jersey Boys was going to start. I figured if they had empty two seats we would get them if they were discounted since Daniel had not seen Jersey Boys. Chicago still has something to learn from New York. They would not budge on the price even after I told them having one empty seat after the show started was like trying to sell a rotten tomato. Your asset is worthless. The ticket salesman said rules are rules.

Next stop the Rock and Roll McDonalds on Ohio. I was disappointed when I found that McDonald’s Corporation had knocked down the old place and replaced it with an ultra contemporary store. Somehow the romance of McDonald’s creation was gone. The memorabilia of the 50’s, 60’s, 70’s, and 80’s remained enshrined behind glass wall cases. However, none of the customers seemed to connect to the exhibit.

Daniel and I walked about 15 miles on Saturday. Unfortunately, we did not have time for a Cubs game. We slept well. Sunday was another day.

We decided we would try a real old fashion Chicago breakfast. We tried the famous Eleven City Diner in the 1100 block of Washburn. This place is a very happening place for Sunday breakfast. After breakfast I decided I could not possibly eat anything for lunch and perhaps dinner. Every city has its institutions and this is one of Chicago’s.

We had more stimulating conversation during breakfast as we were winding down another special father/son weekend. It is great to be the father of such wonderful boys. They are loving, thoughtful, perceptive, sensitive, innovative and intelligent human beings. What else can a father want from his kids? It is a great pleasure to be involved in their lives. As I said after the weekend with Brad, every father should plan weekends alone with your children.

Whether or not you can plan a get-away weekend,, I have this advice. If you are a father or mother give your son or daughter a hug and a kiss. If you are a son or daughter give your mother and father a hug and a kiss. I believe love and the person to person connection is good preventive medicine.

  • Daniel Feld • April 30, 2008

    Great weekend Dad! Let’s do it again after my feet get some rest.

  • ClizBiz • May 1, 2008

    Great post! A good friend of mine just moved to Chicago and I will share this with him.
    Also, for what it is worth, Chicago always has the best looking men – you and Dan undoubtedly enriched that image …

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The Primary Care Physician Shortage Emphasized By Universal Coverage In Massachusetts

April 27, 2008
inMedicine: Healthcare System, Physician's Problems
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Stanley Feld M.D.,FACP,MACE

Medical students are choosing procedure oriented subspecialties rather than family practice or internal medicine (Primary Care). There has been a 50% decrease between 1997 and 2008. This trend resulted from the fact that it is difficult to make a living in a non procedure oriented practice. Cognitive medical care and positive physician patient relationships have been devalued. The government and the healthcare insurance industry have not adequately compensated cognitive medical care in an attempt to save money.

“Once they discover that she is Dr. Kate, the supplicants line up to approach at dinner parties and ballet recitals. Surely, they suggest to Dr. Katherine J. Atkinson, a family physician here, she might find a way to move them up her lengthy waiting list for new patients.”

“Massachusetts primary care practices like this one in Shelburne Falls have been trying to manage an influx of new patients. Those fortunate enough to make it soon learn they face another long wait: Dr. Atkinson’s next opening for a physical is not until early May — of 2009”

Positive patient physician relationships have an important therapeutic effect. The patient physician relationship is disappearing as primary care physicians have less time to relate to their patients. They have to see more patients in a shorter time in order afford their practice overhead.

“Modest reimbursement, medical school debt, an aging population and the prevalence of chronic disease have each played a role in primary care physician “.

The primary care physician shortage widens with increases in population, decreases in the uninsured in Massachusetts, overuse of the healthcare system by first dollar insurance coverage, increases in obesity and subsequently increases in chronic disease and the decrease in reimbursement to the primary care physician.

“Since last year, when the landmark law took effect, about 340,000 of Massachusetts’ estimated 600,000 uninsured have gained coverage. Many are now searching for doctors and scheduling appointments for long-deferred care.”

The result has been an unintended consequence leading to the realization that Massachusetts has a severe primary care physician shortage. It also has resulted in the state’s widening budget deficit. The solution to the problem is to change the approach to care. The primary care physician has to be taught to extend his intellectual property.

