Stanley Feld M.D.,FACP, MACE

Physicians are smart people. If a physician’s integrity, livelihood and joy of practicing medicine are threatened he will eventually figure out what to do to make life more pleasant. Over the last 15 years physicians’ enjoyment of medical practice has been decreasing.

Some of the reasons are the increasing volume of paper work, decreasing reimbursement, increased delay in payment by healthcare insurance companies, increasing overhead and the pressure of escalating malpractice suits.

Medical practices have attempted to increase efficiency by installing Electronic Medical Records. Many attempts to install Electronic Medical Records have failed at great expense to the medical practice.

Recently Primary Care Internists have attempted to decrease their stress by limiting their practice. They are converting their medical practice to Concierge Care Medical practices. MDVIP has created a national network of 210 physicians so far who practice concierge medicine.

Several models of concierge care decrease the need for a physician to have a large panel of patients, decrease stress and paperwork while creating the ability for physicians to enjoy their medical practice once again.

Healthcare insurance companies are unhappy and are starting to become punitive to patients and physicians who use this innovative approach to medical practice.

“Doctors who charge an annual fee to patients in exchange for customized care including house calls are drawing the ire of some health insurance companies.”

“Cigna is also condemning the practice, in which physicians charge an annual retainer of $1,500 to $1,800 for patients who then receive more personal care. The claim is it is in violation of the physician’s contract with the insurer.”

UnitedHealthcare and Cigna think it is improper. The other insurance companies think it is fine as long as the patients know they will no be reimbursed for the physician retainer.

“Humana would not exclude doctors practicing this model of care from our networks,” said Dr. Mark Netoskie, medical director of Humana, Houston. “It is the consumer’s choice whether or not to pay for these additional services.”

“United Healthcare says the concierge model “directly conflicts” with the insurer’s contract with the doctors.”

I think United Healthcare feels threatened by physicians and patients taking control of their medical care needs. UnitedHealthcare will lose control over the healthcare system.

“Concierge medicine is a relatively small movement in the U.S.”

I believe the retainer charged is too high. However, if patients want to pay the fee it is their decision.

“Typically, physicians who charge an upfront annual fee reduce their caseloads, which allows them to make house calls and focus on wellness matters from weight management to depression. Some give patients their cell phone numbers.”

With a smaller panel of patients, physicians will have time to have a therapeutic physician patient relationship once more.

“Proponents say concierge care is a revolt against the modern health care system where diminishing Medicare and insurance payments have forced doctors to herd dozens of sick patients through their offices in five-minute increments every day.”

The concierge system permits the physician give personalized care without the reimbursement controls imposed by the insurance companies or Medicare. Patients enjoy the service because they have a personal physician who cares for them. The physicians enjoy the setup because it decreases the stress they experience in the present reimbursement system.

“Our national network of physicians remain in-network with most of the insurance companies in which they participate, and MDVIP maintains excellent relationships with a number of national and local insurers,” the CEO said.

I can foresee that if the movement catches on it will intensify the primary care physician shortage in America. I do not believe this movement is the answer to Repairing the Healthcare System.

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

Stanley Feld M.D.,FACP,MACE

The best way to beat competition is to not permit their entry into the marketplace. Businesses would do this if they could.

Medical specialists learn the nuances of disease processes and have the ability to discover early clues of disease. Surgical specialists understand their facility needs to increase their efficiency and effectiveness. They know what they need for effective post operative care. There is no reason that family practice groups can not have a couple of physicians become expert in a particular chronic disease.

“Focused factories’ are needed for medical and surgical care to avoid the complications of both acute and chronic disease. General Hospitals do not have the ability or desire to create focused factories. Focused factories could convert the care of profitable diseases with complications to unprofitable diseases without complications. The economics do not work for General Hospitals. General Hospitals try to prevent Specialty Clinics and Specialty Hospitals from being developed in their area.

