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Patients Problems


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 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. 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.


 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. 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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What Is It All About?

Stanley Feld M.D.,FACP,MACE

It is all about concentrating control over the healthcare system in the federal government. It is about increasing profits of the healthcare insurance industry. It is about decreasing consumers’ freedom to choose a physician. It is about inhibiting physicians’ freedom to use clinical judgment. 

It is designed to happen slowly and insidiously. The trick is to increase control and decrease freedom so that it is not noticed until after it has happened.

Obamacare will not collapse in the next day or two. It will take months to a few years before the major stakeholders (consumers/patients) realize what has happened to our healthcare system.

Only when every consumer is affected will there be a unified public community outcry to repeal Obamacare.  

It might be too late at that time. All the stakeholders will have adjusted to the new but unsuccessful healthcare system at the taxpayers’ expense.

Socialized medicine has not been cost effective anywhere in the free world.

Eighty percent of the people are not sick at any one time. The healthy think the socialized healthcare system in their society is fine until they get sick.

Most people do not realize that the bureaucratic costs and inefficiency in a socialized medicine system consume a high percentage of the GNP.

 Americans would not tolerate 50% of the GNP going to the healthcare system. Especially when the quality of care and access to care has diminished along with the rationing of care.

Medical care is personal. Commoditization of medical care is not personal. When consumers realize they do not have the freedom to choose there will be a reaction.

President Obama’s public relations machine is pumping out deceptions and half-truths right and left about the success of the web site in December without producing any facts except the number of people who visited the site. The implication is these consumers have signed up and received healthcare insurance.

The defects in the implementation are too numerous to count.  The New York Times is not deterred. It is regurgitating the Obama administrations press releases. The administration admits the rollout has had a lot of glitches. However, the administration as well as the New York Times has said that over time all Americans will all be happy with the results of Obamacare.

The mainstream media is spinning President Obama’s story.

Eugene Robinson of the Washington Post started off the New Year with the following statement.

“Now that the fight over ObamaCare is history, perhaps everyone can finally focus on making the program work the way it was designed. Or, preferably, better.”

It is no longer a matter of logic. It is no longer a question of what will work or what will not work. Obamacare is the law of the land. Therefore it is best to shut up and live with it.

No one is talking about Obamacare defects or its inevitable failure.

The fight is history, you realize. Done. Finito. Yesterday's news.

Any existential threat to the Affordable Care Act ended with the popping of champagne corks as the New Year arrived.

 “That was when an estimated 6 million uninsured Americans received coverage through expanded Medicaid eligibility or the federal and state health insurance exchanges.”

“ObamaCare is now a fait accompli; nobody is going to take this coverage away from the millions of uninsured”

 Let us keep half-truths in perspective. Where did Eugene Robinson get the fact that 6 million people got insurance coverage on the health insurance exchanges?

Over 6.5 million people lost their healthcare insurance already under Obamacare and 48 million people were said to be uninsured before Obamacare. President Obama promised that 30 million new people would receive insurance under Obamacare.

These calculations should give most thinking people a headache.

Carl Sandburg, in the Prairie Years ,said that a liar has to have a good memory. However, if you tell enough lies and cover them with enough distractions the audience experiences information overload and doesn’t remember the lies.

It seems to me that Obamacare does not solve any of the problems in the healthcare system.

It is going to make the healthcare insurance industry richer, the pharmaceutical industry richer and the middle class poorer as coverage is reduced, deductibles are increased, access to care is reduced and rationing of care is increased.

Access to medical care should be universal.

Obamacare changes the entire healthcare system. It permits 20% of the population to have access to healthcare insurance while destroying the present healthcare coverage system for 80% of the population. Most of that 80% claim they liked their insurance and their doctor.

President Obama lied to them when he told them they could keep their insurance and their doctor. He is now telling them Obamacare is for their own good.

Why should the government decide on our healthcare coverage?

Healthcare insurance never made people healthy. People help themselves stay healthy.

The main issue is the present healthcare system is unsustainable.

Medicare and Medicaid are unsustainable.

The private employer sponsored healthcare system is unsustainable.

The Veterans Administration healthcare system is unsustainable.

The present and impending failures of Obamacare are unsustainable.   

What can America do?

The consumer’s responsibility is missing from the entire discussion. How do you create a system that lets consumers be responsible for their health and healthcare?

How do consumers stop healthcare insurance executives from making obscene salaries and drug companies obscene profits?

It is by consumers not buying their products.

There must be total transparency of healthcare products available to consumers. Consumers must be educated to evaluate these products. Only then can consumers choose the best healthcare and medical care value for them.

There must also be a financial incentive for consumers to be responsible for their own healthcare and medical care decisions.  

It is not by imposing an ideology that promotes central government control of the healthcare system.

