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I Am Not The Only One

Stanley Feld M.D.,FACP,MACE

Readers ask if I think practicing medicine is becoming more difficult because of Obamacare.

 My answer has been it is becoming impossible to practice medicine. The overwhelming bureaucratic rules and regulations are becoming too difficult to understand and even harder to execute.

Patients will suffer the most because of the disappearance of a physician-patient relationship. Patients are being converted from patients to commodities.

Why don’t more physicians protest? Why don’t they describe their problems in the age of Obamacare?”

There are complex reasons that there has not been an organized physician outcry.

Organized medicine (AMA) and other organizations representing specialties in medicine and surgery are afraid to lead an outcry. Their main goal is to not lose their seat at the table.

This is strange goal. Politicians and their health policy advisers have ignored organized medicine for the last 50 years. Many smart physicians in or out of these organizations have tried to have their voice heard but have failed.

Since Medicare was passed (the last 50 years) there have been many outrageous changes proposed by non-physicians The healthcare policy changes were proposed to decrease the increasing cost of healthcare. Instead these changes have increased the cost of care.

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The politicians and healthcare policy advisers are always changing the wrong policies. They are always putting more power into the government bureaucrats and healthcare industry’s hands rather that putting power into the patients’ hands.

Physicians who have seen these policy changes work out for their benefit are hesitant to participate in an Obamacare protest. These physicians assume Obamacare will also work out well for them

However, physicians do not realize that their intellectual property and surgical skills have been devalued with each of the present changes in healthcare policy.

In a 2006 blog I described how to cook a frog without the frog jumping out of the pot water. Everyone knows that you increase the temperature of the water one degree at a time. When the frog realizes what is going on he is too weak to jump out.

Obamacare has increased the temperature of the water to an intolerable level. At present few frogs have the energy to jump out of the water.

Most of the changes in Obamacare are going hurt patients by decreasing access to care and rationing of care. The physician/patient relationship has also been destroyed.

Dr. Mark Sklar, a Clinical Endocrinologist in Washington D.C., had enough energy to jump out of the hot water. He launched his protest in an excellent article and got the attention of the editors of the WJS.

My hope is Dr. Sklar’s article will launch a consumer protest demanding that a change be made from Obamacare to a healthcare system that will empower consumers.

The new healthcare system should be a consumer driven healthcare system that puts consumers in control of their health and healthcare dollars. The control of the healthcare system should not be in the government’s or the healthcare insurance industry’s hands.

A consumer driven healthcare system should provide incentives to consumers to remain healthy, and provide financial reward if they do. It should also make shopper of consumers.

A consumer driven healthcare system will drive the other stakeholders into a competitive mode to vie for the business of the consumer.

The financial reward should be for consumers, not to the healthcare insurance industry, government, hospital systems or physicians.

I want to echo Dr. Sklar’s protest. I will try to help Dr. Sklar  make his article  a wake up call for consumers.

Consumers are the only stakeholders that can turn the destruction of the medical system around.

Consumers elect politicians. Politicians like the advantages and perks they receive from their elected positions. Politicians are afraid of the consumers that vote to reelect politicians. They will comply with their voters demands.

Below is Dr. Sklar’s article listing most of the issues that are making the delivery of healthcare very difficult.

"Doctoring in the Age of ObamaCare"

"Endlessly entering data or calling for permission to prescribe or trying to avoid Medicare penalties—when should I see patients?

MARK SKLAR M.D., FACE

Sept. 11, 2014 7:35 p.m. ET

http://online.wsj.com/articles/mark-sklar-doctoring-in-the-age-of-obamacare-1410478521

‘It has been four years since the passage of the Affordable Care Act, so I thought it may be useful to provide the perspective of a physician providing daily medical care. I am an endocrinologist in Washington, D.C., and have been in solo private practice for 17 years after seven years at an academic institution. Since 1990, the practice of medicine has changed significantly, seldom for the better.

In the 1990s insurance companies developed managed-care plans that greatly increased their profits at the expense of the physician. With the Affordable Care Act, we are seeing new groups profiting from changes to the health-care system. Entrepreneurs and hospital executives are capitalizing on organizing physicians into groups called Accountable Care Organizations from which they will take a very substantial percentage of collected income. Now that physicians are being required to use electronic medical records, the companies that develop them are harvesting money from physicians' practices and from hospitals.

The push to use electronic medical records has had more than financial costs. Although it is convenient to have patient records accessible on the Internet, the data processing involved has been extremely time consuming—a sentiment echoed by most of my colleagues. To save time, I was advised by a consultant to enter data into the electronic record during the office visit. When I tried this I found that typing in the data was disruptive to the patient visit. My eyes were focused on the keyboard and the lack of direct contact kept patients from opening up and discussing their medical and personal problems. I soon returned to my old method of dictating notes and pasting a print-out of the dictation into the electronic record.

Barrier between patient and physician
 David Klein

Barrier between Patient and Physician

Yet to avoid future financial penalties from Medicare, I must demonstrate "meaningful use" of the electronic record. This involves documenting that I covered a checklist of items during the office visit, so I spend 90 minutes each day entering mostly meaningless data. This is time better spent calling patients to answer questions or keeping updated with the medical literature.

If electronic records ever allow physicians to obtain data from previous laboratory and imaging testing, it will improve costs and patient care. So far, however, the data in electronic records—like paper charts—can't be shared unless physicians work in the same health-care system.

My practice quickly adopted the new Medicare requirements for electronically prescribing medications. Yet patients often do not want their prescription sent electronically. They want a physical copy—either because they don't trust the Internet or because they don't need to fill the prescription immediately. If I don't electronically prescribe for a certain number of Medicare patients, I am penalized with a decrease in reimbursement that can rise to a maximum of 5%. Patients should have a choice in how their prescriptions are delivered, and physicians shouldn't be penalized for how the patients choose.