“Hospitals are still the heart of the health care industry, consuming a third of the $2 trillion U.S. health care bill. Some are very good. But many are not, brimming with infectious bugs, systemic error and negative hospitality. And because the hospital industry does all it can to thwart competition, many communities are stuck with the hospitals they have.”

Hospitals hide behind the provisions of the Stark law to prevent the development of doctor owned efficient facilities for treating specific diseases (Focused Factories). There are many examples proving Focused Factories’ expertise used in treating particular diseases are more effective than a General Hospital. The most quoted examples are a hernia hospital in Canada and the Heart Hospital in Houston.

“Congressman Fortney “Pete” Stark (D-Calif.) passed legislation in two parts between 1989 and 1995, banning physicians from “self-referral,” meaning that a doctor can’t refer a patient to an physical therapy practice, lab or other facility that she owns part of because then she’ll benefit from the revenue associated with the services provided. Without Stark, the theory goes, unnecessary and expensive procedures would proliferate”

Congressman Stark thinks all physicians are crooks and will take advantage of patients. However, I think he is realizing the unintended consequences of his thoughts about physicians and his legislation. If patients own their healthcare dollar(ideal medicalsavingsaccount) they would be wary of anyone taking advantage of them.

“Recently Congressman Stark told a Forbes reporter that he regretted the bill because of the perverse effects and the army of lawyers creating an industry to take advantages of loopholes in the bill” .“The Stark laws have had a huge impact on how medical business models are structured.”

The laws have had an impact on discouraging physicians from creating Focused Factories. Focused factories are one stop clinics. They avoid fragmentation of and duplication of care. They take advantage of the concept of continuing quality improvement of care. They provide care in the most cost efficient way to remain competitive in the marketplace. They also permit the physicians to retain the value of his intellectual property rather than giving their intellectual property to a third party businessperson. .

“Yet in an interview today the Congressman lamented that he had ever made his legislative intrusion into medical practices. The unintended consequences of trying to legislate good behavior, as Sen. John McCain would tell you about campaign finance reform, is too many lawyers looking for loopholes.”

The loopholes have given an advantage to already large clinics and hospitals and do not provide incentives to smaller clinics to devise efficient models of medical care.

“Patients have a choice, but it’s not widespread yet. It’s called the specialty hospital, a center that focuses on the care of a particular body part such as the heart, spine or joints, or on a specific disease such as cancer. There are 200 specialty hospitals in the U.S. (out of 6,000 hospitals overall).”

The protection for large healthcare institutions is cracking with the realization that hospitals absorb two thirds of 2 trillion dollars spent on healthcare. Hospitals earn much of this money treating hospital acquired illnesses and complications of surgery. The government and the insurance industry is now making noise to stop paying for hospital acquired complications. In order to protect themselves, hospitals are starting to enter into joint ventures with their physicians.

” The specialty hospital often deliver services better, more safely and at lower cost. A recent University of Iowa study of tens of thousands of Medicare patients found that complication rates (bleeding, infections or death) are 40% lower for hip and knee surgeries at specialty hospitals than at big community hospitals. A 2006 study funded by Medicare found that patients of all types are four times as likely to die in a full-service hospital after orthopedic surgery as they would after the same procedure in a specialty hospital.”

If the correct rules are made by the government Mr. Stark’s fear of physician being crooks can be assuaged. The government must collect appropriate data to determine the need for car the quality of care, and the real cost of that care. So far no one has figured out how to collect correct data.

“Three of the nation’s top ten cardiac programs are at specialty hospitals in South Dakota, Indiana and Texas. Three of the top ten hospitals for total joint replacement surgery are specialty centers in Oklahoma, Ohio and Georgia.”

There is good reason for this. The physicians develop the facility they need and use it efficiently. Their motivation is quality care and a good cash return in a competitive marketplace.