It is not by creating more entitlements

Government bureaucracy is inefficient. It does not help the masses. It helps insiders. It leads to cost overruns.

 It stifles innovations.

 It is not by imposing a system of redistribution of wealth that is going to fix the healthcare system.

Politicians are forced to disguise the redistribution of wealth because it threatens their re-election prospects.  

Our elected officials passed the 10 hidden taxes that have been in force for four years going on five to finance Obamacare before it is fully implemented.

The costs of these taxes have been passed on to consumers. The majority of consumers are in the middle class. They are paying for these taxes indirectly.

In reality President Obama is taxing the working middle class and lower class as well as people making over $250,000 a year. Despite these increased in taxes Obamacare still in for more cost overruns.

The taxpayers’ problem is the administration is unwilling to reveal these cost overruns.

President Obama recently promised to bail out the healthcare insurance industry if they lose money on Obamacare.

This promise is almost as upsetting as providing a waiver to Congress from Obamacare.

Government’s role is to educate consumers.

It is not to create increasing entitlements to have more and more central control over the population.

Entitlements do not work!

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

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  • Richard A Dickey,MD

    I agree with your assertion that the greed of the insurance and drug industry leaders are wrong and that Obama and Congress accepted feeding that greed to get the ACA passed. It is time to correct that but, on the whole, I support the ACA. Here is my recently submitted letter to the Editor of the NC Med Journal about this:
    To the Editor — The November/December NCMJ’s letter to the Editor, ‘Health Care Costs Must Come Down’ by Ron Howrigen, president of Fulcrum Strategies, Raleigh, NC, demands a response. This is mine.
    I heartily agree with the author that Health care costs must come down. This is inarguable and, in spite of the author’s pessimism, I note that the rate of rise of health care costs has already moderated since the Affordable Care Act ( ACA) was passed, even though it will cause a rise (estimated at 6%) as the millions of uninsured (at least double the 6%) are extended coverage by the ACA as it is fully implemented. However, the author totally avoided discussion of the ethical and moral issues the ACA sought to address, particularly the American public’s right to access and coverage of good health care. It has been our obligation, as fellow members of a wealthy nation, to provide that coverage after having failed to address it for over fifty years. Notably, the author, a consultant to physicians, is certainly not a disinterested party in the health care system and therefore his denial of any conflict of interest is hardly forthright. He actually admits his conflict in his statement of his ‘biggest concern,’ i.e. that the ACA will try to control costs by drastically reducing reimbursement to physicians. He and we must realize that our health care system is rapidly evolving to become not nearly as dependent on the physician as it has been in the past.
    When the ACA was being considered by the Congress, those whose corporate bottom lines might be significantly impacted by it and the lobbyists who represent those interests read and studied the ACA carefully. I too read it, all of it. Yet few physicians or patients to whom I spoke had actually read even a small portion of the ACA. As I discussed it with others, I shared my excitement about the significant amount of the ACA which was directed to research ways to assess and improve medical care and coverage. I believe these aspects of the ACA had been included with the expectation that, someday, the findings of the research funded by the ACA could and would be used to improve health care and save money through the implementation of evidence-based practices and payment policies identified by that research. I am not unaware of the considerable compromises and gifts our elected officials in Washington, including our President, had to accept to get the ACA through Congress. I hoped that, over time, the positive effects and benefits of the ACA, such as the coverage of the nearly 50 million Americans without insurance and the removal of the pre-existing condition clauses, would be appreciated by most Americans. While I was disappointed especially in the failure of our President to be successful in his quest to avoid many of those concessions in the final ACA, I hoped those gifts to some corporate interests, including hospital, insurance, and pharmaceutical businesses, could be ameliorated or even reversed with time.
    While I am dismayed by the unrelenting efforts in Congress to undo or limit funds for the ACA, the deficiencies of which are remediable, I remain excited about the good things which have already come and will be coming from this act, one of the most courageous, morally right steps our nation has ever taken.
    Richard A Dickey, MD, FACP, FACE
    Retired endocrinologist
    51 Players Ridge Road
    Hickory, North Carolina 28601-8839
    (828) 495-1230

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Maybe Obamacare Is Not Such A Good Idea


President Obama;

Maybe Obamacare
is not such a good idea.

I suspect
you will not read this nor have you read my letters to you when you were first

The letters
were about how our healthcare system became so dysfunctional and what solutions, that will work,
are needed to repair the healthcare system.

Dear President Obama Part 1

Dear President Obama Part 2

Dear President Obama Part 3

Dear President Obama Part 4

Dear President Obama Part 5–elect-barack-obama-part-5.html

Dear President Obama Part 6


Stanley Feld M.D., FACP, MACE

President Obama did not listen to me at all. It looks like his
agenda was not to "Repair the Healthcare System." It was to destroy it and
replace it with a government control single party payer system.