“It’s a recipe for disaster,” Dr. Sereno said. “It’s great that people have access to health care, but now we’ve got to find a way to give them access to preventive services. The point of this legislation was not to get people episodic care.”

Dr. Serno is right on target. There are not enough Clinical Endocrinologists to take care of all the patients with Diabetes Mellitus. There are not enough Clinical Cardiologists to take care of all the heart disease patients. There are not enough Clinical Pulmonologists to take care of all the lung disease patients. Primary care physicians have to install systems of care of chronic disease in their practices. They initially see most of the chronic disease patients. The complications of chronic diseases absorbs ninety percent (90%) of the healthcare dollar. These costs can be decreased by at least 50% with effective chronic disease management.

“Whether there is a national shortage of primary care providers is a matter of considerable debate. Some researchers contend the United States has too many doctors, driving overutilization of the system.”

It seems obvious there is a growing shortage of primary care physicians. Politicians always want to do a study. All they have to do is go into a typical physician’s office and observe the demands on the physicians and the problems the physicians have.

“But there is little dispute that the general practice of medicine is under strain at a time when there is bipartisan consensus that better prevention and chronic disease management would not only improve health but also help control costs.”

“With its population aging, the country will need 40 percent more primary care doctors by 2020, according to the American College of Physicians, which represents 125,000 internists, and the 94,000-member American Academy of Family Physicians. Community health centers, bolstered by increases in federal financing during the Bush years, are having particular difficulty finding doctors.”

There are many who say we have more primary care physicians than previously. I believe all of their arguments blur the issue. The truth is every community there is a shortage of primary care physicians.

“I think it’s pretty serious,” said Dr. David C. Dale, president of the American College of Physicians and former dean of the University of Washington’s medical school. “Maybe we’re at the front of the wave, but there are several factors making it harder for the average American, particularly older Americans, to have a good personal physician.”

“Studies show that the number of medical school graduates in the United States entering family medicine training programs, or residencies, has dropped by 50 percent since 1997.”

Physicians are not becoming primary care physician because they can not afford to become primary care physicians. The Medicare reimbursement for a half-hour primary care visit in Boston is $103.42 while reimbursement to a gastroenterologist for a colonoscopy requiring roughly the same time would be $449.44.

“Dr. Atkinson, 45, said she paid herself a salary of $110,000 last year. Her insurance reimbursements often do not cover her costs, she said.”

“I calculated that every time I have a Medicare patient it’s like handing them a $20 bill when they leave,” she said. “I never went into medicine to get rich, but I never expected to feel as disrespected as I feel. Where is the incentive for a practice like ours?”

The physicians’ goal is to help people get well. They also want to earn a reasonable livelihood for their efforts and intellectual property. Physicians have not done a good job arguing this point.

Organized medicine (AMA,AAFP,ACP) has not done a very good job of defending the physicians’ value.

As time passes the problems with the delivery of healthcare will escalate as the secondary stakeholders, the healthcare insurance industry, the pharmaceutical industry, and hospitals thrive making egregious profits while the primary care physician shortage intensifies.

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

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Can You Believe This? Health Savings Account Threatened By The “Taxpayer Assistance and Simplification Act

April 22, 2008
inHealth Savings Accounts vs Medical Savings Accounts, Medicine: Healthcare System
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Stanley Feld M.D.,FACP,MACE

The House of Representatives passed a bill called the “Taxpayer Assistance and Simplification Act” last week that will essential destroy Health Savings Accounts and the quest for consumer independence from the government’s control of the healthcare system. I have criticized HSAs in the past because they only give consumers partial control and not full control of their healthcare dollar. If you do not use the money you lose it. In my opinion this creates a perverse incentive that does not stimulate wellness. It stimulates potential abuse. Patients keep the money they do not spend with my Ideal Medical Savings Account. The MSA would increase incentives for wellness and decrease abuse, because if patients abused the system they losing their own money.

“Democrats have made affordable health care a mainstay of their election agenda, but apparently only if you’re willing to get insurance through the government. Witness their stealthy assault on Americans who prefer the private-sector option of Health Savings Accounts.”