“Specialization is a law of nature,” says Robert Tibbs, a neurosurgeon and part-owner of the Oklahoma Spine Hospital. “Spine surgery is an elective procedure. One of the biggest risks to any surgery is infections. Last year, out of 1,773 patients who slept over at the hospital, only 7 got an infection. That’s one-third to one-ninth the rate seen for similar patients at a big hospital.”

“At Oklahoma Spine anesthesiologists are practiced in putting patients under in the prone position for back surgery. At a big hospital few anesthesiologists would be skilled in that particular task. “You don’t take your Ford to the VW mechanic,” says Tibbs’ partner Stephen Cagle.”

If physicians are permitted to be innovative under appropriate rules without fear of penalty or disgrace they can accomplish amazing things. Our government should be looking at making rules that encourage innovation not abuse.

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

Stanley Feld M.D.,FACP,MACE

It is refreshing to know that the politicians in various states are becoming aware of the need to do something to help the uninsured. However, most are doing it the wrong way by maintaining a model of insurance that continues placing patients in a passive position dependent on a third party payer. The only thing that will Repair the Healthcare System is to place potential patients in a responsible position for their care and ownership of their healthcare dollar. The government should make appropriate rules and then get out of the way. They should then modify the rules so no stakeholder has an advantage over another.

New Jersey is the most recent state to try to adopt mandatory universal coverage even though the state is reeling from financial problems.

“ A bipartisan group of legislators unveiled a proposal on Monday that would require all residents to have health care coverage within three years. New Jersey is reeling from financial problems, and the country appears headed toward a recession, the plan would avoid adding to the budget and would instead try to redistribute federal and state dollars in a more efficient way.”

It would be a nice trick if they could do it in the present payment system. You will recall Massachusetts budget has increase 85% from the baseline in 1 year.

“About 1.4 million of New Jersey’s residents — or nearly 1 in 5 — do not have health insurance. To bridge that gap, State Senator Joseph F. Vitale, a Democrat from Middlesex County who is chairman of the health committee, recommended that the state focus first on enrolling more children in the existing NJ Family Care program for families who earn as much as 350 percent of the federal poverty level, or about $74,200 for a family of four.”

The fact that states are beginning to recognize that hard working people earning over the federally defined poverty level of $20,000 a year can not afford healthcare insurance and are not eligible for federal or state aid is encouraging. All should review Moises and Medicaid. Additionally President Bush has refused to expand federal coverage to families with income greater than the obsolete 1955 definition of poverty.

“Then, Mr. Vitale said, the state would focus on cutting costs while establishing a self-financed plan, run by the state, to provide individuals with health insurance at affordable rates on a sliding scale.”

Self finance healthcare insurance has been adopted by many large and small companies. These companies saw a way of avoiding ERISA regulations and decrease their healthcare costs for employees. County governments in Texas formed an association to provide self funded healthcare insurance to its county employees. Both private corporation self funded and the Texas Association of County government healthcare costs have continued to escalate. This model was destined to fail because they outsourced the administration of the coverage healthcare insurance coverage to the healthcare insurance industry. The price of the insurance the next year is based on their medical cost experience for the previous years. The control of those cost are still determined by the healthcare insurance industry. They have not created a system of coverage in which patients have incentives to reduce healthcare costs.

“The insurance would be required, not an option: Residents would need to prove they have health insurance, similar to the way drivers must obtain auto insurance.”

How can this be enforced?

“ It would be financed, Mr. Vitale said, by using small surpluses in NJ Family Care and Medicaid.”

This is the same mistake Massachusetts made. Medicaid reimbursement to providers is small. A large proportion of the indigent are not covered by Medicaid .The indigents’ income can not exceed the federal poverty level of $10,000 year to receive Medicaid coverage. I suspect most of the federal and state funded Medicaid dollar are spent on the states’ bureaucracy.

“An additional contribution would be made by revamping the costly and much-maligned system of Charity Care, under which the state reimburses hospitals for costs associated with caring for the poor, often in emergency rooms.”

