Stanley Feld M.D.,FACP,MACE

After posting today’s blog on administrative waste I came across this article in the Buffalo News. You will also recall that much power to regulate abuse in the system lies with the State Boards of Insurance, Hospitals, and Physicians.

Today, Buffalo News published actions by the New York State Insurance Board fining 21 companies $310,000 for withholding claims payment and violating New York’s Prompt Pay Law. The Prompt Pay Law requires insurance companies to pay uncontested claims within 45 day or face fines.

“Health insurers in New York were fined $310,000 over a six-month period for failing to pay claims on time, according to the state insurance department.”

One might think $310,000 is an insignificant amount money. However, I suspect it represents just a glimpse of the abuse payments for claims not made by the insurance companies. It is often to costly to refer these abuses to the Insurance board. The publicity might motivate physicians and hospitals to report their unpaid claims

We have to understand delays in payment simply add to the administrative costs of healthcare system. These unnecessary administrative costs add no medical care value to the healthcare system. One can easily visual these abuses occurring daily and adding to the inefficiency of the system throughout the system. The Medical Saving Account system of instant adjudication of claims would eliminate all this waste and permit decreasing cost of insurance premiums.

Stanley Feld M.D.,FACP,MACE

In my view none of the published estimates of administrative costs to the healthcare system are correct. The latest estimate of administrative costs to the healthcare system was $150 billion dollars. I bet this estimate is only half of the administrative costs. The estimate represents only the costs the insurance companies add on to their insurance premium calculation. It does not represent the cost to the physicians to process each claim.

My estimate for the administrative cost to the physician for each office visit is $35- $40. The physicians’ administrative costs include the cost of physicians’ time to complete the paper work for each encounter as well as the cost of back office personnel for processing each claim to completion. Many claims are adjusted by the insurance company and disputed by the providers. The claims are then resubmitted for another round of non medical value added costs. The total cost to the system could represent $300 billion dollars. Three hundred billion dollar savings can go a long way to reducing insurance premiums to manageable and affordable levels. I could also go a long way toward increasing accessibility to care.

A few weeks ago I wrote about economists declaring that we can afford the cost of our excellent healthcare system. I blasted the concept as ridiculous. The economists ignore the inefficiencies and not medical value added cost to the system.

This week an article appeared titled “Running on Empty: Healthcare As the Engine of the Economy by Brian Kleeper and Alian Enthoven.
“Healthcare insiders know that the industry’s rosy prospects can continue only if its funding remains stable. Most also acknowledge that the dollars are not likely to flow as they have in the past.
The reality into the foreseeable future is that healthcare–at least beyond a narrow definition of “basic care”–will remain a voluntary buy. In fact, there’s every indication that group purchasers are quietly abandoning the market. A wealth of recent data shows that healthcare cost growth is pricing corporate and governmental purchasers out of the market for coverage.
Reports from the Kaiser Family Foundation and the Department of Commerce’s Bureau of Economic Analysis show that, between 1999 and 2004, premiums–the point where costs converge from throughout the healthcare continuum–grew 5.5 times general inflation, 4.0 times workers earnings and 2.3 times the growth of business income.”

Please recall that much of the increase also results from a faulty DRG system. The present system reimburses on hospital charges and not hospital costs. The DRG system contributes to the engine of the inflationary medical costs.

“The numbers are spectacular. And purchasers are responding. In September 2006, another Kaiser report on employer health benefits showed that, between 2001 and 2006, the percentage of employers offering coverage plummeted from 68 percent to 61 percent, a 10.3 percent drop over five years or a 2.1 percent annual erosion rate. During the same period, the percentage of employees with coverage dropped from 65 percent to 59 percent. Data from other sources show that certain workers–those in the private sector, service workers, retail employees–were particularly vulnerable to losing coverage.
Meanwhile, Florida’s Office of Insurance Regulation released data showing that, between 1996 and 2004, 132,000 small employers (with 50 or fewer employees) stopped offering health coverage. This represents a 53 percent drop, while enrollees in small group plans fell by 760,000 individuals (42 percent, or 5.25 percent annually). The state’s population grew by three million during this period.”

As fewer and fewer people have health insurance coverage there is less and less premium dollars in the system. At present we have 46.7 million uninsured in America, 80% of whom would buy affordable insurance if they could.