To prevent physicians from prescribing more costly medications and tests on patients, insurers are increasingly requiring physicians to obtain pre-authorizations. This involves calling a telephone number, often being rerouted several times and then waiting on hold for a representative. The process is demeaning and can take 30-45 minutes. Rather than having physicians pre-authorize expensive medications, the outrageous costs of many non-generic medications must be addressed. I understand that pharmaceutical companies need to make profits to cover investments in drug development. However, they should have some compassion for their customers.

To avoid Medicare penalties, I also must participate in the Physician Quality Reporting System program. Initially, this involved choosing three codes during the patient visit to reflect quality of care, such as blood pressure or blood-sugar control, and reporting them to Medicare. In 2015, the requirement will increase to nine codes.

Coming down the pike, but thankfully postponed from the October 2014 deadline, is something called ICD-10. This is a newer system that will contain about 70,000 medical diagnostic codes used for billing insurance. The present ICD-9 system has about 15,000 codes. The Physician Quality Reporting System and ICD-10 requirements are intended to benefit population research, but the effect is to turn physicians into adjuncts of the Census Bureau who spend time searching for codes—and to further decrease the amount of direct contact with patients.

The practice of medicine in the current environment is unsustainable. The multiple bureaucratic distractions in my day consume so much time that I have to give up what little personal time I have in the morning, evening and on weekends if I want to continue to provide excellent care during office hours.

If high-quality medical care is the goal, the bureaucracies need to be tamed. Our government and insurance companies understandably want to measure outcomes of health-care dollars spent. However, if the health-care system rewards data entry, that is what it will get—the quality of care seems an afterthought.

The patient should be the arbiter of the physician's quality of care. Contrary to what our government may believe, the average American has the intellectual capacity to judge. To give people more control of their medical choices, we should move away from third-party payment. It may be more prudent to offer the public a high-deductible insurance plan with a tax-deductible medical savings account that people could use until the insurance deductible is reached. Members of the public thus would be spending their own health-care dollars and have an incentive to shop around for better value. This would encourage competition among providers and ultimately lower health-care costs.

By contrast, the Affordable Care Act's plans for establishing "medical homes"—a team-based health-care delivery model—and accountability-care organizations will only add more bureaucracy and enrich the consultants and companies organizing these entities.

To improve quality, we need to unchain health-care providers from the bureaucracies that are strangling them fiscally and temporally. We can better control medical costs if we strengthen physicians' relationships with their patients rather than with their computers.”

“Dr. Sklar is an assistant professor of medicine at the Georgetown University Medical Center and at the George Washington University Medical Center.”

I hope all the consumers of healthcare can feel the pain physicians are experiencing in delivering care on their patients behalf because of Obamacare.

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



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A CMS Mistake!!

Stanley Feld M.D.,FACP,MACE

For years practicing physicians knew that hospital outpatient clinics charges were 30-60 percent higher that physicians’ free standing clinics.

CMS didn’t know it or didn’t want to know it.

CMS administers Medicare and Medicaid. CMS was restricting payment for outpatient procedures and tests done in freestanding practicing physicians’ offices while paying higher fees for the exact same outpatient hospital procedures and tests.

As rules and regulations and the complexity of the business of practicing medicine in private freestanding outpatient clinics increased physicians sold their practices to hospital systems.

The government and the healthcare industry encouraged these sales by increasing the complexity of running a private practice.

The probable logic was they would only have to deal with one entity (the Hospital System) rather than 600 individual doctors or clinics using that hospital system.

The government’s excuse for cutting out freestanding individual practices and clinics was efficiency and patient safety.

The hospitals were overjoyed to be able to buy physician practices.

“As the Affordable Care Act attempts to steer people away from pricey hospital inpatient admissions, hospitals have begun buying up doctors’ offices in hopes of increasing their revenue and market share.”

The hospital systems’ then discovered they were losing money by buying physicians’ free standing practices.

 In essence they were trying to buy physicians’ intellectual property and surgical skills because the traditional brick and mortar hospital building was becoming less profitable. Many surgical procedures were being done as outpatient procedures.

Physicians were less productive as hospital employees than they were when they owned their own practices. They were guarantied a salary.

Hospitals did not bother to calculate the money they made from doing the entire outpatient testing and procedures when presenting the loss to the government.

Hospital systems have been selective, first buying Primary Care Physicians’ freestanding office practices. Next they started trying to buy oncology practices.

The number of oncology practices owned by hospitals increased by 24 percent from 2011 to 2012. By turning what used to be independent medical offices into so-called hospital outpatient centers, hospitals are creating networks that, critics say, give them the power to set prices and ultimately raise costs for private insurers and government programs such as Medicare.”

To further encourage physician owned clinics to migrate to hospital system owned practices the government and the healthcare insurance industry provided separate revenue codes to allow hospital systems to collect more for the same tests and procedures done in physicians’ free standing offices.

Finally,

“The Medicare Payment Advisory Commission, which advises Congress, are sounding the alarm. In May, MedPAC Executive Director Mark Miller testified before a House panel that these price differences “need immediate attention.”

 Medicare should align rates “to limit the incentive to shift cases to higher cost settings,”

The hospital systems’ excuse for the higher charges is it has higher operating costs than freestanding clinics such as running an emergency room.

Hospital systems receive higher reimbursement than private freestanding clinics doing the same procedure or delivering the same treatment.

The hospital system’s retail price is much higher than what it receives from CMS and the healthcare insurance industry. The discount price is somewhere around 50%

Even with the discount the hospital systems’ prices are 30-50% higher than the freestanding clinics’ prices.

The glossary of charges and discounts should be available to all consumers of healthcare. None of the prices are transparent. Patients’ have to fight hard to get the prices.

The focus or reports of prices has been on the outrageous prices for cancer drugs.

“A treatment of Herceptin, a breast cancer drug from Genentech, cost private insurers $2,740 when used in an independent clinic and $5,350 in a hospital outpatient setting, according to an analysis of 2012 claims by PricewaterhouseCoopers’ Health Research Institute.”

“The price of Avastin, another Genentech cancer drug, increased from $6,620 to $14,100, the Health Research Institute says.”

Echocardiograms in a hospital facility are reimbursed at twice the price as the reimbursement in a private physician owned facility. 