We have only to look at what happened in Massachusetts. When the state was forced to exempt citizen from the insurance mandate the safety net hospital use increased. The hospitals’ cost escalated while they were receiving less from the state for charity care because the money was shifted to the mandated universal healthcare insurance system. I suspect the same thing would happen in New Jersey.

“New Jersey’s plan would be similar in that the responsibility for obtaining the insurance would rest with residents and would expand existing state and federal health insurance programs. But unlike Massachusetts, New Jersey would use a single plan administered by the state rather than requiring individuals to buy such a plan in the private market.”

This is exactly what should not be done. The state bureaucracy will not compete with itself to be innovative. It will simply reduce reimbursement to providers and decrease access to care. A competitive environment must be created with appropriate rules made by the government so the healthcare insurance industry competes for individual patients’ healthcare dollar. The result will be to create a cheaper and better healthcare insurance product.

“While most of our members provide health insurance, those that don’t have consistently said the cost is what is preventing them from purchasing insurance,” said Jim Leonard, a vice president with the New Jersey Chamber of Commerce. “This initiative will make health insurance more affordable.”

This is an empty statement. There is no evidence that creating another government run bureaucratic system will make health insurance more affordable. It might cost the citizen less in the short run but more in taxes or restrictions to access of services or both. The New Jersey plan will reduce the responsibility to employees and increasing the costs to businesses in state. The result could be to drive business out of the state.

“But some unions and consumer groups reacted tepidly, saying it could prompt employers to drop health insurance plans.”
“Of grave concern is the proposal’s underlying policy that seeks to shift the cost of coverage away from a shared responsibility between employers and employees,”

This is exactly what will happen. I think the State of New Jersey has to go back to the drawing board to avert a state economic disaster.

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

Stanley Feld M.D.,FACP,MACE

I predicted the bipartisan Romney universal healthcare plan for Massachusetts would fail. The reason is simple. The rules of the game were not changed for the insurance industry, the hospital systems and the physicians. The reason this important idea cannot work is because the program was superimposed on the rules of a broken healthcare system.

“The state’s new subsidized health insurance program will cost “significantly” more than the $869 million Governor Deval Patrick proposed in his 2009 budget just two months ago, the state’s top financial official said yesterday, after insurers were granted an increase of about 10 percent.”

As long as the insurance industry controls the pricing without price transparency the price is going to escalate. If hospitals and doctors are not competing in a price transparent market place, prices will escalate. As long as patients are not responsible for their healthcare dollar there will not be provider competition.

“Officials are scrambling for alternatives after the four healthcare insurance companies providing subsidized insurance under the state’s universal health care law offered bids for continued coverage that were far higher than expected.”

“To close the gap, the Patrick administration has asked insurers, hospitals, healthcare advocates, and business leaders to propose ways to cut costs and raise revenue.”

Notice the group missing from the discussions. Physicians are missing from the table. Physicians are the providers that control healthcare costs. Physicians should contribute to a discussion on how to control costs. Why has no one thought of asking physicians to contribute to the discussion? Perhaps physicians as the non contributing scapegoat is required?

“Leslie Kirwan, secretary of administration and finance, declined yesterday to discuss specifics of the proposals or the size of the budget gap, but said that without changes, the state doesn’t expect “to be able to live within” the proposed budget.”

You may recall that Leslie Kirwan, chairperson of the Commonwealth Health Insurance Connector, said 4 months ago’ “It’s too early to make any departure from the health reform plan,” “We will follow the trends and adjust, if needed.” http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2007/12/romneys-univers.html

“To partly offset the increased costs, the panel yesterday also voted to raise premiums by 10 percent for some of the 176,000 people enrolled in Commonwealth Care, and to increase copayments for many more. Starting July 1, the lowest premiums will range from $39 to $116 per month.”

If Massachusetts raises healthcare premiums and increases the healthcare copayment many more people will not be able to afford the mandated insurance. The state has already exempted 30,000 people from the mandate to date.