Jon Lowder’s blog entry of November 10, 2006 nailed the problem. There are precipitous enrollment drops and an increasing uninsured population.

“These precipitous enrollment drops make sense, particularly when you compare the scale of healthcare cost to earnings. The actuarial firm Milliman calculated that the total coverage costs for a family of four averaged $12,214 in 2005. But one-quarter of the nation’s workers made less than $18,800, and one-third of its families made less than $35,000. How can mainstream Americans stay in a game that’s stacked like this?”

Worse, healthcare is 1/7th of the economy and 1/11th of its job market. If this sector develops a large demand-resource mismatch and becomes financially unstable, the disruptions could cascade to and destabilize others sectors, threatening the national economic security.

Many people who follow the healthcare crisis know all of this. Unfortunately the public is not aware of much of it. We only realize that health insurance cost more and more. We have discussed much of this previously.
However, no leader has the courage to step forward and do something about it. I have emphasized much of the leadership can be exerted at the state level by state boards that license the insurance industry,hospitals and physicians. No one has organized the people to protest. The excuse is that the healthcare system can not be fixed. It is impossible to control physicians. I believe all these excuses are smoke to cloud the solution. The facilitator stakeholders are simply holding on to what they falsely perceive is their vested interest.

“A theory of limits applies here. In a voluntary market, healthcare purchasers–employers or taxpayers–will tolerate only so much cost growth. Then they’ll recede. It is preposterous to believe the well won’t run dry.”

All of these pricing mismatches and excess non medical value added costs can be eliminated by permitting the patient to be in control of their healthcare dollar and selling pure insurance that is fairly priced. The ideal Medical Saving Accounts system represent pure insurance in the form of high deducible health insurance and motivation for the patient to become an informed consumer.

The cost of processing claim could be eliminated completely. The service claims could be adjudicated instantly with a credit card. Thousands of diverse businesses adjudicate claims on purchases instantly daily at a low cost. The use of credit cards to pay for Medical Savings Accounts could provide an instant savings of 150 billion dollars to costs in the healthcare system. The losers will be the non competitive insurance company. The winner will be the bright flexible company that puts the system in place.

Stanley Feld M.D.,FACP,MACE

United Healthcare and HCA settled their contract negotiations for the 850,000 patients in the Denver area. The contract is a long term contract lasting until 2011. Additionally, HCA reached a long contract settlement with United Healthcare throughout the country. None of the terms of the contract were transparent nor can we expect a reduction in insurance costs.

We have discussed the outrageous salaries of the United Healthcare Company’s executives under previous contracts as they continue to raise insurance rates. We have also discussed the leveraged buyout by KKR and partners.

United Healthcare decided, rather than playing a role in changing the paradigm of the structure of healthcare insurance by promoting price transparency and Medical Savings Accounts, it would be prudent for them to remained in total control of the potential patients’ medical care and their healthcare dollars.

The Denver Post reported “Some United members sought care at hospitals outside the HCA-HealthOne network, leaving hospital beds unfilled.”

The unaddressed point was how many hospital beds were left unfilled? How much money was lost by HCA in the last few months of the dispute? The contract dispute permitted patients to choose because their own money is involved.

“United had faced the possibility of losing corporate and individual policy-holders to other insurers during the open-enrollment season.”

United Healthcare rather being innovative, probably concluded that it was “too dangerous” and costly to lead the way toward insurance reform.

“More and more insurers and hospitals are looking to sign longer-term deals, given that the insurance premiums they can charge are increasing at relatively modest, single-digit rates.”

I think hospitals and insurers decided that the enemy to their outrageous profits is the major stakeholders, the patients and the physicians and not each other. I suspect United will offer employers long term contracts in order to keep patients in the ossified healthcare system that has lead to uncontrolled costs, excessive waste, and the vast number of uninsured.

“It’s a case of two very large health- care companies that truly needed each other,” said Paul Newsome, a financial analyst with A.G. Edwards in St. Louis. “It works both ways.”

“United had claimed that HCA-HealthOne demanded a 35 percent reimbursement rate increase over four years in Colorado. HCA-HealthOne countered that its requested increase would translate into a 1.6 percent premium increase per year for employers and individuals.”

Neither side disclosed terms of the local or national deal.

Leadership for change is what is needed now! It is going to take a bright innovative company with the knowledge and capability to use information technology techniques for the benefit of the patients and the physicians to create a paradigm shift. We must remember without patients or physicians there is no need for a healthcare industry.