Dr. Keith Smith with the Oklahoma Surgical Center charges less than some patients’ deductible for some surgical procedures without accepting Medicare or private insurance.

If Medicare paid the lower office rate for 66 outpatient services even when they’re performed in hospital-owned facilities, the government would save $1 billion a year and lower Medicare patients’ bills by $200 million, MedPAC Executive Director Mark Miller said before the House panel. Medicare insured 49 million Americans at a cost of $573 billion in 2012.

This is an analysis of only 66 outpatient procedures. There are hundreds of outpatient procedures. Imagine the savings if all the procedures were captured.

Hospital outpatient visits for echocardiograms jumped 33 percent from 2010 to 2012, MedPAC found, while visits to independent offices declined. Echocardiograms cost more than double in hospital-owned locations.”

As hospital system merge the price will go up even further. The hospital systems are now negotiating from a position of strength. Hospital systems are making the money as private physicians’ reimbursement shrinks.

The government and the healthcare insurance industry are finding their scheme to destroy private practice was a big mistake.

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

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Physicians Are Getting Ready To Fight Back

 

 

Stanley Feld M.D.,FACP, MACE

Practicing physicians’ frustrations with the healthcare systems are mounting. It is clear that patients are not first. The secondary stakeholders such as the healthcare insurance industry, pharmaceutical companies, hospital systems and the government come before patients in the healthcare system. Money is first for these stakeholders.

The government tries to control its cost as it outsources most of its administrative services to the healthcare insurance industry.

The healthcare insurance industry, pharmaceutical companies and hospital systems try to maximize their profits by trying to get around many of the government’s complex regulations.

The result of maximizing profit is abusing patients’ ability to get medical care and physicians’ attempts to deliver medical care.

Traditional healthcare insurance is not the only way of paying for patient care. It is the most expensive way. Traditional healthcare insurance is most prone to political and moral corruption.

Moral and political corruption leads to increased insurance processing costs which lead to higher premiums and higher deductibles. This leads to less health insurance coverage.

Recently, I wrote about physicians being pawns in the healthcare system. They are the easiest to attack because they are the least organized.

Physicians are the easiest to abuse by the secondary stakeholders because they believe patients come first. Physicians are too busy taking care of their patients to figure out how to respond.

A reader sent me an article that appeared in the Dallas Morning News illustrating a tiny fraction of the abuse physicians take and the lack of respect they encounter when their orders interfere with the healthcare industry’s profit.

The article is about the need for prior authorization to reduce drug costs in an insured patient. As you read this, think of the increase in the insurance company’s administrative waste, and the disrespect for the physician’s time and judgment.

Millions of prior authorization letters are sent every day for drugs, hospitalizations, and treatment plans. They are the result of actions that do not fit into a healthcare insurance company’s computer algorithm.

Insurance company workers know little about medical care these prior authorizations are challenging. These workers know little about medical judgment or medical care.

The healthcare insurance industry believes it is an effective way to prod physicians away from more expensive treatments and toward less expensive alternatives.

It makes it harder to prescribe costlier medications. In reality, it is a wasteful administrative nightmare.

The letter in my hand concerned one of my patients, Mr. V., who suffers from stubborn hypertension. His chart is a veritable tome, documenting the years of effort it took to find the combination of four different blood-pressure medications that controls his hypertension without upsetting his diabetes, kidney disease and valvular heart disease or making his life miserable from side effects. We’ve been on stable ground for a few years now, a state neither of us takes for granted.

But Mr. V. had changed insurance companies, and now one of his medications required a prior authorization. The last thing I wanted was for him to be turned away at his pharmacy and have his blood pressure spiral out of control, so I called right away to sort things out.

Twenty minutes of phone tree later, I discovered that the problem was that I had exceeded a pill limit for one of his medications. Mr. V. needed to take 90 of those pills each month for the high dosage that his blood pressure required. I patiently explained this to the customer care representative.

Equally patiently, she told me that 45 pills a month was the maximum allowed for this particular medication.

Three more phone trees and three more customer care representatives later, my patience was flagging. Apparently a request for 90 pills was flummoxing the system. Representative No. 4 went down her checklist. “Would taking 45 pills per month instead of 90 pills adversely affect Mr. V.’s health?” she asked.

At first I thought she was joking. “Well,” I replied, “it would probably make his blood pressure shoot up in the second half of the month.”

She paused, then asked her next question with the encouraging uplift of suggestion. “Has Mr. V. ever tried 45 pills per month instead of 90 pills?”

Then I realized that she was not joking. “Are you out of your mind?” I hollered into the phone. “It’s taken years — years! — to find the right combination of meds to control his blood pressure without killing his kidneys or making him dizzy or nauseated or depressed or ruining his libido or running his potassium off the charts or breaking his bank account. Do you really think I’m going to randomly jiggle the dosages just for the hell of it?”

“A simple yes or no will suffice, doctor.”

This interaction demonstrates a lack of respect for the physician and his judgment, and a lack of understanding of the patient’s illness. I have said over and over again that you cannot commoditize patients’ illnesses or physicians’ skills.

If the insurance company’s computer system has a beef with physicians’ judgment it should get a second opinion by a neutral expert physician in the field of hypertension to review the chart and the patient’s illness. 

The writer says,

 I bit my tongue for the remainder of my conversation with the insurance company, holding back long enough to obtain the prior authorization that would allow Mr. V. the 90 pills he needed each month. I tried not to break the phone when I finally slammed down the receiver.”

These interactions are not good for physicians’ health or morale.

They increase physicians’ cynicism.

 “I’m all for controlling medical costs and trying to apply rational rules to our use of expensive medications and procedures. But in the current system, everything seems to be in service of the corporate side of medicine, not the patient. The clinical rationale and the actual patient — not to mention the doctors and nurses involved in the care — are at best secondary concerns.

In the end, we were able to keep Mr. V.’s blood pressure under control. My blood pressure, however, was a different story.”

These interactions go on daily and waste physicians’ time and energy. Physicians have no ability or representatives to fight back. However, they are ready to fight back. All they need is someone to come up with a plan.