No one in the Democratic Party dominated House of Representative nor the Democratic Party’s presidential candidates seem to understand the government can not afford to have a government dominated system. It is also clear they do not trust patients to pursue their vested interest.

“The House passed legislation on Tuesday, the mis-named “Taxpayer Assistance and Simplification Act,” that contained the awful provision that would throw a mountain of paperwork at Health Savings Accounts.”

<President Bush sent a note to congress stating that he would veto the bill if it contained the anti HSA provision. I do not think the Senate will accept the provision either. The frightening thing is the lack of understanding by the Democratic Party of what is necessary to Repair the Healthcare System.

“A key player here is Ways and Means Health Subcommittee Chairman Pete Stark, whose main purpose in politics is to give the U.S. a government-run health-care system. He is a known opponent of HSAs – once comparing them to “weapons of mass destruction” – because they introduce more individual choice into the health-care marketplace.”

“Mr. Stark and his friends want to impose the same bureaucratic overhead even on spending that consumers do with their own money. The Senate should stop this one dead in its tracks.”

I thought Pete Stark finally understood the folly of his thinking. He trusts neither physicians nor patients. I was misled by his comments in Forbes magazine when he admitted he made a mistake with his Stark Laws.

“This week, the House passed legislation that included a provision to require every HSA transaction be reviewed and verified as a legitimate medical expense. Democrats say this is to ensure that consumers are using their tax-free withdrawals for a knee replacement, rather than a new iPod. In reality it adds a layer of bureaucracy that could sharply reduce the appeal and cost savings of HSAs.”

Presently the healthcare insurance industry administers these health savings accounts and does not permit misuse to occur. Maybe the only way the Democratic Party can reach its goal of government controlled single party payer healthcare system is to destroy HSAs?

“Pushing for the provision was a company called Evolution Benefits, which has patented a system for the substantiation of health-care expenses. Evolution’s lobbyist, John McManus, was the former staff director of the Health Subcommittee under Republican Bill Thomas.”

Unfortunately, this is how the government works. It is influenced by vested interested other than the people it is suppose to represent. Republicans are furious at John McManus, a former Republican congressman’s staff director now a lobbyist.

“Liberals claim HSAs are insurance for the “healthy and wealthy,” but there’s little evidence this is true. “

There is no evidence that HSAs are only for the healthy and wealthy. It is a potential mechanism for the government to subsidize insurance for the poor and not so poor to promote patient responsibility and stimulate a substantial reduction in cost and increase incentive for citizens to improve healthcare habits. All congress has to do is pass a law saying everyone automatically will be insured using a community rating system and pre tax dollars.

“The high deductable insurance permits the insured to open an HSA and make an annual contribution up to $2,900 for an individual in 2008, which he can use to pay for ordinary health needs. Savings not spent in any given year can build up tax-free for medical expenses. HSAs also give consumers more reason to care about prices, bringing much-needed market discipline.”

A family contribution is over $5,000 in 2008.

“ In any case if people cheat on their HSAs, they are only cheating themselves.”

I wonder how many congresspersons really understand the problems in the healthcare system and what will motivate the people they represent?

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

  • Ryan Murphy • May 1, 2008

    Dr. Feld,
    You are absolutely wrong, with Health Savings Accounts the individual does keep the money if they don’t use it. HSA’s were designed with precisely this premise.
    See more information here: http://www.ustreas.gov/offices/public-affairs/hsa/

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Costs Soar For Mass. Health Care Law

April 20, 2008
inMedicine: Healthcare System, Universal Healthcare
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Stanley Feld M.D.,FACP,MACE

I hesitate to spend more time on the impending failure of the new Massachusetts healthcare law. However, the results of this experiment have consequences for the up coming presidential election. I have previous stated that Hillary Clinton healthcare plan is similar to the Massachusetts plan. The difference is Ms. Clinton would have the government plan competing with the insurance companies plan. It is destined to fail. The outcome will be the complete government take over of the healthcare system, an entitlement plan America can ill afford.