Stanley Feld M.D.,FACE,MACE

Let us assume that everyone wants the best Healthcare System possible. I have proposed an effective Medical Savings Account system as the backbone to repairing the healthcare system. Many stakeholders would disagree. Their vested interest would be disrupted by a change in the system. However, the system has to change to a self repairing system because the existing system is so dysfunctional. It hardly works anymore for the most important stakeholder the patient.

The difference between the MSA and the present managed care fee for service model is both philosophical and technical. The philosophy difference deals with respect for the consumers (patients) ability to make wise medical choices. The technical component is the ineffective manner information technology is used presently and should be used in the future.

Presently, to control the costs in the system we pass laws and rules and regulation to limit usage and abuse of the system. In turn, we need larger bureaucratic institutions to administer the new rules and regulations. The result is a tremendous waste and an increase in utilization of non value added resources, resulting in increased cost. The increase in cost leads to an increase in healthcare rationing. The resulting fall out is the increasing number of uninsured patients. The result is a further increase in healthcare costs to society. Rather than controlling the perverse incentives the system creates, the increase bureaucracy stimulates more perverse incentives. Individual self interests continue to spend other peoples’ money, while bureaucratic institutions like the government and the insurance industry continue to make more rules and regulations to block the individuals’ self interests.

The Medical Saving Accounts system creates a system that provides incentive for individuals to become prudent purchaser of health care services in a price transparent environment. Individuals’ having control over their own health care dollar will be prudent and only purchase services that are needed and worth the price. They are spending their own money, or money awarded to them, and not other peoples’ money. The right amount to spend is their choice as long as the prices reflect the real costs of medical services. The government, the employers and the insurance industry would need to negotiate charges from their real costs in a transparent environment.

The result of negotiating charges on the basis of costs creates a need for innovative thinking by insurance companies, hospitals and physicians. The competitive medical market place of consumer driven healthcare forces the hospitals, insurance companies and physicians to realize it is in their vested interest to lower price, improve quality of care and improve communications with the patient in order to survive.

If we develop this system, the healthcare system would become self repairing and cost efficient.

Stanley Feld M.D., FACP, MACE

Medical Savings Accounts for our discussion are tax free trust accounts that are funded by the employer, the self-employed, and the government for the employee, or the Medicare or Medicaid beneficiary. The Medical Insurance provided by the employer, the self employed, or the Medicare or Medicaid beneficiary in addition to the MSA trust account is a high deductible insurance plan. The rating on the high deductible insurance should be community rating without exclusions for preexisting illness.

The deductible is $6,000. The MSA contribution will be $6,000. If the patient does not spend the trust accounts money in the current year that money accumulates tax free until retirement. In the case of Medicare the money accumulates tax free until used at the beneficiaries discretion or is deposited in the beneficiaries’ estate. At that time the rules for traditional IRA’s apply.

It is mandatory to have insurance and the premiums will be subsidized by the government for persons that qualify. Price transparency by the insurance industry, hospitals, and physicians is also mandatory. It is the responsibility of all parties to aid the patient to become an educated consumer. If they want to purchase an unnecessary or inflated medical care product it is their decision and not the insurance industry or government’s decision. The patient pays the inflated price and not the insurance industry and the government.

This is the basic formula for the Medical Savings Accounts. It is important for this system of insurance not be contaminated by modifications made by stakeholders in order to benefit their vested interest. The formula creates a system of insurance that compels the patient to be an informed consumer. It also compels the stakeholders to be competitive for the patients’ healthcare dollar.

The result will be lower prices and increased quality. The advantages to stakeholders are obvious. It would foster individual ownership of the healthcare dollar with individual responsibility for the healthcare dollar. The result would be lowering the cost of health insurance with a high deductible. People would no longer face premium increases resulting from wasteful medical care decisions made by others. This is the famous restaurant effect discussed earlier. It would also lower the administrative costs of adjudicating bills. The charges would be adjudicated at the point of service serving to lowering the cost of insurance further.

Patients would have a vested self interest to avoid unnecessary costs because the result would be additional savings for the patient in their Medical Savings Trust Account. Also, MSAs would eliminate the barriers for the purchase of insurance by the temporarily unemployed. Patients would create a competitive medical marketplace with their individual purchasing power. We will see this happening right now with the Wal-Mart $4 generic drug policy.