A good start is changing the paradigm of healthcare insurance so that it is a consumer driven healthcare system with consumers being in charge of their healthcare dollars and their health. 

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

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The Growth Of Concierge Medicine

 Stanley Feld M.D.,FACP,MACE

In the accelerated chaos Obamacare has created for both patients and physicians an increasing number are trying to find ways to maintain their freedom of choice. Patients are recognizing that Obamacare is causing a commoditizing of healthcare and the destruction of the Patient/Physician relationship.

Patients and physicians yearn to have a good Patient/Physician relationship.

Physicians love the practice of medicine but they hate the burden being imposed on them.,

  1. Increased government regulations and requirements,
  2. Increased paper work to prove every clinical decision they make on the patient’s behalf.
  3. The restrictions on their use of clinical judgment.
  4. The increased overhead to comply with regulations of both the government and the private insurance plans.
  5. The decreasing reimbursement.
  6. The lack of malpractice reform.
  7. The pressure on primary care physicians to see 30-50 patients a day to cover overhead resulting from decreased reimbursement.
  8. The inability to spend more time with patients because of this patient volume pressure.
  9. The inability to get to know their patient better because of time constraints.

      10. Their inability for physicians to have empathy for patients after they see the tenth patient   because of burnout.

       11. Their inability to develop a viable patient/physician relationship.

       12. Spending at least three hours weekly dealing with insurance plans preauthorization.

       13. Their clerical staff and nursing staff spending at least fifteen hours weekly obtaining preauthorization from the insurance company or government before providing patient care.

        14.Their ability to keep up and comply with all the bureaucratic requlations and requirements.

An AMA survey of 2,400 primary care physicians believe private insurers and government insurers have excessive requirements for preauthorization for tests, procedures, and medications.  

  • More than one out of three have a rejection rate of 20 percent for first-time preauthorization on tests and procedures,
  • More than half of physicians have a 20 percent rejection rate on prescriptions.
  • About one half of physicians have difficulty obtaining preauthorization from insurance plans.
  • About two out of three wait several days for permission.
  • About the same proportion report difficulty in determining which tests, procedures and medications require preauthorization.

These are just a few of the reasons the enjoyment has been taken of the practice of medicine. Many physicians have said I am finished dealing with all these rules and regulations, the government and the private insurance industry.

Many Primary Care Physicians are converting their medical practices to Concierge Medical Practices.

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.”

What is concierge medicine?

Concierge medicine is a relationship between a patient and a primary care physician in which the patient pays an annual fee or retainer. This may or may not be in addition to other charges depending on the business model being used and the retainer charged.

The up front retainer allows physicians to decrease full time staff to a minimum. It decreases the complexity of practicing medicine. Physicians do not deal with insurance companies or the government. They only deal with their patients. This permits physicians to decrease the number of patients they see a day and increase time spent with and relating to patients.

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.”

Concierge medicine is a way of taking first dollar coverage away from the healthcare insurance industry and putting control of care in patients’ hands. It prevents the insurance companies from feeling they own physicians and patients.

If the Patient/Physician relationship is not important too many large healthcare companies. Physician are simply one provider among many such as nurse practitioners, physicians assistants, social workers and pharmacists.

All these healthcare companies are interested in is maximizing their profits from this 2.7 trillion dollar business.

Concierge medicine would not be growing by leaps and bonds if this companies concentrated on the welfare of consumers.

Both physicians and patients are feed up with the development of central control of the healthcare system.

All of us remember President Obama’s lie, “If you like your doctor you can keep your doctor with Obamacare.”

Obamacare was passed because of this lie.

The concierge retainer fees can vary from $500 to $38,000 dollars per year. Concierge medicine will create a two tier Healthcare System. I disagree with a two tier system!

It is occurring because we have a dysfunctional healthcare system. Obamacare is making the healthcare system more dysfunctional.

The healthcare system is not servicing either patients or physicians well. Each is searching for an alternative before Obamacare and the entire healthcare system collapses under it own weight.  

Patients yearn for a positive Patient/Physician relationship. As more physicians are adopting the concierge business model patients are signing up to the surprise of the government and the healthcare insurance industry.

These stakeholders have underestimated the value of the Patient/Physician relationship.

Maybe the trend will wake up the government and the healthcare insurance industry and fix the things that are broken.

Obamacare is not doing it! It is making things worse.

Maybe these two stakeholders will realize that they do not own the physicians or patients. Any attempt to own them is futile. It is not in the American culture being to be enslaved.

The answer is not fancy information systems that do not work perfectly. It is not by creating expert panels to tell physicians what they can do. It is not these panels telling patients the care they can have. Our healthcare system is dysfunctional. The system does not evaluate the quality of care effectively.

All one has to do is look at the VA system’s problems. The VA system’s problems are a disgrace. It should also be a warning about the future of Obamacare.

Obamacare and its bureaucracies are going to create another VA system for all Americans.

The answer is to teach consumers what is good treatment and what is not good treatment. It is to help consumers evaluate their physicians. Price transparency is a good beginning in order to get the stakeholders to start competing.

Tort reform is another good start.

Government could help by teaching consumers to ask the right questions.

It should start realizing that we have to have a consumer driven patient centric system where patients are responsible for their health and healthcare dollars.

The problems in the healthcare system can be solved with a consumer driven healthcare system using my ideal medical saving account.

The public health problems are a different issue. There are three diseases we can prevent. They are obesity, alcoholism and drug addiction. The government must deal with these diseases on an educational and social level.

The government has not done a very good job with any of these three diseases. The prevention of these diseases is a public health problem.

It should not be mixed up with individual medical care. Obamacare does with the causes of these diseases or the environmental cures.

Obamacare is another unsustainable entitlement program. The government should not be creating another unsustainable entitlement program.

It should be creating a program that promotes individual responsibility for health, healthcare, and healthcare dollars.  

Hopefully the growth of concierge medicine will be a wake up call to a misguided Obama administration wanting top down control of the healthcare system.

They must realize that the Patient/Physician relationship is sacred to cost effective medical care.