I continually think about the statement President Obama made to
Barney Frank and John Kerry when passing the law. They said the law must have a
public option and a single party payer to work.

President Obama told them not to worry about the public option.

Now Obamacare is experiencing objections from the interest
groups whose support is needed.

The unions, government workers in congress, the IRS, the healthcare
insurance industry, small businesses, large corporations, large fast food
businesses, privately insured Americans, Medicare insured seniors, physicians, hospital
systems all have objections to the law now.

Many states realized they would get stuck with the bill for the
health insurance exchange. Thirty-three states did not want to participate.
Many did not want to increase their budget deficits.   

All these stakeholders are realizing that President Obama has thrown
them under the bus despite his initial promises.

Obamacare does not serve the vested interests of any of these

Some of the stakeholders are going to get special treatment with

For Obamacare to work, everyone must participate. The mandate was
included in the law to force everyone to participate.

The Supreme Court called it a tax to allow the Obamacare law to be

A basic insurance principle is that everyone must participate to spread
the risk for the insurance industry.

The present system and Obamacare exempts the insurance companies from incurring risk.
It also exempts patients from being responsible for their own health and
healthcare dollars. When Americans spend their own money the free market works as
we have seen in many industries. They support the best product within their

The government could support the underprivileged by providing them with
their healthcare dollars and teaching them how to use them.

The biggest villains in the healthcare system are the healthcare
insurance companies. They take 40% of every healthcare dollar spent by private
and public insurers off the top.

The healthcare insurance industry is the administrative service
provider for all public employees, public healthcare entitilments and private health insurance plans. The 40% overhead is charged
to all. The charge is not transparent.

Obamacare sets the conditions for continued abuse by the healthcare
insurance industry.

The Obama Administration estimates that
of the projected 7 million exchange enrollees next year, 2.7 million need to be young adults (with a low
risk of being sick) to make the premiums work.

 If young people don’t show up for Obamacare,
premiums for everyone else in the exchanges will skyrocket—which, of course,
dramatically increases the cost for taxpayers.

and congressional government workers wanted to be exempt from Obamacare because

 “The 2010 law
generally requires lawmakers and aides who work in their personal offices to
get coverage through the exchanges.”

That implies that they would no longer receive
coverage through the Federal Employees Health Benefits Program…

It does not clearly
authorize the government to pay premiums for federal employees who obtain
insurance through the exchanges.

Nor does it
authorize the government to reimburse federal employees who buy health
insurance on their own.”

Congress and their aides have
the best insurance coverage in the nation. Taxpayers subsidize their healthcare

Through the years this
subsidy has been discussed.  Many have objected
to the cost of this Congressional benefit.

Congress has
objected to Obamacare changing the healthcare insurance they have enjoyed. Congress wants to be exempt from Obamacare.

Barack Obama privately told Democratic senators he is now personally involved
in resolving
a heated dispute over how Obamacare treats Capitol Hill aides and
lawmakers, according to senators in the meeting.”

Few on Capital Hill objected to President Obama changing the
rules of the law himself to protect their benefit.

A question should be asked, “Why should Congress and
congressional aides be treated differently than the general population?”

“At issue is whether
Obama’s health care law allows the federal government to continue to pay part
of the health insurance premiums for members of Congress and thousands of Hill
aides when they are nudged onto health exchanges.”

Currently, the government
pays nearly 75 percent of these premiums.

 The government’s contributions are in jeopardy
due to a controversial Republican amendment to Obamacare, which
says that by 2014, lawmakers and their staff must be covered by plans “created”
by the law or “offered through an exchange.”

President Obama declared,
“I'm on it”
to clear up Capital Hill’s objections to Obamacare’s effect on
Capital Hill’s healthcare insurance.

The IRS employees also want to be exempt from Obamacare.

chief Danny Werfel, the head of the agency charged with administering Obamacare
said that he would rather keep his own insurance than get coverage under the
system created by President Barack Obama's single domestic policy

Danny Werfel made this statement before the
House Ways and Means Committee,

"I would prefer to stay with the current policy that I'm
pleased with rather than go through a change if I don't need to go through that

other federal workers, IRS employees currently get their health insurance
through the Federal Employees Health Benefits Program, which also covers
members of Congress.

House Ways and Means Committee Chairman Dave Camp said he has long
believed, every American ought to be exempt from
the law, which is why he supports full repeal,”

IRS employees have the
responsibility to enforce much of the health insurance law
especially in terms of collecting the taxes and distributing subsidies that finance
the whole system.

IRS agents, in addition to
collecting taxes will also collect data and apply penalties for those who fail
to comply with many of Obamacare’s requirements.

The special favors are coming
next. The Obama administration will only create more dysfunction in the
healthcare system. President Obama’s published goals are good. However, the law
is bad and its execution is worse.