The high deductible insurance would be true insurance and not the “managed cost insurance” we have presently. Managed cost insurance simply angers every stakeholder in the system. Patients would now have incentive to think about as well as learn about the risk of certain lifestyles and the need for lifestyle changes to prevent the complications of chronic diseases. The patient by avoiding the complications of chronic diseases with be earning money in their own Medical Savings Trust Account that would continue to grow tax free until retirement.

All of these incentives are free market incentives. None of the incentives force the patient to have certain behaviors. It is in their vested economic interest to make appropriate lifestyle changes and wise medical care decisions.

With pure Medical Savings Accounts the Healthcare System will be in a position to self repair.

Stanley Feld M.D.,FACP,MACE

I received a comment from Karen Madrono. You can read her complete comment in the “War on Obesity” post.

The point Karen makes below is critical to the understanding of how change must occur.

“Battling against obesity seems easy but I’m telling you, it takes courage and faith in yourself.
One must be conscious about every food that they put in their mouth. It could either make the person healthy or sick. It’s not the teacher’s obligation, though they should teach children the right food to eat but it is still up to person himself not to the doctor.

Our health is our most precious possession. We inherit our genetic predispositions. For example, twenty percent or more of us have a disposition for Type 2 Diabetes Mellitus. However, the Diabetes declares itself in only 5% of the Caucasian population. In America the percentage of Caucasians with Type 2 Diabetes Mellitus is rising. The incidence is much higher in Hispanics and Blacks. In fact, Clinical Type 2 Diabetes Mellitus is now appearing at a younger and younger age as the epidemic of obesity in America is spreading. Our Super-sized Fast Food portions are contributing to the epidemic.

The rising incidence of Type 2 Diabetes Mellitus is directly related to the increase in Obesity in this country. Obesity represents an environmental abuse to our genetically predisposition. Increasing weight results in insulin resistance. Insulin resistance leads to increasing blood sugars. Type 2 Diabetes Mellitus can be thought of as a disease that results from our inability to overcome the increasing insulin resistance resulting from increasing weight gain. The insulin resistance results in hypertension and a rising cholesterol. The end result is Coronary Artery Disease. The combination of diseases is currently called Metabolic Syndrome. Metabolic Syndrome is the major cause of heart disease in this country. It takes 8 years from the time of onset of Metabolic Syndrome to the time of discovery of Type 2 Diabetes Mellitus. Many times the diagnosis of Diabetes Mellitus is made at the time the patient has a heart attack.
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The entire Metabolic Syndrome can be reversed by weight loss. Weight loss can be achieved by decreasing food intake and increasing caloric output. Weight gain is the environmental abuse to our genetic predisposition. Weight loss is difficult to accomplish. It requires a consistent and long lasting change in life style activities. Many “tricks” have been tried. None of the “tricks” seem to work long term. Industries have been built around these “tricks” because we are a nation of instant gratification.

In the long term, it remains the patient’s responsibility to fix the problem by changing his lifestyle. Systems of Care can help the patient develop a lifestyle change. Government campaigns could provide educational tools. However, it is up to us to be responsible for ourselves.
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Karen has made the point abundantly clear. Thank you Karen.

Stanley Feld M.D.,FACP,MACE

Our little neighborhood in Far North Dallas Texas has spoken!! We have spoken through the use of “People Power”. Far North Dallas is divided into many neighborhoods. Each neighborhood has a Neighborhood Association. All the members in my neighborhood are connected via e-mail. The definition of community in America is being changed by the internet. We are informed about vandalism, robberies, gathering, elected official meetings as well as births and deaths by our neighborhood association’s V.P. of Communications.

Our neighborhood Communictions V.P. is doing a terrific job. She informs and educates us. A few weeks ago the Dallas Area Rapid Transit Authority had a public meeting. Dallas has struggled to have an effective Rapid Transit System. DART has been minimally to moderately effective.
Recently, the DART staff made a decision to build a ground level line using diesel trains on the defunct Cotton Belt tracks. The decision was opposed by neighborhood representatives and the Dallas City Counsel. The Dallas City Council proposed an alternate plan. The plan was a less disruptive below surface electric train line. The Dallas City Council decision is the first unanimous decision I can recall in the 38 years we have lived in the city. The long unused Cotton Belt line touches the back yards of some of the houses in the Far North Dallas area. Over 1000 people from the North Dallas neighborhoods came to a Town Meeting to protest the DART staff’s unilateral decision. The DART staff was overwhelmed by the turn out and our protest.