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

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More Magic Of The Patient/Physicians Relationship

Stanley Feld M.D.,FACP,MACE

The complications of chronic diseases account for 80% of the costs of those diseases for the healthcare system.

The role of patients with chronic diseases and their physicians must be clear to both patients and physicians.

President Obama wants to make physicians responsible for the outcome of their care for patients. Physicians have control of making the diagnosis and prescribing treatment.

Physicians do not have control of patients’ adherence to therapy and control of patients’ behavior.

Only patients can be responsible for their behavior. Physicians are managers of a healthcare team. The healthcare team is composed of physician extenders (assistant coaches).

Patients are in the center of the team. Patients live with their disease 24 hours a day. Patients have to learn how to manage the day-to-day fluctuations in the control of their chronic disease.

If the disease is managed well both the acute complications (emergency room visits) and chronic complications (in Diabetes Mellitus heart attacks, blindness, kidney failure and strokes from hypertension) can be avoided.

The cost of care would be markedly reduced if these complications were avoided.

Patients with diabetes need to understand the disease use methods to control their blood sugar, blood pressure and lipid levels.

Patients have to become “professors of their disease” in order to control their disease.

Physician visits are only a snapshot of what is going on in that patient’s disease process. The information brought to physicians by patients can help physicians, using their clinical judgment, help patients control their disease.

Patients must to be inspired to manage their chronic disease. This requires patients having confidence in their physicians and his assistants.

A good patient/physician relationship can encourage patients to control their chronic disease.

It is hard work for patients to monitor their blood sugar, blood pressure and weight. It is also hard to learn the causes of the fluctuations in their blood sugars and blood pressure.

This idea of mutual trust and confidence between the manager and player are illustrated by something that happened between a teacher and me in high school.

This example is an example of a student/teacher relationship.

It is also an excellent example of the power of an effective patient/physician relationship.

It was a rainy day in the spring of 1953 during my junior year in high school. I was on the high school baseball team. The team could not practice that afternoon because of the weather. The team was sent to the Study Hall for the 8th period.

Ms. W. was one of the 8th period Study Hall teachers. She was my geometry teacher. I thought she was the greatest. I never missed a question in class or on a test. She came over to me that rainy spring day to say hello. She asked how I was doing in trigonometry.

I told her I was not doing well. I can not learn a thing from Mr. B. teaching.

Mr. B. was the chairman of the math department. He taught trig in a very dry way. He was detached. Trig had no meaning to me. He did not teach us to understand the logic of trigonometry and its practical use.

No matter how much I tried to derive meaning from the textbook by myself the material covered was not understandable.

 I felt my ability to learn and problem solve was suppressed. Mr. B’s goal was to have us memorize the material.

Mrs. W. asked me which period I had trigonometry and lunch. I told her trig 5th period and lunch 6th period. She said great she taught trig 6th period. She could get me transferred to her class. I could have lunch 5th period.

I was thrilled beyond belief. She also said she hoped I was aware of the departmental quiz being given the next day. I would be required to take the test.

Ms. W said the chances are I would do poorly on the test.  She encouraged me to study for it when I got home.

The most amazing thing happened that night when I started studying for the quiz.

All of a sudden I grasped the concepts I could not grasp in Mr. B’s class. Now that I was in Ms. W. class I solved problems I could not solve previously. A difficult textbook became easy to understand.

The next day I went into Ms. W’s trigonometry class, took the test, and got 100%.

I know this has happened to all of us at some time in our life. I know it was the result of my knowing that someone had respect for and confidence in me.  

The lesson of Mrs. W. is a powerful lesson. Mrs. W. did enable me to have confidence in my learning ability because of her confidence in me.  She empowered me to learn by myself.

If a relationship is positive, with mutual respect and commitment by both physician and patient, patients can learn to control their chronic disease properly.  

 Chronic diseases such as diabetes frighten patients. This fright makes it difficult to learn how to control their disease to avoid its complications.

Physicians must deal with this through a positive patient/physician relationship. A positive patient physician relationship can make it easier for patients to learn to control their disease.

In practicing endocrinology I developed a patient physician contract to define this physician/patient relationship.

My son Daniel wrote a letter to me about my patient-physician contract that brought tears to my eyes.  

Dear Dad;

I love you. I think everyone should know about your patient-physician contract.

I tell people all the time about your patient-physician contract.

The way you use it to have patients take responsibility for their health and healing.

I’ve adopted this myself in my own health and healing and believe it’s critical since we know ourselves better than anyone else.

 Daniel”

The Physician Patient contract as it appeared in Endocrine Practice 2002:8 (Supp 1)

  1. a.    Sample Patient-Physician Contract

 

 
I understand that if I agree to participate in the System of Intensive Diabetes Self-Management, I will be expected to do 
the following:

 
1. Dedicate myself to getting my blood glucose level as close to normal as possible by following the instructions of the 
diabetes self-management team.


2. Regularly visit the clinic for a physical examination, laboratory tests, and nutrition counseling; follow-up visits will 
be scheduled every 3 months or more frequently if deemed necessary by my physician or other members of my 
health-care team.


3. Bring a detailed 1-day food record to each follow-up visit, provide necessary nutrition information for me and my 
dietitian, and adjust my eating habits to meet the nutrition goals established by my dietitian.


4. Use medications as prescribed by my health-care team


5. Monitor my blood glucose levels at home as instructed and brings the results to each follow-up visit.


6. Follow my prescribed exercise plan.


7. Obtain identification as a patient with diabetes, for prompt assistance in case of an emergency.


8. Ask my physician and other members of my health-care team to explain any aspect of my care that I do not entirely 
understand.

I understand that if I do not monitor myself carefully, there is a risk of hypoglycemia.

I also understand that if I do not strive to normalize my blood glucose, I am at increased risk of developing the 
complications of diabetes mellitus.

My signature indicates that I have read and understand the above agreement.


__________________________________________ 
Patient

 
________________ 
Date


I agree to provide the leadership for the diabetes self-management team. Team members will be available to answer 
your questions and help you self-manage your diabetes. I will continue to encourage you to maintain the best possible 
control of your diabetes.