Maybe he ought to consider
my Ideal Medical Savings Accounts as a free market solution to our healthcare
system’s problems.

If you do
not like what is going on, please write your senator, congressman and the
President and tell them that,

“Maybe Obamacare Is Not Such A Good

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

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Obamacare’s Games For Stakeholders And The Unintended Consequences


I can’t help remembering
Nancy Pelosi’s famous statement, “We have to pass the bill to find out what is
in it.”

The public didn’t like
Obamacare to begin with.

Each day “we are finding out what is in it.”

Each day it gets worse
despite the fact the President Obama keeps saying Obamacare is great and will save us
money. Americans do not believe him.

If you are a big
government control advocate, the ideology of Obamacare could be applauded.

Practically, Obamacare is
naïve and an impending “train wreck.
Unintended consequences keep appearing because of defects in the theory and poor

Patients, the healthcare
care insurance industry, physicians, hospital systems, and drug companies could
have predicated these unintended consequence if they knew what was it the bill
at its passage. Those who did understand the Accountable Care Act (Obamacare)
hated the act at its passage.

Many of my progressive
friends blame the problems Obamacare is having on Republicans.

I think they are getting
that idea because the New York Times and its editorial op-ed writers that are making
that claim. However, the New York Times offers no concrete proof.

Obamacare is failing on it
own. Its implementation gets harder and more expensive each day.

The unions were President
Obama biggest ally. All of a sudden Obamacare’s unintended consequences has
angered the unions. The unions realize what Obamacare is doing to them.

On July 12, James Hoffa of the Teamsters (1.4
million members), Joseph Hansen of the Food and Commercial Workers (1.3 million
members) and D. Taylor of UNITE-HERE (200,000 members, mostly culinary and
hotel workers) wrote to complain about the president's Affordable Care Act.

Obamacare is destroying
the 40-hour workweek unions worked many years to achieve.  Employers are hiring part time employees to replace full
time employees that had been laid off because of the recession.

Employers are doing this
to avoid a $2,000 penalty for not providing healthcare insurance for each employee.

The majority of the job
growth figure of 195,000 for June consisted of part time job growth.

leaders are correct. Obamacare "creates
an incentive to keep employees’
work hours below 30
hours a week."

all, employers can avoid a $2,000-per-worker penalty if they don't provide mandated insurance as long as employees
work fewer than 30 hours a week.

" Union leaders have realized—too late—that
ObamaCare will affect the livelihood of millions of workers who wait tables,
wash dishes, clean hotels, man registers, stock shelves and perform other tasks
that can be limited to shifts of less than 30 hours a week."

house Press Secretary Jay Carney said it "is
belied by the facts."

again he was lying. He used 2010 Bureau of Labor Statistics numbers to answer
the complaint.

“So far
this year, as ObamaCare is being implemented, full-time employment has grown at
an average monthly rate of 21,700 while part-time employment has increased an average
of 93,000 a month.”

are terrible numbers that belie Jay Carney’s “facts.”

 Three big unions
worry that the health law will hurt their members' benefits and paychecks.

The letter to Nancy
Pelosi and Harry Reid was unusually harsh.

The letter was not from
Mr. Obama's GOP adversaries but from the president’s allies, the big three most
powerful unions. A fourth union joined the group a few days later.

The unions finally
realized that Obamacare was going to cut unions out of some government
subsidies. Obamacare makes a unionized workforce more expensive for employers.  It makes it less attractive for workers to
join unions.

"Millions of union workers, the
letter notes, are covered by nonprofit health plans jointly administered by
employers and unions, and won't qualify for ObamaCare's generous taxpayer

This will drive union
members out of their unions.

Further, the unions
nonprofit insurance plans are subject to "Obamacare’s new 2-3% tax on each
insurance policy they place."

The union wants their members
exempt from this tax because the union will be forced to pass it on to their
members. Members will be forced to use the health insurance exchanges to buy
their healthcare insurance.

Unions are starting to
realize the goal of Obamacare is to force everyone into his “Public Option”
that will default to a single party payer. The result will be complete
government control of the healthcare system.

There are three insurance
options in the health insurance exchanges. Citizens will buy the cheapest
“affordable option.”  The deductibles
will be high. Citizens will have to pay deductibles out of pocket decreasing
their purchasing power.

Republicans are enjoying
this meltdown. They want Obamacare

House Republicans say their goal is to repeal President Obama's
health care law, not to present an alternative plan.”

This is a big mistake on
the part of the Republicans
. Republicans do not have a viable substitute to
repair the dysfunctional healthcare system.

"Every voter knows what Republicans are against. They don't
know what they're for" on health care, said Rep. Steve Israel of New York,
who heads House Democrats' campaign committee.”

