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Why? How? In Healthcare Reform

Stanley Feld M.D.,FACP,MACE

“Why” and “How” are the two most important questions to ask when revising a business model for healthcare reform.

“Why” the healthcare system has to be reformed is easy to answer.

The present business model for healthcare reform has failed. No one would dispute the fact that the healthcare system is dysfunctional and is failing because of the increasing cost of care.

Medical care is still excellent, although, with the changes in "Obamacare" up to this point it is becoming questionable.

The healthcare system’s costs are unsustainable.

President Obama’s healthcare reform act has accelerated costs. The healthcare system is rapidly headed toward total collapse.

The collapse will occur when the government cannot produce funds to pay the costs. We have heard that Medicare and Medicaid will run out of money by 2016 or 2024.

In reality, Medicare and Medicaid have no trust fund money. The federal government has borrowed the monies paid into the trust fund.  

The initiatives introduced by "Obamacare" with pilot studies have failed or are failing. Initiatives such as chronic disease management, pay for performance, electronic medical records, accountable care organizations and revisions of coding have all failed or in the process of failing. These initiatives were performed by hand picked practices, hospital systems and clinics.

How could we expect ordinary medical practices to carry out these initiatives?

The problems increase daily. Nancy Pelosi was right when she said, “We would know what is in the healthcare reform act when we pass it.”

Nancy Pelosi was right. The more we learn the worse it gets.

“The Affordable Care Act impose much stiffer financial penalties on hospitals with higher 30-day readmission rates than for hospitals with higher 30-day mortality? Isn't preventing death, the ultimate bad outcome, much more important to incentivize”

Let us assume the goal of President Obama’s healthcare reform act is to increase quality of care at affordable cost with improving access to care.

Perverse incentives are created for hospitals to avoid hospital readmissions for sick people in order to be penalized less than if the patient dies in 30 days. The incentive is bizarre.

The penalty for having higher rates of risk-adjusted readmissions starts at 1% of a hospital's Medicare DRG rates for heart failure, pneumonia, or acute myocardial infarction patient discharges as of Oct. 1, 2012 and increases to 3% in 2015. 

But hospital 30-day mortality, which moves into the formula in FY 2013, is just one of more than 20 quality elements that make up the 1% to 2% of the value-based purchasing incentive payment hospitals with higher mortality will lose. 

The result could be a decrease in healthcare expenditures in a community because there would be less sick people in the community. The community would be healthier because the sicker people were not readmitted to the hospital and died. The result might be lower healthcare costs.

Is this what Americans want to do to fulfill President Obama’s goals?

The wrong incentives are being advocated with Obamacare.

A perfect example would be Beth Israel Deaconess Medical Center in Boston. According to Medicare's current Hospital Compare spreadsheet Beth Israel is "better than" other U.S. hospitals in 30-day mortality rates for all three measured disease categories—heart attack, pneumonia and heart failure.

On the other hand Beth Israel is "worse than" other hospitals in 30-day readmission rates in the same disease categories.

Beth Israel Deaconess will be vulnerable to steep penalties for readmissions starting October 1,2012. 

Any business would be crazy to continue a practice that would cause them to lose money. The hospital would start realigning resources in favor of avoiding readmission at the cost of improving survival rate.

Dr.Ashish Jha, , a Harvard School of Public Health policy researcher and practicing internist said,

"I don't know any patient who would say, 'Oh, well, I'll take a higher risk of dying as long as I don't have to be readmitted,' "

"It's hard to fathom that now avoiding readmissions are more important than mortality rates.”

I could visualize the Obama administration confessing that this was an unintended consequence.

This is just one of the unintended consequences resulting from President Obama’s healthcare reform act.

The “How”  in President Obama’s healthcare reform in many circumstances is all wrong.

It is time Americans said enough is enough.

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

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ObamaCare Is Not A Cost Savings Act

Stanley Feld M.D., FACP,MACE

The evidence is mounting that President Obama’s healthcare reform act will not make healthcare more efficient or more affordable.

I have pointed out that Obamacare will create a healthcare system that will limit innovation, lead to healthcare rationing, and lower the quality of care.  All this is coming our way.

The theoretical cost savings proposed and confirmed by the CBO on data given to it by President Obama has not worked out as promised.

It couldn’t work out as I predicted with the creation of a massive bureaucracy and its generation of massive rules and regulations to enable the government to control the healthcare system.