__________________________________________ 
Physician 
________________ 
Date

 

Obamacare in its attempt to standardize medical care is converting healthcare into a commodity and in the process destroying patient/physician relationships.

The healthcare system cannot be repaired without effective chronic disease management. Chronic disease management will not be effective without effective patient-physician relationships.

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

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The VA Healthcare System-The Precursor Of Obamacare

Stanley Feld M.D.,FACP,MACE

The VA Healthcare System scandal has been in the headlines for a few weeks. The scandal has brought out the fact, once more, that President Obama lied to the American people.

His excuses are very thin. He knew about the VA problems in 2005. He pledged to fix the problems before he was elected President in 2008. In 2011 he repeated his pledge.

Now he has the gall to tell the American public in 2014 that he didn’t know anything about the problems until he read about them in the press.

President Obama addressed the Veterans Affairs scandal on Wednesday, saying he's waiting for an Inspector General "audit" of what went wrong.

How stupid does he think we are?

President Obama probably wishes he had control over You-Tube and the Internet. He could then eliminate his past statements and promises.

It looks like he is trying his best by attempting to defeat Net Neutrality.

Liberals have long hailed the VA Healthcare System as the model of government health care.  Liberals believe everything the government runs is the best thing for America.

Can you think of anything that the US government runs works really, really well? 

If so, please share that information with the rest of us. 

How can it run a healthcare system?

The government has systems problems in everything it tries to run. It can publish mountains of regulations. It cannot execute much because of the way the systems have been set up or not changed over time. There are multiple examples of such failures of execution.

None of these agencies seem to work including the Post Office, Amtrak, FEMA (Katrina rescue), Obamacare (website or the health insurance exchanges), and even the government itself.

 I believe it is because government has imbedded in it a deadening bureaucracy.

The bureaucracy suppresses innovation and the ability to repair defects quickly as they occur. This leads to cover ups that are eventually leaked.

The fact that no one is ever held responsible for errors of execution just adds to the awkwardness of the cover up.

The recent scandals, Benghazi, the IRS, Fast and Furious and the reporting on Obamacare, are a few examples of this.

The press never shows us facts about the supposed “investigations” and who was responsible for the missteps. It only leads to more mistrust and suspicion.

The forced resignation of VA Secretary Eric Shinseki will not serve as a distraction from the real problems in the VA.  Eric Shinseki’s firing is not going to fix the VA’s Healthcare System’s problems.

 

http://youtu.be/eBc8ag-fS3s

Liberals are blinded by their ideology. They have long hailed the VA as the model of government health care. They ignore the facts. The VA Healthcare System’s problems have been around for a long time.  

There is little evidence that President Obama has tried to do anything about the VA Healthcare System since he became President.

 All the public heard is how great the VA system of healthcare delivery is and how his administration is going to make it better.

Paul Krugman is the chief purveyor of the Obama administration’s progressive ideology. Mr. Krugman’s problem is he ignores facts as he formulates his “socialistic” beliefs.

It is almost as if he is saying, “don’t confuse me with facts.” Just believe that I know what I am talking about because I am a Nobel Prize winner.

The crazy thing is many very smart people believe him, just as they believe President Obama.

Paul Krugman praised the VA as a triumph of "socialized medicine."  He even listed what's behind this success.

“Crucially, the V.H.A. is an integrated system, which provides health care as well as paying for it.”

“So it's free from the perverse incentives created when doctors and hospitals profit from expensive tests and procedures, whether or not those procedures actually make medical sense."

The progressives ignore the government system’s own “perverse incentives.” The most important is as VA bureaucrats they must cover their own backside for non- performance.

It leads to long treatment delays and deaths that are preventable. This is only the tip of the iceberg. The rationing of care has been devastating for those veterans awaiting appointments.

 The bureaucracy is forced to cover up the errors. The problem the bureaucrats have is free speech in America. The morality of some is drives them to tell the rest of us about the problems.

“VA centers fudge their data.” The VA has consistently boasted in its performance reviews that more than 90% of patients receive appointments within 14 days of their "desired date."

The hidden waiting lines and treatment delays are not the only problems.

Infection rates and poor treatment outcomes have also been hidden from other bureaucrats in the system as well as the public. These problems are as important or more important than hiding appointment lists.

"The rate of potentially lethal bloodstream infections from central-intravenous lines was more than 11 times as high among patients at the Phoenix facility than it was at top VA hospitals, data from the year ended March 31, 2014, show," notes the Journal.

"Those infections, called sepsis, can quickly cause multiple organ failure and kill an otherwise relatively healthy patient within days or even hours. The data don't show what percentage of patients died as a result."

 The Journal also reports, "Among patients admitted to the hospital for acute care, the Phoenix VA Health Care System had a 32% higher 30-day death rate than did the top-performing VA hospitals, a finding flagged as statistically significant by the agency's medical analysts."

William E. Duncan, supervised publication of VA Healthcare Systems medical outcomes until his 2012 departure.

He said in an interview that he urged that more data be posted regardless of the impact," adds the Journal. But he tells the paper that he was forced out of the VA amid a dispute over the issue.”

President Obama has said all we need to do is throw more money at the problem.

Wrong!

President Obama needs to fix the defects in the VA Healthcare System’s business model.

Inherent in the present VA Healthcare System business model is a system of misallocation of resources and inefficiency. Resources are allocated by political force rather than individual consumer choices.

This is true in most socialistic systems.

It is all about who you know. It is not about who are the most innovative, creative or truthful people trying to execute a system for the consumers’ benefit.

Obamacare's ultimate destination is the same as the VA Healthcare System.

It is going to happen by President Obama’s design. The government will completely control America’s healthcare system. The transformation is happening slowing by design to avoid protest. President Obama doesn’t care about the cost or creating a more efficient system.

He is doing it the same way you cook a live frog. He is raising the temperature one degree at a time. The frog will never notice the heat until he is cooked.

It is time for America to wake up!

We cannot take it any more.

America must demand that we change the business model NOW!

Repeal Obamacare now. 