 “He said the strategy would haunt Republicans next year among
moderate and independent voters who want changes, not outright repeal.”

Republicans need an
innovative alternative to Obamacare that will work and excite the public.
  They need a plan that will put consumers in
charge of their health and healthcare dollar. Consumers do not want a healthcare
system that puts the government in charge of their health.

Consumer driven
with my democratic ideal medical savings account should be adopted
by the Republican Party to replace Obamacare.

Republicans must take a
stand and help Americans avoid Obamacare’s impending disaster to our economy,
job growth and financial viability. 

Republicans must show Americans
that they care about them and have a viable solution to our healthcare systems problems.

Otherwise as President
Obama said this week, “he will blow right
through it”
as he
has done in the past.

 Now that Americans are waking up it is time
for the Republican leadership to start waking up and fight back effectively.

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

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A Special Message from the Dallas County Medical Society President

Stanley Feld M.D.,FACP,MACE

The following is a special message to members of the Dallas
County Medical Society (DCMS) from Dr. Cindy Sherry. Dr. Sherry is a very smart
woman and an excellent physician.

She is also extremely tactful. If you read between the lines of
her message, you will sense the difficulty and mistrust physicians have for
hospital systems.  You will also
understand the government’s lack of interest in physician innovation.

If physicians threaten hospital system’s vested interest even if
it is to improve patient care in a community the hospital system is against it.

There is no need to ask why physicians should mistrust the
promises of hospital systems. Hospital systems must prove their sincerity to
the physicians in the community and not the other way around.

Dr. Sherry describes the way Centers for Medicare and Medicaid
Services (CMS) received the Dallas County Medical Society (DCMS)
representatives. The DCMS has a plan that can help the indigent patients in our

I think the plan will work.

The message I got from Dr. Sherry’s special message is CMS is too
busy to listen to physicians.

They simply do not have the time or the bench strength to work
on something that might capture the imagination of medical communities in other
cities and other states. The physicians’ ideas might lead to additional
innovative ideas that could markedly decrease the cost of delivering medical
care in America.

However, the government has its mind made up and is not

“DCMS News: Special
Message from the Dallas County Medical Society President


Fellow Members of DCMS:

As your
president, I would like to tell you about your DCMS executive committee’s May
visit to the national headquarters of CMS (Centers for Medicare and Medicaid
Services) in Baltimore. Joining me were Immediate Past President Rick Snyder
III, MD; President-elect Jeff Janis, MD; Secretary-treasurer Jim Walton, DO,
and CEO Michael Darrouzet.

To begin
with, getting into CMS was more complicated than getting through security at
DFW airport. At the gate, our car was thoroughly checked, including under the
hood, in the trunk and inside all suitcases, and all passenger IDs were
examined. IDs were rechecked at the building entrance, plus we and all our
belongings passed through metal detectors, overseen by armed guards and guard

preparation for the trip, we acknowledged that the Medicaid 1115 Waiver
opportunity had passed to transition Project Access Dallas to a physician-led
ACO (accountable care organization) called My Medical Home. Therefore, the
intent of our meeting with CMS was not to create a last-minute effort to revive
the program, but rather to keep our concerns about the Waiver alive, and to
express these concerns to the people in charge. We wanted to inform the CMS
policymakers about how their plans and goals for the underserved population of
our region are being interpreted and implemented in the offices of physicians
and in the halls of hospitals. Furthermore, although we remain sorely
disappointed in our Big 5 Dallas-area hospital systems for their role in
thwarting the transition of Project Access Dallas to My Medical Home, we did
not make this trip to air dirty laundry or to ask CMS to intervene in a
hospital-physician dispute.

concerns are centered on the reality that health care is in transformation
across this country, including Dallas. Now is the time for DCMS physicians to
assert our leadership and to work to ensure that the transformation occurs
according to guiding principles — principles that will lead to programs that
provide quality care to all of our citizens; principles that will ensure that
resources are deployed across the healthcare continuum, not only for
hospitalizations and ER visits. We had embraced the principles and goals
espoused in the Waiver, including collaboration, accountability, transparency,
and a focus on access, wellness and quality.

While in
Baltimore, we spent about 90 minutes voicing our concerns with CMS representatives,
including Steven Cha, MD, chief medical officer; Rob Nelb, Texas 1115 Waiver
project officer; Therese DeCaro, senior adviser to Cindy Mann, deputy
administrator, responsible for development and implementation of national
policies governing Medicaid; and Julia Hinckley, acting deputy director of the
Children and Adults Health Program Group. We realized that they are
office-based, policy personnel who have no interaction with patients or
physicians that would enable them to fully grasp how their plans play out
across communities. We also recognized that a resolution to our immediate
problem would not be forthcoming, so we remained focused on constructively
sharing concerns that have the potential to impact future programs and

emphasized our belief that a truly transformative plan would create a new
financing and delivery model that would include outpatient clinics, specialty
and primary care physicians, community care transitions, community health and
pharmacy navigation and transportation, referral management and case
management, and preventive and wellness services.