I would have loved to see President Obama create a system of affordable healthcare that is accessible to everyone. President Obama’s did not. He has created a financial and healthcare delivery mess.

He has the wrong business model.

He was able to pass his healthcare reform act by faking out the congress and the CBO using unrealistic numbers about cost saving.

President Obama repeatedly claimed that the annual healthcare premium per family would decrease by $2,500 per year before the end of his first term. We are almost at the end of his first term and the average cost of a yearly premium has increased $2,200 according to a Kaiser Family Foundation report.

President Obama claims seniors enjoy their Medicare coverage. I believe it is great to provide guaranteed insurance for seniors despite pre-existing illness.

However, the costs of Medicare premiums and Medicare’s initial deductibles have increased since 2009 while the covered services have decreased.  

President Obama has also told seniors that their Medicare Part D benefits have improved under his watch. However, the cost of Part D, the deductibles and the costs of the different tier drugs have all increased.

“The CBO's initial estimate in March 2010 of ObamaCare's budget impact showed it saving money, reducing the federal deficit by $143 billion in the first 10 years. But that positive estimate was largely the product of gimmicks inserted into the bill by Democratic leaders to hide the law's true cost.”

Last month President Obama’s proposed fiscal 2013 budget included $111 billion in additional spending for the premium subsidies in the health law's insurance exchanges. Many states are refusing to sign up for health Insurance exchanges even though President Obama said he would pay 90% of the cost of these exchange in the first couple of years.

The states are broke and in the red. They have a constitutional obligation to have a balance budget.

The healthcare insurance exchanges are a President Obama ploy to get states to sell insurance to the uninsured increasing the state’s deficit. President Obama and congressional leaders said it would only affect one million Americans who would lose their employer-sponsored healthcare coverage.

This did not seem like an accurate number to me. The healthcare insurance premiums were $13,000 per family. If the employer did not provide healthcare coverage the penalty to an employer would be $2,000 per employee per year.  The numbers given to the CBO clearly was a misrepresentation.

According to the CBO, 154 million Americans are covered under employer-sponsored plans. The cost to taxpayers would be huge and further increase the deficit if 50% of those individuals lost their coverage and became eligible for the $10,000 per year subsidy.

A McKinsey & Co. study in June 2011 showed that 30%-50% of employers plan to stop offering health insurance to their employees once the health law is implemented in 2014.

Employers dropping employer sponsored healthcare coverage will expose their employees to large financial risk even with the proposed government subsidy.

Employers would be making most employees eligible for huge subsidies in the new health-care exchanges. The government paid subsidy would be up to $10,000 for a household income of $64,000 per year.

This was another trick play by President Obama to get everyone into a public option and government run socialized medicine.

 “In recent testimony before the Senate Appropriations Committee, Health and Human Services Secretary Kathleen Sebelius told me that America's health insurance system is in a "death spiral." She failed to acknowledge that implementation of ObamaCare will be the cause of that death spiral, and American taxpayers will be left to pick up the tab.”

We have also learned that President Obama gave 1400 corporations exemptions from Obamacare. These corporations provided “Minimed healthcare insurance” to their low wage earning employees. Minimed healthcare insurance provides little coverage to low wage earning employees. Hundreds of thousands of these people are essentially uninsured.

On the data given to the CBO, the premiums collected by the Community Living Assistance Services and Support Act (CLASS Act) were estimated to reduce the budget deficit by $70 billion dollars per year.

The new CLASS Act program is voluntary. Premiums are estimated to be $123 per month for workers who choose to participate. It covers home care for those who become disabled at any age, not just those over age 65.

This is a pretty low premium. It seemed too cheap to be true. Congress had to impose a secret tax on all taxpayers to cover the cost of CLASS.

 

All taxpayers will all be taxed $150-$250 PER MONTH beginning in 2011 for the NEW Community Living Assistance Services and Support Act (CLASS Act) that was added to the Reconciliation Bill on Friday night, Mar 19, 2010, before Congress voted on Sunday, Mar. 21, 2010. It will help pay for long-term home-care for the elderly. Isn’t that nice?”

 

These are only a few examples of President Obama’s disinformation provided to the American taxpayer before and after his healthcare reform act was passed.

If the American taxpayer only listened and knew these facts and unintended consequences beforehand this bill would have never passed. If the Democrats in congress studied the bill beforehand they would have never passed it.