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

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Another Obamacare Trick Exposed And Backfiring

Stanley Feld M.D., FACP, MACE

The drug industry has been quiet during the Obamacare debate. However, the industry’s lobbying group worked with the Obama administration to get Obamacare.

Why would PhRMA do that when President Obama encouraged everyone to buy generic drugs in order to get full coverage for their drug costs?

It is because President Obama promised PhRMA huge concessions and windfall profits after the health insurance exchanges were successful.

PhRMA is not going to make those windfall profits. When Americans see that the health insurance exchanges are more expensive than the private plans. Only those who cannot buy private insurance because they have pre-existing illnesses will sign up for Obamacare.

This will drive the health insurance exchange premiums higher,cover less, restrict access to care and drugs and ration care.

President Obama provided waivers from the implementation of Obamacare to many special groups except the individual market. Those waivers delayed implementation of Obamacare for one to two years.

The administration was concerned that implementation of Obamacare to everyone would cause a storm of protest that the administration could not contain.

These special groups will lobby for the continuation of those waivers as they realize that premiums and deductibles will be higher in the health insurance exchange market than the private market. 

The profits PhRMA expected will evaporate.  

Consumers not subsidized by Obamacare who bought Silver plans in the individual market through the health insurance exchanges are cooked.

They will pay one and one half to two times the price for drugs next year than they are paying this year.

The government will be paying drug companies for the increased price of drugs for people whose Silver plans are subsidized.

The result will be an increased cost of Obamacare to the public as President Obama redistributes wealth on the backs of the middle class making $50,000.01 or more

How did PhRMA help President Obama get Obamacare passed?

PhRMA paid for the multimillion dollar Harry and Louise ad campaign on TV during the debate for passage of Obamacare.

It financed a false message that was in support of Obamacare as opposed to its original Harry and Louise message that sunk the passage of Hillarycare in 1993.

   

http://youtu.be/fOr17a4ZOIU

 “A new report by Milliman, Inc. finds that Silver plans with combined deductibles offered through the Health Insurance Exchanges may require patients to pay more than twice as much out of pocket for prescription medicines overall as they would under a typical employer plan.”

“This is a far larger increase in out-of-pocket costs than was found for other medical care.”

The cost of drugs to consumers buying a Silver plan through the Health Insurance exchange without government subsidy and high deductibles will cost twice as much as employer sponsored plans.

 “Americans participating in the Exchanges were promised coverage comparable to employer plans and yet the reality is that many new plans are failing to provide an appropriate level of access to quality, affordable health care,” said John Castellani, President and CEO of PhRMA.

Patients’ with high deductible Silver plans will have difficulty affording medicines necessary to manage their illnesses. Paying for medications will be especially difficult for consumers earning more than $50,000.00 who are not subsidized and have chronic diseases. These people need multiple medications to control their chronic disease in order to avoid complications of their disease.  

Eighty percent of the healthcare dollars are spent on treating the complications of chronic disease.

The unaffordability of medication to prevent acute and chronic complications of chronic diseases such as Diabetes Mellitus results in an increase in hospitalizations and higher health care costs overall.

Conversely, programs that encourage better adherence have been shown to reduce emergency department visits, hospitalizations, and other preventable, costly care.

The Obamacare rules and regulations are going to encourage an increase, not a decrease, in healthcare costs for non-subsidized Americans.

This contradicts President Obama’s pledge to encourage prevention of illness.

However, it fulfills President Obama’s goal of redistribution of wealth. It could also be interpreted as increasing the tax on the middle class.

If the public realized this would happen with Obamacare it would have protested the passage of Obamacare.

A house panel uncovered the secret deal in an email between PhRMA and the Obama administration in 2012. It was not revealed to the public until recently.

Nancy Pelosi’s statement about not knowing what is in Obamacare until it is passed was an ominous signal that the public would be taken advantage of. No one picked up the signal.

 

President Obama’s signal legislation is leaving hard working Americans no option but to demand that Obamacare be repealed.

 It must be replaced by a healthcare plan that will work.

 It must be replaced by a plan that gives consumers the opportunity to be responsible for their health and their healthcare dollars.

It must be replaced by a plan where common sense prevails.

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

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Physicians Have To Wake Up!


 

 Stanley Feld M.D.,FACP,MACE

It is time for physicians to wake up and take an active part in Repairing the Healthcare System.

Physician job satisfaction is at an all time low. Physicians are uncertain about staying in private practice. Others who have joined hospital systems as salaried physicians are uncertain about the wisdom of that decision.

Patient satisfaction is even lower as medical care is becoming less personalized. The patient/physician relationship has all but disappeared.

None of the secondary stakeholders (hospital systems, insurance companies, pharmaceutical companies and even government) are having a good time. The government is unable to sustain the costs without raising taxes and restricting access to care.

Today, I want to concentrate on the problems as physicians are feeling them.

A reader sent me this commentary a few weeks ago.

                                                              

"Have you ever been to Sea World?"

 

"Last evening I was at a staff meeting at my community hospital.  The hospital had recently rolled out “Computerized Physician Order Entry” software that was supposed to enable improvements in the orders and delivering of pharmaceuticals to the patients in the hospital. 

 Apparently, it did not go well.  One of the speakers at the meeting was an articulate physician from the “world headquarters” who came to offer encouragement and reassurance.  He cited the benefits: instant transmittal of the doctors’ orders to the pharmacy. 

Orders were legible, reducing the risk for misreading of the doctor’s handwriting.  Quicker delivery of medication to the patient was also cited. 

After the doctor’s presentation, questions rained down upon his head from the physicians in the audience.

They cited a wide range of problems, and the speaker attempted to answer them with patience and courtesy.

Finally one physician asked, “Why are we doing this at all, when there are so many problems?”  Another added, “Why is the company using an antiquated platform for the new software, since the platform is 20 years old, and so obsolete?”

And so it went lots of problems, and no solutions except a request for patience as the problems are addressed, with remedies apparently months away. 

 That set me to thinking:

 If we go back to the formulation of the >2000 pages that evolved to become “Obamacare”, we would be hard pressed to find evidence of the input from working doctors as the legislation and the resulting regulations were formulated and decreed.