“The budget figure of $869 million already was significantly higher than projected by legislative architects of the plan because of the enrollment boom.”

The state budgeted $472 million in 2007 for the subsidized program, based on enrollment estimates made last winter. Commonwealth Care provides comprehensive insurance to people without access to work-based coverage who earn less than 300 percent of the federal poverty level, or about $31,000 for an individual. This represents an 84% increase and is not close to the insurance industry bids.

“In order to make up some of the difference Leslie Kirwan has shifted some of the money from the $448 million Health Care Safety Net Trust Fund, which pays for care at hospitals and health centers for uninsured patients.”

Officials at many so-called safety net hospitals said that as the new system – which requires all residents to buy health insurance – phases out payments for free care provided to the uninsured, hospitals are facing budget shortfalls and have been forced to cut back on investing in new equipment.

The Romney plan was suppose to be the new hope for a free market healthcare economy. Hillary Clinton’s healthcare plan is similar. However, I believe she knows her healthcare plan will fail. The nation would then be presented with her only alternative, a government run single party payer. In other words the politically incorrect term “socialized medicine” is the only remaining alternative.

No one has thought of giving patients responsibility for their care and ownership of their healthcare dollar. The ideal medical savings account can motivate people to be responsible for their health, their use of the healthcare system and be diligent in their use of their own healthcare dollar.

Stanley Feld M.D.,FACP,MACE

Shortly before President Bush’s state of the union address the AMA President Ronald M Davis M.D. published the AMA view of the state of health care.

The AMA is for universal healthcare for all.

“Every American deserves health care coverage, and we need to build on the strengths of our system to make that happen,” said AMA President Ronald M. Davis, MD “As the nation’s largest physician organization, the AMA is leading the fight to get all Americans covered through our Voice for the Uninsured campaign.” www.VoiceForTheUninsured.org

The AMA’s call for action needs to be implemented with a system that includes patients responsibility for their care, and ownership of their healthcare dollar. The healthcare model of a third party payer is an anachronism. It has proven to be inefficient, ineffective and abused by all the stakeholders. Patients are the only ones who can set up a competitive environment for other stakeholders. If the third parties (government or healthcare insurance companies) created incentives for people to take care of themselves to avoid the complications of chronic disease the cost of healthcare would fall dramatically.

Implicit in the AMA’s recommendation is the creation of government driven public service campaigns to discourage obesity, smoking, pollution, and other environmental hazards to health.

“A leading cause of rising health care costs is treatment for patients with chronic conditions such as diabetes and hypertension. “We need to make an investment in helping patients quit smoking, avoid alcohol abuse, improve diet and increase exercise levels, as these lifestyle changes will not only lead to healthier lives, but lower health care costs,” advised Dr. Davis. “National rates of obesity and diabetes have doubled over the past 25 years, if we can get folks off the sofa and away from the pantry we can reduce these growth rates.”

In the past I have outlined suggestions to decrease the complications of chronic disease. The key is to educate the patients so they are the “Professor of Their Disease”. In my view the government is trying to reduce costs by penalizing the wrong stakeholders. Physicians cannot afford to care for Medicare patients’ because overhead is rising and reimbursement is falling. The result will be seniors on Medicare will not have access to care.

“Congress made a promise to America’s seniors to provide them with health insurance through Medicare, but that promise means little if seniors can’t get in and see the doctor,” said Dr. Davis. An AMA survey found that 60 percent of physicians would be forced to limit the number of new Medicare patients they can treat if the 10 percent cut occurs this July. “Medicare’s physician foundation is at terrible risk because of a short-sighted payment plan that will cut physician payments 15 percent over the next year and a half, beginning this July.”

At the present manpower levels America is facing a physician shortage. This physician shortage will become worse with Medicare’s reimbursement cuts. As practice cost increase it is impossible for physicians to afford investments in technology to create efficiencies in practice.