America had President Obama’s healthcare pulled over its eyes. This is the reason Vice President Biden said on an open mike, “This is a big f—–g deal”

  

 

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

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  • GED Online

    This is a very beautiful and interesting research
    The most educating one i have read today!
    GED Online

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Let’s Talk About Statins

Stanley Feld M.D.,FACP,MACE

The New York Times did it again. Once again we are experiencing media hyperbole. The first sentence tells it all.

We’re overdosing on cholesterol-lowering statins, and the consequence could be a sharp increase in the incidence of Type 2 diabetes.

Bingo.  For years teaching physicians have worked hard trying to convince practicing physicians the virtues of statin therapy to lower the incidence of coronary artery disease by lowering LDL cholesterol (bad cholesterol).

Finally, it took hold. Practicing physicians tried for years to convince their patients to take statins to decrease the risk of heart attacks.

Over the years evidence mounted proving that normal total cholesterol value should be lower than 200 mgs% from a previous normal of 240 mg%.  The normal LDL cholesterol should be lowered to 100 mgs% from 150% mgs%.

This was not a pharmaceutical industry’s conspiracy. It was arrived at with actual statistically significant clinical data.

The New York Times goes on to say;

This past week, the Food and Drug Administration raised questions about the side effects of these drugs and developed new labels for these medications that will now warn of the risk of diabetes and memory loss. The announcement said the risk was “small” and should not materially affect the use of these medications.”

As soon as the first sentence was read it immediately put the safety of statins in question. There was no discussion of the flawed data used to reach this conclusion.

I predict the warning that resulted from flawed data will result in the unwarranted  decrease in physicians prescribing statins and patients refusing to take statins.

“ The data are somewhat ambiguous for memory loss. But the magnitude of the problem for diabetes becomes much more apparent with careful examination of the data from large clinical trials.”

I believe the data is shabby for both increasing the incidence of diabetes and the decrease in cognitive function.

I also believe the scientists at the FDA also believe the data is shabby.

FDA’s statements include;

"1. However, because statins are so widely used, there is a heightened awareness by the public when we make any safety-related labeling changes to this class of drugs."

"These changes do not in any way alter the risk-benefit calculus for this class of drugs. We continue to believe that the benefits of statins far outweigh their risks, but we do want clinicians and patients to be aware of their side effects so that they can be used in the most safe and effective manner possible."

The media has emphasized the safety label change warning patients of the possibility of getting diabetes as a result of taking statins. The fact is there are so many flaws in the studies sited that initiated the label change that the changes are unwarranted.

The FDA goes on to state,

“ We are not recommending that patients be discontinued from their statin therapy based on a small increase in blood sugar levels.”

“Rather, elevations in blood sugar levels should be treated with dietary and lifestyle management and/or adjustment or initiation of antidiabetic therapies. We do not consider this a reason to not continue or not initiate statins, particularly in the diabetic population where patients are at increased risk for major adverse cardiovascular events and statin therapy has been shown to reduce that risk.”

This disclaimer had not been emphasized in the traditional media. The Women’s Health Initiative (WHI) another flawed study did not have one statistically significant leg to the study. Yet it’s handling in the traditional media changed the course of women’s health forever. Evidence from the WHI was used as study material. The statement below assumes the conclusion of harmful effects of statins is real.

“Despite the higher hazard ratios observed in the WHI study, we do not have strong evidence suggesting that there is a gender effect for the development of this adverse effect.”

The FDA looked at the effect of statins on neurocognitive function.

“We looked at those study results; there was no difference in neurocognitive functioning observed between patients exposed to statin therapy vs those unexposed, including in executive function (attention and speed) and memory, both immediate and delayed.”

There is no evidence here.

"There were trials conducted with statins to see if they could improve cognitive functioning in patients with mild to moderate Alzheimer disease. We reviewed the results of one such study, which showed neither evidence of benefit nor harm in cognitive functioning associated with statin therapy.”

My fear is the misleading warnings being publicized in the press will change the course of therapy for patients at risk for coronary artery disease.

The science used to arrive at these warnings is shabby. It is important to understand the defects in the evidence so that society does not do to statins what it did to hormone replacement therapy for women's health.

 

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

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I Left My Job: What Do I Do Now For Healthcare Insurance Coverage?

Stanley Feld M.D.,FACP,MACE

“Dear Dr. Feld

My wife and I are 43 years old. We have a 7 year old daughter. All three of us are in excellent health. We have minimal medical bills and yearly checkups. 