We further
stressed the need for more balance in the use of funds. With current funding
focused on hospitals, how could one realistically expect the transition to more
affordable and more coordinated outpatient care? The current focus on hospital
funding disregards the recent results of the needs assessment completed as part
of the Waiver process, which largely is outpatient-focused. This funding
imbalance omits ambulatory care clinics, care coordinators and physician
compensation from the equation.

How did
the CMS staffers respond to us? They pointed out the depth of the problem they
face — each state is submitting numerous proposals, adding up to innumerable
programs from across the country. They simply don’t have the bench strength or
depth to adequately oversee the programs in the detail we described. They used
glorified terms of transformation such as “collaboration,” “innovation” and
“transparency” in the Waiver, but also acknowledged that these are long-term
goals, and that they do not expect their immediate fulfillment. They have no
plan or capability to police the programs, instead relying on state and local
administrators. They acknowledged that the letter from county medical societies
represented a desirable component of a region’s proposal, but the medical
society did not possess veto power, and that the letter would be considered as
one piece of information among many in the proposals. In point of fact, the
medical society letter was a requirement added at the state level; it did not
originate at the federal level. 

CMS officials also acknowledged that the dispersal of funds should be more
balanced. However, they said there is no mechanism or pathway for the funds to
flow differently, and integration of outpatient care truly is a big challenge.

To the CMS
officials, our visit was a reality check for them to hone in on questions such
as, “How is the process working? Can it be improved?” Our visit served as the
launching pad for them to begin a conversation for future policies. Based on
our initial conversation, they have bolstered some of their regulations for
interim follow-up reports and they have incorporated requirements for learning
collaboration plans. These midcourse corrections now allow for future 2-year
funding windows rather than 5-year approvals.

their best take-home message for us was that we (physicians, in general, and
DCMS, specifically) need to strengthen our voice and increase our clout through
our political connections, and that we should have been able to recruit
political allies locally and statewide to help us be more effective and support
our position.

conclusion, the visit with CMS strengthened the DCMS executive committee’s
resolve that the Blue Ribbon Task Force for the Underserved is heading in the
right direction. We remain committed to moving forward and creating an
innovative plan through activating leaders — including physicians, hospitals,
outpatient facilities and services, midlevel providers, and business leaders—
from all corners of the community to work together to blaze a trail for a more
cohesive plan to provide health care for the underserved citizens of Dallas. It
was an honor to represent the 6,500 members of DCMS in Baltimore.

Cynthia Sherry, MD
President, Dallas County Medical Society”

 Many physicians
throughout the country have said, “Why bother?” The answer is because you cannot give up. Some how Americans will wake up. 

Our government is by the people for the people. We are the people.

Not government bureaucrats!

There you have it. Leonard
Cohen is right. “The Dice are Loaded.”



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

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  • Wake County

    Greetings! Very useful advice in this particular article! It’s the little changes which will make the most significant changes. Many thanks for sharing!

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Getting Around The Rules: Hospital Readmission Rates


Everybody knows about the
Obama administration’s tricks and cover-ups. Few know what to do about them. Some know what to do. More and more people are seeing right
through the charades. 

In America, unfortunately,
strong vested interest lobbies are effective. I pointed out some of the abuses
of hospital systems lobbies a few weeks ago.

Consumer advocacy
lobbyists do not seem to understand the real issues causing the healthcare
system to be dysfunctional, nor have the money to fight these issues.

Steve Brill’s article in
Time Magazine
published hospital retail prices and not the actual prices the
hospital collects. Retail price get the public’s attention. The real issue is
the wholesale prices the government and the healthcare insurance industry pay.
These allowed wholesale prices are also grotesque.

There is a lot of non-transparent
funny business going on behind closed doors with Medicare. It is going to be
accentuated with Obamacare.

Most of us have heard that
hospitals will be responsible for the costs of patient care if the patient is
readmitted to the hospital within 30 days.

This is a very stupid
rule. Sometimes it is the hospital that should be responsible for readmission
because the care was poor, the patient was not ready to be discharged or the
patient had inadequate education about their disease to avoid hospitalization.

The hospital systems’
pressures are to get patients discharged quickly.

My guess is it is the
patient that is responsible for the readmission most of the time.

Many factors could
contribute to a patient’s readmission. They include

  1. Not
    following the physician’s post discharge orders.
  2. Not
    given appropriate post discharge orders
  3. Not
    being taught to become the professor the their disease.
  4.  Not participating in adequate follow-up care.
    Follow-up care is important but it has become outrageously expensive.
  5. Medicare
    has permitted home healthcare services to charge high prices for simple
    services and procedures that have little impact on patient education and
    avoidance of readmission.
  6. Documentation
    by the home healthcare service drives the expensive reimbursement and not the
    value of the care.