“Before the cut begins in July, Congress must take action to replace 18 months of cuts with payment increases that reflect medical practice costs. This will give Congress time to begin creating a new Medicare physician payment system that is based on medical practice costs.”

The AMA has outlined four broad strategies to achieve greater value for healthcare spending.

“The strategies are; reduce the burden of preventable disease; make health care delivery more efficient; reduce non-clinical health system costs that do not contribute to patient care; and promote value-based decision-making at all levels.”

The healthcare system needs governmental support to promote these strategies as well as the introduction of more innovative strategies. Andy Grove, ex CEO of Intel spoke of some innovative ideas that can be achieved with available technologies.

“The cost of caring for the elderly is huge and will only grow as our population ages. Of the $440,000 the average American spends on health care in his lifetime, $280,000 will be spent after age 65.”

Some say the longer people live the more they cost the healthcare system. This is a glib remark. The real issue is the better a person’s quality of life, the less ill those people will be, and the less they will cost the healthcare system.

I believe this is an underestimate of spending after age 65. Most people would like to stay in their own homes and be independent as long as they can. Present day technology can help make that happen.
Probably 50% of that post-65 outlay goes to assisted-living facilities and nursing homes. So it stands to reason that if there were a way to keep elderly patients in their own homes longer – without degrading quality of care – we’d have a cheaper and better system.

“I’m talking everyday, low-cost technology – the sensors, microchips, small radios you’d find in today’s PCs, in cell phones, and in Bluetooth earpieces. It’s not too difficult to use this stuff as monitoring tools. Not to spy, but to detect trouble. For example, did the patient go outside to get the newspaper or did she wander away? Has the patient taken his meds?”

Would seniors be opposed to this surveillance? I doubt it. Can these tools be used as teaching tools for a motivated population to maintain health and avoid the complications of chronic diseases and subsequent assisted living? Does Medicare, the provider for most seniors have any interest in supporting initiatives such as this? We have not seen any sign of it. The initial reaction is these maneuvers open the door to more bureaucracy and subsequent abuse. I do not think so. If patients were in charge of their healthcare dollar and were responsible for their healthcare expenditures the system would be efficient.

“Can we afford all this? Let’s do the math. In my estimation, the ER plan can be implemented for $20 billion per year, paid for with the 1% surtax I suggest. As for the elder-care plan, the savings achieved by keeping just 10% of the aging population in their homes can amount to a savings of $30 billion a year.”

America must afford innovations that can save $30 billion dollars or more a year. The more people are kept out of nursing homes the more money would be saved. It would also force the nursing homes charges to decrease.

The Presidential candidates have not introduced this or any obvious innovative solutions to Repair The Healthcare System.

Stanley Feld M.D.,FACP,MACE

“Critical” What We Can Do About The Healthcare Crisis is a book by Tom Daschle, Scott Greenberg and Jeanne M. Lambrew. It provides a more detailed outline of the Democratic Party’s approach to overhauling American health care than either Mr. Obama or Hillary Clinton has offered on the campaign trail.

“The most important proposal in “Critical” is the creation of a “Federal Health Board,” explicitly modeled on the Federal Reserve Board. Its duties would include “recommending coverage of those drugs and procedures backed by solid evidence. It would exert influence by ranking services and therapies by their health and cost impacts.”

I knew this was the way the Democratic Party and Hillary Clinton are thinking. The thinking is dead wrong in my opinion. Increasing regulation and price control would lead to a more dysfunctional healthcare system.

“The Federal Health Board duties would include “recommending coverage of those drugs and procedures backed by solid evidence. It would exert influence by ranking services and therapies by their health and cost impacts.”

Previous rankings have had errors. I suspect these measurements will have errors also. It sounds as if the government is going to dictate the kind of care patients will have access to. It will not be the care the patients’ physicians think is best. Generic medication will replace newer medications. Innovation and inventiveness will be suppressed. Some medical devices will not be available unless the board says it is cost effective.