Below is the e-mail we received today. Cecelia and I have rescheduled our return to Dallas to attend the meeting. We want to be heard. I have a feeling the DART board of trustees will change their plan for the train line. We support a below ground level electric car rail system proposed by the Dallas City Council.

Our local virtual community is a perfect example of “People Power”. Politicians are supposed represent our wishes. They will represent our wished if we know what we want and demand our wishes be expressed. This process requires awareness on the part of the neighbors and education on the part of the leaders. Multiple North Dallas neighborhoods connected by the internet allowed our community to understand the issue, and demand that our interest be represented.

The mobilization of common goals is the future of freedom in America. Networked communities will supersede hierarchical bureaucracy as the representative form of policy making in the future. We are expressing this desire for freedom and choice in our neighborhood.

The healthcare system can be fixed by this type of virtual community. A networked community armed with a logical plan to meet the needs of the people is needed to repair the broken healthcare system.
Effective uncontaminated Medical Savings Accounts is a system that is logical and promotes freedom to manage our own money and permits choice. Once communities of people understand the Medical savings Account system “People Power” by the uses of RSS, and email can demand and affect repair of the healthcare system rapidly.

I believe it is as simple as the methodology of change expressed by our virtual community leader below. We the people have to chance the healthcare system with “People Power”. We can not leave it to the politicians or the next guy any more. Enough is enough!

Below is the recent email to all members of our Virtual North Dallas Community

Thank You! …
To everyone who attended the September 25th public meeting in Addison to protest DART’s plan for diesel trains on the Cotton Belt. Approximately 900-1200 of us burst the seams of Addison Center.
There’s nothing new about citizens protesting changes to their neighborhoods, but the protest we staged in Addison last month has created quite a stir! The feedback we’re getting is that DART and the cities involved have never seen anything like our demonstration of opposition to the DART plan. Our collective efforts are having a positive effect, but OUR WORK IS NOT YET DONE – We cannot claim victory until DART votes to abandon its plan for diesel trains on the Cotton Belt and adopt the Natinsky plan for more sensible light rail instead. THE VOTE TAKES PLACE OCTOBER 24TH.
Ron Natinsky, District 12 Councilman, and Linda Koop, District 11 Council-woman, have the unanimous support of the Dallas City Council and are working hard in our favor. As citizens, we must support their official efforts by attending the DART Board meeting on October 24th, when the Dart Board votes for the “2030 Plan”. We must fill up the entire meeting room and confront each and every DART Board member, face-to-face, as they cast their votes.
There will be an opportunity for citizens to speak directly to the DART Board members. You may make the same eloquent remarks as you did on September 25. Although your previous speeches are on the public record, they may not have been heard in their entirety by every DART Board member.
October 24 will be an incredible evening, an experience in local democracy that you will not want to miss. It will not be as lengthy as the Addison meeting. Please inform all your concerned neighbors and arrange carpools to drive downtown in groups. Anyone who needs a ride should use the contact info below and we will help you coordinate carpools.
PLEASE MAKE PLANS TO ATTEND THIS CRITICAL MEETING!

Stanley Feld M.D.,FACP,MACE

With Medical Savings Accounts notice what could happen when you put purchasing power in the patients’ hands. You give patients the incentive to spend money wisely.

Some patients are going to make good medical care decisions. Some patients will make poor medical care decisions. If the patients make poor medical care decision and do not purchase necessary care they will get sick and even experience complications of chronic disease. They will not only lose the money in the trust accounts for that year, they may lose their health. Patients would now be in the position to be responsible for their health care decisions. The decision would not be a bureaucratic and politically influenced decision.

Patients would be the principle buyers of their healthcare, not the insurance industry, the employer or the government. Patients would have the opportunity to compare prices and options for their own medical care

Physicians would be relating care and price to the patient and not to the third party payer. Hospital would no longer be making deals with the insurance industry and the government. They would once again be competing for patients by lowering prices and increasing quality of care.

The insurance industry would have to change. It would have to provide true insurance for expensive illnesses. They would provide insurance coverage for illness costing more than $6,000 in one year. Presently the insurance industry is an industry that owns patients, owns their insurance dollar, and decides the patients’ needs. It tries to control the physician and the hospital.