We can, if we want to feel really good, go back to Medicare itself and the rules that came along as to what could and could not be done without pre-approval.

Medicare part D added another layer of similar rules that seemed to appear de novo from sources other than working doctors.

Managed care, in its various ramifications showed a similar tendency to be created by people who didn’t have patients as their first concern, but rather the cost of services. 

So, how, you ask, does all this relate to “Sea World”?

Think about the trained seals act.  The seals do their thing on command from trainers who are not seals.

The seals bark loudly, the crowd applauds, and if the seals perform well, they each get a fish.

Doctors are much like that, in that they do their thing the best way they can, but they are abiding by rules they had little input in their creation, reporting their charges using codes they did not write, accepting payments that have no relation to the charges they report, using a system they did not create and one that gets sillier by the year.

So, fellow physicians, welcome to Sea World, as long as we continue to act like the seals, we’ll be able to get a fish now and then, I suppose."

Ladies and gentlemen, we are highly trained professionals. Our job is to solve and fix medical illness using clinical judgment gained through clinical experience and life long learning.

We are not trained seals.

 It is time for physicians to wake up and take an active part in Repairing the Healthcare System.

 The medical profession got itself into this position because it did not step up and fix the dysfunction itself.

 There would not be a healthcare system with consumers and physicians.

 Neither consumers nor physicians know how powerful they are. Consumers must exercise their power and drive the healthcare system by owning their healthcare dollars and be responsible for their health and their medical care

Physicians must teach consumers how to drive the healthcare system.

The politicians, businessmen and bureaucrats think they can fix it.

They can’t. 

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

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What An Experience!

Stanley Feld M.D.,FACP,MACE

Every congressman should try registering a poor (below poverty level) constituent for Obamacare aid.

If you have not, you do not deserve to be in office or have a vote.

Most of you know my story of Moses and his healthcare insurance. I have tried to obtain Medicaid healthcare coverage for both Moses and his wife in the past in Texas. I failed after trying hard.

I had been successful in registering his kids for SCHIP.

Moses annual income qualifies him and his family for Medicaid in Texas. Texas is a state that isn’t expanding Medicaid.

You might recall that Medicaid is not great insurance. The reimbursement is extremely low and there are few physicians who participate.

If Moses lived in a state that is expanding Medicaid, he could earn up to $32,500 dollars per year and still qualify.

"If your state is expanding Medicaid, you’ll probably qualify if you make up to about $15,800 a year for 1 person ($32,500 for a family of 4). (These are 2013 numbers, and likely to be slightly higher in 2014.)"

 "If your state isn’t expanding Medicaid in 2014

Some states aren’t expanding their Medicaid programs in 2014. If you live in one of these states, you may not have as many options for health coverage. It will depend on where your income falls.

Moses earns less than $23,500 a year. He should qualify for Medicaid in Texas.

I have encouraged him to apply for Medicaid using the Obama Health Insurance Exchange in Texas. Texas has a federal Health Insurance Exchange.

I offered to help him fill out the application online at the beginning of December. He did not want to bother me.

He said he had a friend in North Texas who works for one of the Texas insurance  companies. He said his company has people who help people like Moses fill out the healthcare insurance application. He said they are called Navigators. 

I told him the Navigator should be able to help him complete the application. The insurance company assigned him a Navigator in Las Vegas, Nevada.

Moses said she was very nice. She asked Moses all of the questions over the telephone.

I called him on December 12th and asked him if he had insurance yet. If you recall President Obama extended the deadline for applying until December 23th and then December 31th in order to have coverage for January 1st, 2014.

Moses said she told him she did not understand why his application was not accepted.  I told him to call her every day and find out what is going on.

She was going to try again the next day. It sounded like she tried at least every other day through December 31st and failed to get any information or his application accepted.

I told him to keep having her try. This went on through the next extended deadline of January 15th. She said could not understand it. I couldn’t understand it either.

Everything I read said the web site healthcare.gov was working smoothly. However, the back end was not connected to the application process.

 She was unsuccessful through January 30th. On January 30th I told him to come over. I would try and I would fill out an application online for him.

Again he did not want to bother me. I insisted. In the meantime another friend in North Texas connected him with a Spanish speaking Navigator in North Texas.

The Navigator called him when we were about to start filling out the application. After speaking with Moses in Spanish, he asked to speak to me. He practically begged me to let him complete the application for Moses and get him healthcare insurance.

I said O.K.

He asked Moses to come over to him that afternoon. Moses went to him. They spoke for an hour. He then gave Moses a list of questions and a telephone number to call.

Moses told me the questions were complicated. He was afraid he would make a mistake in answering them. The Navigator told him he would not get Medicaid but he could buy a number of insurance policies.

I told him to let me try to register him online.

Last Thursday Moses came over to the house with his citizenship papers and social security numbers of his wife and two kids.

I started to complete the form at 9 am. I completed the form for him at 11.30 am. The form was long and tedious.

Ten seconds after the application was completed the health insurance exchange acknowledged the submission of application. It then accepted the application.

The next screen asked if I wanted to see coverage the applicant was qualified to receive. Within four minutes of accepting the application the message was sent that the application does not qualify for Medicaid. 

This decision seems impossible. Healthcare.gov is not connected to insurance carriers or government databases. The decision was too fast. It would have had to be done by hand.

In any event I clicked on the coverage the application was qualified for. As I clicked on that I noticed there was an appeals button on the previous screen. I figured I could get back to the appeals button shortly.

He was given a choice of healthcare policies. There was no discussion of the possibility of government subsidies.

See below.

  Scan

 The deductibles offered for his income level were outrageous. The lowest deductible was $1500 which he couldn't afford it.  

It was painful to see the dejection on his face.

I tried to re-log into his application.  Healthcare.gov would not recognize the registration number they had given him fifteen minutes earlier.

Where is his application?

When will he receive notification of his eligibility for subsidy?

How much subsidy will he receive?

How does he appeal the Medicaid decision?

Is there anyone out there that can help?

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

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