America can not afford the future value of our present entitlements. The debt will be compounded by adding the entire population to the healthcare insurance rolls. Politicians at all levels have ignored the debt problem of 100 trillion dollars.

Hopefully, someone will wake up and realize the present healthcare insurance system must change. .

“Two years after the state’s landmark health law was signed, the cracks are starting to show.”
“Costs are soaring and Massachusetts lawmakers are weighing a dollar-a-pack hike in the state’s cigarette tax to help pay for a larger-than-expected enrollment in the law’s subsidized insurance plans”.

I believe the cracks were present before the law was passed. Governor Romney was going to run for President and needed an innovative and heroic accomplishment. A bipartisan healthcare law with mandated universal coverage was politically driven and foolishly passed.

“But that hasn’t dampened enthusiasm at the Statehouse. Leaders there boast that in the two years since former Gov. Mitt Romney signed the law with a choreographed flourish at historic Faneuil Hall, the number of insured residents has soared by nearly 350,000.”

The lawmakers in Massachusetts are living in a dream world denying the problem of the program’s cost and the increased state spending deficit. The state is raising the healthcare premium, decreasing the healthcare coverage and increasing taxes. Nonetheless, the state can not afford the entitlement.

“Along the way the law has been scrutinized by other states, sparked the ire of critics on the right and left, and drawn the attention of presidential candidates.”

The blind are leading the blind. One state develops a healthcare system that does not work and all the others try to jump in with slight modifications of the same plan with its mistakes.

“It’s the very first question I get when I’m with other governors,” said Massachusetts Gov. Deval Patrick. “I don’t think anybody is prepared to say that what we have done here in Massachusetts is necessarily the formula for the rest of the country or for a national reform, but at least we are trying.”

Massachusetts has tried to maintain the private healthcare insurance system without reforming the private healthcare insurance system. It has to fail because the basic problem is the incentives for the private healthcare insurance industry have not been changed.

“The Massachusetts reform law remains the focal point for other states and the nation in trying to figure out if state-based reform is possible,” said Alan Weil, head of the Maine-based National Academy for State Health Policy. “It’s the biggest game in town.”

“One of the most radical fixtures of the law is the so-called “individual mandate” — the requirement that virtually everyone have health insurance or face tax penalties.”

Policy makers are always thinking in punitive terms toward patients and physicians rather than creating incentives for people. I believe people should get a tax credit for losing weight, controlling their chronic disease and not over utilizing the healthcare system. They should be rewarded for good health and not a penalized for not wanting to pay an inflated healthcare insurance premium.

“Anyone deemed able to afford health insurance but who refused to buy it during 2007 already faces the loss of a $219 personal tax exemption. New monthly fines that kicked in this year could total as much as $912 for individuals and $1,824 for couples by December.”

How can a government determine the reward? It could be difficult. It is easier for the government to collect a penalty for a person not having insurance. The reward should be contributed to the person is tax free retirement fund. Patients should own their healthcare dollar. They would be motivated to shop for the best price. The more they saved the more they would have added to their retirement fund. If someone had a chronic disease and controlled the disease with proper treatment they should receive a reward. The payer could afford to give that person a bonus because of the money saved on the treatment of complications of that disease. My plan would in effect shift responsibility and motivation to control cost to the patients. It would motivate patients to fight the War on Obesity.

“Michael Tanner, a senior fellow at the libertarian-leaning Cato Institute, said the law has been an unqualified failure. He also noted the vast majority of the newly insured are receiving subsidized care.”

“They said it would get us universal coverage and reduce costs and it’s done neither,” Tanner said. “

The biggest problem is the rising costs of healthcare. Neither the Massachusetts plan nor any of the other state plans have done anything to change the motivation of the drivers of the old healthcare system.

“The law — and its individual mandate — has become a key talking point in the presidential race.”

None of the presidential candidates have even spoken of the importance of patient responsibility. If the government set the appropriate rules it could eliminate all the administrative waste in the system and decrease the complications of chronic disease. We would then have an affordable healthcare system. This can be accomplished by motivating and not punishing the patients and physicians.