The employers would provide the money for the trust account and the high deductible policy. The patients would manage the first $6,000. The employer would help the employee pick the best high deductible policy. The employer would also help the employee make informed purchasing decisions.

The government would no longer be the buyer of last resort. It would provide subsidies for senior patients and indigent patients. It would regulate policy for the advantage of the patient. The government would not dictate what the patient should do. The government could create the environment for competitive markets by regulation. If physicians’ services, hospital services and private health insurance would compete for all customers, prices will fall.

We will see the fall in drug prices over the next six months as Wal-Mart rolls the $4 generic plan throughout the country. The government could achieved price competition on a state level by license requirements of price transparency.

I am not the first person to say all of this. However, vested interests other than the patients’ have stood in the way of its implementation. Remember, no one in power likes the balance of power disrupted, even if the system he controls is a failure. Individual interests rule over the common good. This needs to be changed.

There are criticisms and fears of implementing the MSA system. The criticisms and fears all seem lame to me. We will discuss these criticisms and fears shortly.

Stanley Feld M.D.,FACP,MACE

If we as a society do not become innovative about healthcare delivery, medical care in this country will deteriorate.

The Medical Savings Accounts described in the last posting can be utilized as a motivational tool for patients. A true Consumer Driven System can have a positive impact on cost and quality. I hope to demonstrate that total cost will decrease and quality of care will increase.

With 46.7 million people uninsured, America has a problem. I estimate that 30 million people can afford to pay the true cost of a high deductible insurance. The cost of insurance to an individual not in a group plan is not tax deductible. The group plans are tax deductible to the employer.

A simple change in the tax law would correct this. Additionally, if an individual has a preexisting illness, presently the insurance industry can elect to refuse offering a policy, rate the premium or exclude that illness from the insurance offered. The insurance industry can not do that in a group plan. If they have a group with many patients at risk they can try to raise the premium.

The insurance premium for individuals should be the same as corporate rates. The insurance rates should be transparent in order to shop for rates. The rates should also be calculated as a community rate rather than as and individual rate. A fifty year old male with hypertension, high cholesterol and moderate obesity is at increased risk for a myocardial infarction and the need for chronic cardiac care. In the present system he would be refused an individual insurance policy. If he could get one any care related to his heart disease would be excluded.

A simple regulation mandating community rating would correct the problem of discriminatory rates and ratings. In the Medical Saving Account System, the 55 year old patient would be guaranteed a high deductible policy which could be purchased with after tax dollars.

The system could be set up so that patient could apply and receive state or federal subsidy. This simple change could cure our Medicaid problem. The Medicaid system presently spends more per patient than it would cost the government using an effective Medical Savings Account system. The Medical Saving Account system would also encourage patient compliance. The patient would not longer be a burden to the state because costs could decrease.

The key is motivating the patient to be responsible for his care. He would be in control of purchasing his care and to adhering to the care recommended. There have been many pilot programs rewarding expectant mothers on Medicaid. If the mothers participated and fulfilled their obligations for prenatal care, the fetal and post partum complication rates fell dramatically. The neonatal and post partum care costs plummeted. The reward of some pilots was simply free formula for the first year of the infant’s life.

Consumer driven responsibility for one’s medical care is an invigorating concept to patients long abused by a hierarchical bureaucratic power seeking healthcare system. The power should be given back to the consumer.

One can see how the system could work in Medicare patients. The government subsidizes the insurance of people over 65 years old. Constantly, the government must raise the insurance premium the elderly pay. Ninety percent of Medicare’s payments are for the complication of the chronic diseases. If the system were set up to reward the elderly for effective self management of their chronic disease many unnecessary costly complications could be avoided. The patients could be motivated by the money accumulating in their Medical Saving Account. Since they are retired they could use the unused trust money as a supplement to their Social Security. More on the mechanism of the various plans in the future.

Will it work? Absolutely!!

We will see “Patient Power” in action when Wal-Mart rolls out the $4 per month for generic drugs nation wide. The elderly will force their physicians to order generic drugs. The CVS and Walgreen will also be forced to decrease the cost of their generic drugs. The Medicare Part D fiasco will evaporate. There will be no need for Medicare D. It will be cheaper to buy the medication from Wal-Mart. The price of brand name medication will decrease because of the price competition. Adherence to medication regimes will increase because patients can once again afford their medication.