The real question is
should the hospital system be responsible for patient irresponsibility?

The answer is clearly no.
The bureaucracy’s answer to the problem is that one size fits all.

Hospital systems are aware
of this defect. Hospital administrators and their lobbyists are working hard to
get around the rule.

Some have figured it out.
They are keeping the patients in the emergency room and charging ER fees that
they can collect rather that putting patients in the hospital and generating
charges they cannot collect.

Hospital systems can
charge patients increasing fees the longer patients stay in the emergency room.

Medicare does
not count most discharged patients who come to the emergency department (ED)
but are not readmitted, according to a 
study in Annals
of Emergency Medicine.”

The study
looked at nearly 12,000 discharged patients from Boston Medical Center. Twenty
five percent of the patients discharged from the hospital appeared in the
emergency room in less than 30 days and forty percent of those patients were readmitted
to the hospital.

keeping patients in the ER amounted to a great saving and indeed profit for the

rules and regulations lead to many unintended consequences. No one has tried to
motivate patients to be responsible for not being readmitted to the hospital.

readmissions cannot be avoided. Many readmissions can be avoided.

The main
question would be how to motivate all stakeholders to have incentive to avoid
readmission to the hospital.

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

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The PSA Fiasco

Stanley Feld MD.FACP,MACE

It is common knowledge that prostate cancer is a slow growing cancer. It is also believed that something happens and suddenly this slow growing cancer becomes aggressive and then metastatic.  

As the cancer increases in size, the Prostatic Specific Antigen (PSA) value increases. It is obvious that a baseline PSA should be obtained. The PSA’s value should be followed yearly to see if it is increases over time. 

The United State Preventative Task Force’s (USPTF’s) conclusions are incorrect. There are problems with the studies reviewed leading to its conclusions.

The media sensationalism of the USPTF’s conclusions was an indictment of PSA testing and urologists’ judgment.

"The USPSTF concludes that there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harm," the report stated.

“The U.S. Preventive Services Task Force said in a report that the PSA test is too inaccurate, creates needless anxiety for patients, and can lead to costly and potentially harmful follow-up procedures”.

Clinical judgment by physicians is ignored by the USPTF. The PSA increases as prostate cancer progresses. How are you going to know if the PSA is increasing, if you do not have a baseline PSA?

The nation's leading urology associations are fuming over a USPTF report  that discredits the widely used prostate-specific antigen-screening test for prostate cancer.

 "It's an absurd recommendation. It is ill-researched and ill-conceived," Sanford J. Siegel, MD, a board member with the Large Urology Group Practice Association, told HealthLeaders Media. "This will only do damage to all the great work that has been done for prostate cancer awareness and to control the deaths from prostate cancer."

The USPTF should have at least had an urologist on its task force to evaluate the literature of PSA testing.

The USPTF is a “non-government agency” that will be used by the administration to ration medical care.

How can the government say it advocates preventing cancer when it’s setting us up to restrict access to care (prevention)?

American Urological Association President Sushil S. Lacy, MD, said in prepared remarks that he was "outraged" by the report. "It is inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations such as African-American men," Lacy said. "Men who are in good health and have more than 10-15 years life expectancy should have the choice to be tested and not discouraged from doing so."

 The American Association of Clinical Urologists issued a similar statement  week,

The AACU called the USPSTF recommendations "misleading and harmful."

The major urological associations say the USPSTF ignored new studies supporting the value of PSA tests, and that the panel refused to address concerns they raised about the conclusions during the comment period. In addition, the urologists complain that there were no urologists or oncologists on the panel.  

The major urological groups said,

 "It is just a screening test, one of several things we look at when we decide whether a man needs a biopsy or not," he says.

"Yes, it is true that many men can live with this disease their whole life. That is why active surveillance has become a treatment option," he says. "If we knew in advance who would and who wouldn't advance in the cancer, that'd be great!"

"There is no question that men get prostate biopsies that obviously in hindsight shouldn't happen.  But we are looking at improving PSA testing and other testing to help us find out which men will progress with more advanced prostate cancer."

The problem is that no one has yet come up with an alternative to determine which patients will develop advanced prostate cancer

There is case of a famous Texan who yearly had normal PSAs. His physicians told him it was not necessary to get further PSA test since he had been normal all these years. He was now past 80.   

At 86 he presented with severe bone pain.  Laboratory studies and a bone scans revealed a sky-high PSA (over 100) and widely metastatic prostate cancer.