This is essentially price control and controlling access to care. Past experience has shown these maneuvers do not work. The creation of incentives generates innovation.

The principles of Mechanism Design would create a system of rules fair to all stakeholders with patients being the most advantaged.

“What about the uninsured? Mr. Daschle wants to open to all Americans the Federal Employee Health Benefits Plan — a menu of private-insurance options now accessible only to government workers. He would offer, in addition to the current plans, a government-run program, presumably similar to Medicare, although he provides few details. There would also be some form of means-tested premium support (or tax benefits) for Americans who couldn’t afford one of the available plans.”

The good thing is access to care will be available to all regardless of preexisting illness. The bad thing is it will not create a competitive market place healthcare system so badly needs. It will create another level of bureaucratic complexity.

“Most of Medicare’s costs are borne by doctors and hospitals that must meet the requirements of a host of regulations; if they do not, they may face federal investigations and lawsuits for noncompliance.”

Tom Daschle’s (the Democratic) vision creates a punitive atmosphere for stakeholders that inhibit innovation and usually leads to higher costs.

“Medicare has employeed a mere handful of mostly generalist clinicians reviewing its coverage and payment decisions.”

There is no way a handful of generalist clinicians are able to understand the nuances of complicated disease processes and enforce the new bureaucratic rules. The only way reform will be successful is if the patients force competition for their healthcare needs.

“Mr. Daschle federal health-board proposal is not exactly a new idea. Mr. Daschle himself proposed it as part of the failed American Health Security Act of 1993.”

This was translated into (Hillary Care) a program that assured the government as a single party payer dictated access to care and choice of provider. It failed because public opinion opposed it before it got started.

“Tom Daschle admits that the board is based on the National Institute for Clinical Excellence in Britain and the Federal Joint Committee in Germany. Both are charged with managing the public’s access to higher-cost drugs, medical devices and procedures. But both are growing increasingly unpopular in their home countries — precisely because they’ve become a triumph of cost-containment over patient access and choice.”

Americans had the same experience with HMOs. They failed because of public disenchantment with the system that eliminated choice and access to care. Public opinion turned against HMOs.

“Mr. Daschle proposes a dozen or so “experts” who would be “chosen based on their stature, knowledge, and experience, ensuring that the decisions they make have credibility across the health-care spectrum.”

I have outlined a system that puts the patients in charge. If Americans are given the appropriate incentives and the correct education they can make wise healthcare choices.

The trick is to not let the politicians sneak a defective system into law in the middle of the night.

I hope if Mr. Obama becomes President he does not fall for the Democratic Party’s folly. So far he has camouflaged his intentions.

Stanley Feld M.D.,FACP,MACE

Ninety percent of the Medicare dollars are spent on the complications of chronic disease. Obesity is the cause of the onset of many chronic diseases such as Type 2 diabetes mellitus, and heart disease.
I have said there is a solution to the predicted $34 trillion dollar healthcare deficit. It is the prevention of the onset of chronic diseases. The government, corporate policies, patients, and physicians do little to prevent to onset of chronic disease or its complications.

In pursuit of the dollar Major League Baseball has outdone McDonald’s as an irresponsible corporate citizen. You will recall the relationship of McDonald’s super sized campaign and its relationship to elevating cholesterol and heart disease.

The public outcry caused McDonalds to retreat from its super sized campaign.

“Baseball and gluttony, two of America’s favorite pastimes, are merging in a controversial trend taking hold at Major League Baseball stadiums across the nation: all-you-can-eat seats.”

These cheap seats were difficult to sell. Now these seats are more expensive. They are advertised as party time with all you can eat food and drink. When people go to a ballgame they want to have fun. The message is fun equals baseball, hot dogs, nachos and soda pop. In a world where the” media is the message”

Major League Baseball is playing on the emotional message of fun while promoting the Obesity Epidemic.