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

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Medicare Finds How Hard It Is to Save Money Part 2

April 16, 2008
inMedicare, Medicine: Healthcare System
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Stanley Feld M.D.,FACP,MACE

Whatever happens with this particular program, Medicare says it wants to keep experimenting. “We’re not giving up on this stuff,” said Mr. Kuhn, the Medicare deputy. “We definitely want these programs to work.”

Mr. Kuhn is referring to Medicare’s $350 million dollar disease management program that has failed. I hope Mr. Kuhn is realizing that the chronic disease management programs must be systems of care directed by physicians in order to succeed. The systems have to be patient centered with the physician being the captain of the care team.

“Medicare is doing exactly what we should want Medicare to do — to test different life forms of disease management and see what works best,” said Dr. Arnold Milstein, the chief physician for Mercer Health and Benefits, a consulting firm. But, he said, “This particular form of disease management is not looking promising.”

Dr. Milstein works for a health benefits consulting firm. He makes no judgment on the defects in the study.

“Medicare is already exploring other ideas, like the development of so-called “medical homes,where a doctor with a team of other professionals oversees a patient’s care. A few doctors’ groups involved in a separate Medicare experiment have reported some success in saving the government money by more actively managing their patients’ care.”

The concept of “medical homes” is a variant of “Focused Factories”. Focused Factories have been championed by Regina Herzlinger at least 15 years ago as a plan to modernize medical care.

I believe the concept of “medical homes” will work. It is physician directed system focused on becoming expert in the care of one disease with a team of physician extenders. The patient is at the center of the management team. I can not find the design of the study Medicare is doing. “Medical Homes” was developed by the American Association of Medical Colleges. (AAMC).

The problem with the American Association of Medical Colleges performing the study is most patients are taken care of by physicians that are not in an academic setting. The system must be tested utilizing practicing physicians in a real world setting.

Twelve years ago I present the concept of AACECare as a system of intensive diabetes self management. It is a system of care with the patient being at the center of the diabetes management team and the Clinical Endocrinologist being the captain of the team that includes nurses, dieticians, and psychologists.

Family Practitioners have to be taught how to develop this system of care in their practices. There are not enough Clinical Endocrinologists to care for all the diabetics in the country. The Family Practitioners see most of the diabetics. In order to have any impact on cost of care they have to be engaged in the system of care.

“Many of the companies involved in the failed program say the experiment was flawed in the way it was designed and that Medicare has failed to work with them to make the program a success.”

Now the eight companies are blaming Medicare for its own faulty design of the $350 million study. I could have told Medicare it would not have worked before it spent a dime.

“We haven’t proven anything,” said Dr. Jeffrey L. Kang, a former Medicare official who is now the chief medical officer for the insurer Cigna.”

“The companies say Medicare signed up patients who were much sicker than they had expected.”

All patients with Type 2 Diabetes Mellitus are very sick. They usually have the disease for eight years before it is discovered and are on the way to develpoing chronic complications.

“The companies also say Medicare failed to make good on its promise to give them timely information about the use of prescription drugs, for example, or lab results that would have allowed them to help direct the patients’ care.”

Medicare is not the medical doctor. Nurse help desks are not a direct extension of a physicians medical care team. They are not going to get patients attention as a physician office team can. The participating companies are now in a defensive mode.

“We overestimated the real desire expressed by the organization,” said Ben R. Leedle Jr., the chief executive of Healthways, who has been an outspoken critic of Medicare.
“Mr. Leedle says that Healthways will probably be able to demonstrate savings from at least some of its Medicare efforts, although the company also says it is projecting a loss on the experiment because it may have to pay back federal fees.”

On the other hand Medicare claims that it worked with the companies.

“For its part, Medicare said that it had worked extensively with the companies to address their concerns and that its final analysis would take into account how sick the patients initially were.”

The blame game has started. This exercise will last the better part of a year and become politicized. An experiment with chronic disease management designed and executed correctly will prove that it works and saves money. If it is done incorrectly it will not save money.

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

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