If his PSAs were monitored the rising PSA would have been detected perhaps early enough to cure him. Prior to the bone pain this man felt perfectly well.

Urologists have many of these same stories.

The USPTF conclusion might aid clinical judgment. However, it should not trump clinical judgment.

Obamacare is getting set to make committee judgments about healthcare policy and clinical care while ignoring physicians’ clinical judgment.

 About 250,000 men are diagnosed with prostate cancer each year. The diagnosis is made by physical examination and PSA measurement. The final diagnosis and decision for surgery or radiation is made after a fine needle biopsy of the lesion.

A prospective double blind study does not exist to predict the grade of cancer that will be cured by surgery, radiation or no treatment.

Nor is there a study for the USPTF to grade about quality of life post op compared to the quality of life during progression of disease. Until then the USPTF conclusions on the basis of the studies they did review are relatively meaningless.

The incidence of 250,000 new cases of prostate cancer a year has been stabile over the last 30 years. 

With early detection the number of males dying per year from metastatic prostate cancer has dramatically fallen from 48,000 per year to 28,000.

 The USPTF statement does not seem correct,

“It could find no evidence to support claims that PSA tests are responsible for "reduction in all-cause mortality."

"Many more men in a screened population will experience the harms of screening and treatment of screen-detected disease than will experience the benefit."

The USPTF report ignores the dramatic decrease in deaths from prostate cancer over the last several decades.

Dr. Marc Siegel, a practicing urologist for 30 years, said,

 When I started training, 40% of African-American men at that time presented with metastatic disease. Now that number is miniscule," Siegel says. "Tell me how that happens without early screening? How do death rates go down from 48,000 when I trained to 28,000 now? How do you explain that without screening? You can't! It's impossible!"

I believe the defect in the USPTF conclusions have to do with the specificity of the PSA and not its clinical value. A more accurate PSA test needs to be developed.

The USPTF’s conclusions will save President Obama a little money in the short run.

However, the cost of care for prostate cancer along with the morbidity and mortality will cost Americans greatly in the long term. 

 The USPTF has to re-examine its premises and methodology.


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

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A Genius Wrote

Stanley Feld M.D.,FACP,MACE

Todd Siler is a famous artist and scientist. He is much more that. He is a genius. He has written many books about visualizing and solving problems. The most famous is “Thinks Like A Genius”.

For many years he created “Truizms” for the Rocky Mountain News. These Truizms deserve a publication of their own. His Truizms’ are insightful and inspiring. Todd sent me some Truizms to help me illustrate the points I am trying to make.

It is an honor to have Todd become a great friend. He is extremely perceptive and a phenomenal teacher, in addition to being a wonderful human being.

Todd wrote a great response to my last blog “Lets (Not) Do Physicals.”    

Stanley, the frustrating situation you've accurately described here invokes Joseph Heller's classic novel Catch-22:

"There was only one catch and that was Catch-22, which specified that a concern for one's safety in the face of dangers that were real and immediate was the process of a rational mind. Orr was crazy and could be grounded. All he had to do was ask; and as soon as he did, he would no longer be crazy and would have to fly more missions. Orr would be crazy to fly more missions and sane if he didn't, but if he were sane he had to fly them. If he flew them he was crazy and didn't have to; but if he didn't want to he was sane and had to. Yossarian was moved very deeply by the absolute simplicity of this clause of Catch-22 and let out a respectful whistle. (p. 56, ch. 5)…."Catch-22 says they have a right to do anything we can't stop them from doing." 

Quoting my blog , Todd wrote,

“It is not enough for the Obama administration to say it is interested in prevention of disease when it restricts access to prevention measures.

It is not right to restrict access to steps needed to prevent the debilitating or deadly complications of hip fracture.   

“The USPSTF concludes that, for men, evidence of the benefits of screening for osteoporosis is lacking and the balance of benefits and harms cannot be determined.” 

To me the trend to reduce physical examinations and lab screening is a ridiculous trend. The present spending on physicals probably should be modified some but not discontinued.” 

I agree!


One of Todd’s insightful Truisms’’ follws

Finger pointing

Our bureaucratic society with its multiple and conflicting rules does not permit us to honestly do the right thing for Americans, especially when money is involved.

President Obama says the right things, but he does not do the right things.

The Healthcare System’s policies should let consumers decide on what is logical for them after listening to the advice of their physicians.

Consumers should control their healthcare dollars with financial incentives  provided for them to stay healthy, become educated about their diseases,  and control their chronic diseases.  

The evidence medicine debate should be between the medical community and the USPTF without creating a media circus.

Healthcare insurance should be a high deductible first dollar coverage plan that would cover everyone.

I covered how this would work in my blog “The Ideal Medical Saving Account is Democratic.

America’s healthcare system is at the home in a “Catch 22”.

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

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  • EndlessImprovement Blog

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