I just left an executive position in a company that had excellent healthcare insurance.

 I am in the process of hunting for a new executive position. I am currently uninsured. I have the option to buy COBRA insurance for the next 18 months or until I get a job with good healthcare benefits.

The COBRA premium quoted to me to be $1600 per month or $19,200 per year. My former employer told me he was paying $15,000 for the same insurance.

I cannot afford $19,200 per year. Neither can I afford not to have healthcare insurance coverage for my family in case of catastrophic illness. I searched the Internet for the best option.

There were at least 97 healthcare insurance policies offered for individual coverage. After I got through understanding the fifth policy I was exhausted. None seemed to be a good deal.

I have been a reader of your blog and always say to myself thank God I do not have to deal with the dysfunction you describe. I could not believe I would be in this situation.

You seem to understand the problems in the healthcare system. What do I do next?

Thank you in advance for any help you can offer.

Sincerely

H”

I have received other letters of disbelief from young people. They did not appreciate how unfair, non transparent and truly dysfunctional the healthcare system was until they encountered the problems.

The future belongs to the 20 -50 year old age group not seniors. They are all consumers and potential patients. They are are going to need a viable healthcare system at some point in their life.

This age group must take an interest in developing an understanding of and take responsibility for getting involved in fixing the dysfunctional healthcare system now.

In general 20-50 year olds are not sick. Only 20% of the population is involved in dealing with the healthcare industry at one time.  Eighty percent of the population does not interact with the healthcare system. When they do they realize how dysfunctional it is.

100% of the consumers must demand, simultaneously, the healthcare system become transparent and equitable.

The structure of Present Obama’s healthcare reform plan has not yet delivered nor does it have a chance to deliver is promises. In fact, it has made the healthcare system more dysfunctional and unfair.   

Change in the system has to be consumer driven in order to force the government to reform the system so it is affordable and accessible to all. This means honestly eliminating waste at all levels.

President Obama’s waivers to favored groups and concession to vested interests political pressures will not improve the system.  

I totally understand that when dysfunction affects the other guy, young busy unaffected consumers have no interest in being involved in actively changing the system. However, they are going to be the other guy at some point.

In answer to the reader’s question “What do I do?”

He could sign up for COBRA. The COBRA system is a flawed system. It is a dishonest promise.  COBRA was accepted by congress and consumers without understanding its underlying consequences.  

The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. “

Nothing in the Department of Labor’s document covers how the premiums are determined by the healthcare insurance industry.

A consumer electing to take COBRA is charged the calculated premium for an individual healthcare plan. The premium is very high.  

Actuarial calculation is designed to the benefit of the healthcare insurance industry. The calculation is not transparent. I suspect the government does not oversee the calculation.

COBRA is about the only option good for a 50 year old obese male with hypertension and hyperlipidemia who has a wife and a 7 year old child. He would be rejected for all private insurance plans.

The individual state’s “high risk pools’” premiums are even higher than COBRA’s premium. The high risk insurance coverage is less inclusive because it excludes any possible risk from underlying conditions.  

I felt compelled to help this reader.

He needed coverage in case of a catastrophic illness in his family until he obtained a new position. At his age and health history he should not have any trouble getting accepted for a high deductible policy.

I told him to check which insurance company his family’s physicians accept. It was UnitedHealth.

The 8th plan down the list of UnitedHealth options for high deductible was a $10,000 called Plan 100. The premium would be $318.82 a month. The deductible was $10,000. The plan provides full first dollar coverage after the $10,000 deductible is met up to 1 million dollars.

UnitedHealth Plan 100 underwritten by Golden Rule also had a $7,500 deductible for $417.

I thought this was the plan for this family. Their routine healthcare costs were less than $1000 year. The premium for the $7,500 deductible is $5004 per year. Total savings vs. COBRA is $19,200-$6004= $13,196.

If there was a catastrophic illness in his family and it cost more than $7,500 his total cost would be $7500 plus $5004 for his premium for a total cost of $12,504. He would still save $6,696 (19,200 for COBRA vs. $12,504= $6,696).

The big disadvantage is his premium costs are not tax deductible as it would be for an employer. At a 30% tax rate this consumer would have to earn $27,429 in order to pay $19,200. 

The adjudication of claims is simple. The physicians send the bill to UnitedHealth. UnitedHealth allows physicians their negotiated fee. The consumer is then sent an explanation of benefits for allowable fees.