“Fans in these diet-busting sections, for a fixed price usually ranging from $30 to $55, are able to gorge on as many hot dogs, nachos, peanuts and soft drinks as they can stomach. Some teams charge extra for beer, desserts and candy.”

I predict all thirty major league teams will have all-you- can–eat-seats in 2009. Where are the Presidential candidates on the issue of the obesity epidemic? Can the government do anything to protect us? Can people do anything to protect themselves? Can major league baseball do anything to stop this madness?

“At least 13 of the 30 major league teams are offering all-you-can-eat seats for all or part of the 2008 season, up from six last year. Some of the teams that offered them last season are expanding their all-you-can-eat sections this season.”

I have been saying for the past 2 years that citizens have to be responsible for themselves. The corporate interest is to make as much money as it can.

No one is going to step forward and protect us from ourselves unless public outrage occurs and we have a culture change toward overeating. “People Power’ expresses itself through public outcry.

“All-you-can-eat seats, usually in distant bleacher or upper-deck sections, are allowing teams to squeeze revenue out of parts of ballparks that used to sit empty game after game, team officials say.”

It is clearly all about money. All you can eat seats is an erroneous policy decision to increase revenue. The baseball executives always have lame excuses for bad policies.

“We’re getting rid of (tickets) and making the public happy” by offering them a way to save money, says Andrew Silverman, executive vice president of sales and marketing for the Texas Rangers. The Rangers saw sales of 616 seats in their stadium’s left-field corner take off last year after the seats were designated as all-you-can-eat areas.”

The public relations ploy is to put the blame on the fans and not their baseball franchise.

Mark Tilson, vice president of sales and marketing for the Kansas City Royals, says it’s up to fans to eat responsibly.
“We’re not making anybody purchase these seats, or eat seven hot dogs,” says Tilson.

Mark Tilson is correct. This is a strong reason for Americans to be responsible to themselves. If they owned their healthcare dollar they might not choose to abuse themselves especially if there was a financial incentive to take good care of their body. If they abuse their body they should be responsible financially as well as emotionally.

“What attracted me was eating as much as I could,” says Toney Fernandez, 20, of Harbor City, Calif., but “then I got hooked by the whole atmosphere:

The Dodgers began offering 3,300 right-field bleacher seats with unlimited Dodger Dogs, nachos, peanuts, popcorn, soft drinks and water. The section averaged 2,200 fans a game last season — and sold out for one-third of the team’s home games.

“Before the unlimited food and drink, such seats sold for $6 or $8, if they sold at all. Now, they go for $35 in advance and $40 for game-day tickets.”

The teams are doing it for money and not the health of their fans. The fans have eating contests.

” At the Braves’ Turner Field, some fans had hot dog eating contests, says Derek Schiller, executive vice president of sales and marketing.”

“The Royals tout their section with the slogan “Eat, drink and be merry!” At one game, a teenage boy scarfed down a dozen hot dogs, nachos and a couple of bags of peanuts.”

Ron Ranieri, general manager of concessionaire Aramark at Atlanta’s Turner Field, calculates that a typical all-you-can-eat customer downed: 3.35 hot dogs; one 20-ounce soda; one 7.9-ounce bag of peanuts; one 3-ounce order of nachos and 32 ounces of popcorn.

This translates to a caloric intake of about 4500 calories or about three times the recommended daily food intake. What is worse is that it also represents about 4 times the recommended saturated fat intake. This excessive intake increases the risk for heart disease, diabetes, stroke, and cancer and in turn the cost of healthcare. The question is who should be responsible for this excessive food intake. Should it be the government, society or the patient? In a free country it should be the patient’s responsibly for the excessive intake.

Should the government pay for care as a result of this abuse? Should the patient be responsible for the abuse? Should a system be created so that the patient acts responsibly and not abuse to his body? My answer is yes. The system be be able to accomplish this goal is not universal healthcare coverage with a single party payer.