Since the consumer has not reached the deductible, he is required to pay the physician’s allowable fee. This fee is credited toward his $7,500 deductible.

When the deductible is reached the full allowable amount for services is paid. This is the best deal under the present healthcare insurance options for this family of three.

He bought the high deductible Plus 100 insurance. He also complained about the confusing array of options and prices, the lack of transparency about these options, and difficulty in easily understanding the options.

He said he is a pretty smart fellow. He had difficulty in figuring out what to do and was ready to pay for COBRA coverage.

He asked, How could people of average intelligence figure it out?

It would be easy if there were a questionnaire that would automatically determine consumers’ healthcare policy needs and direct them toward healthcare insurance policies that would fix their needs.

I told him the game is rigged. The insurance industry does not want you to figure out what policy is best for you. It wants you to buy the most expensive policy that might not address your needs.

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

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  • Jem

    It is consider a hard time to a people like us nowadays whereby our source of income is just a means of our jobs. Insurance is essential for our future assurance, but how to afford it if the private sector insurance premium is so huge, I think the government should step in, and to regulate the policy whereby beneficial to both insurer and the customers.

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Who Said Consumer Driven Healthcare Cannot Be A Market Force?

 

Stanley Feld M.D.,FACP,MACE

I love Costco. Its prices are great and its selection is abundant. Last week I was dazzled by the display of megavitamins as soon as I walked into the store.

2012-01-10 10.50.13

2012-01-10 10.50.56

2012-01-10 10.52.07

Americans want to be healthy. Few have a death wish but many (60%) are obese. Megavitamins have been touted as the instant route to healthy living. The megavitamin business has grown into a $30 billion dollar a year business.

Megavitamins have been successfully oversold.

There is no evidence that megavitamins are the route to health and healthy living.

“A national survey by the US Food and Drug Administration found that 73% of US adults were found to use dietary supplements in 2002.”

There is little good evidence to support the widespread use of dietary supplements.

The US Preventative Health Services Task Forces reviewed some of the literature on megavitamins and dietary supplements. The group stated there was insufficient evidence for or against the use of multivitamins with folic acid or antioxidants. It also stated that the use of Vitamin A, C or E did not have sufficient evidence for or against its use.

 I think these supplements could be helpful if the requisite dosage was known. There is no evidence that these dietary supplements are helpful at the present dosage. There are no scientific studies about which doses would work. There are only testimonials attesting to usefulness.

”Beware of the man with one case.”

 A friend of mine worked for thirty years proving the existence of Vitamin D deficiencies in 50% of the elderly population. It took him half that time to convince the medical population that he proved something.

 

The dosage necessary ended up being 6 times the dosage in multivitamins. Therefore USPHTF conclusions are correct with the present data. However they might have drawn their conclusions from the wrong data.

This is not an unusual occurrence in clinical medicine as I have pointed out previously. 

The American Medical Association hedged its bet by stating,

It recommends supplements specifically for seniors who have generalized decreased food intake.”

Chances are people who are starving or dying from cancer will have a multivitamin and mineral deficiency.

The American Dietetic Association advises,

“low-dose multivitamin and mineral supplements depending on individualized dietary assessment.”

The ADA’s statement is obviously self-serving.

The American Heart Association made the only logical statement in the whole bunch.

“The AHA emphasized healthy eating patterns rather than supplementation with specific nutrients.

The recommendations against the routine use of supplements are grounded in fairly good evidence if one believes in a methodology used by the Cochrane intervention review.

A Cochrane intervention review of 77 randomized controlled trials with 232,550 participants found no evidence to recommend antioxidant supplementation for primary or secondary prevention of mortality.[7]. 

There is shabby evidence that cannot be generalized regarding possible harm related to the use of some supplements.

 “For example, the Alpha-Tocopherol Beta-Carotene Cancer Prevention Trial demonstrated that beta-carotene supplements increased the risk for lung cancer among male smokers.[8] 

At this point there is no good scientific evidence for the use of megavitamins. “People believe what they want to believe.”  The placebo phenomenon is extremely important.

The media is the message. Somehow the power of advertising has convinced the public that it is good to take megavitamins.

Costco is trying to take advantage of the hype. Consumers are driving this healthcare choice. The result is a $30 billion dollar a year business. The money is coming directly out of the consumer’s pocket. It is not included in healthcare costs.

Consumers are trying to be responsible for their health on the basis of hype. It is much easier in the mind of most to stay healthy taking a pill than do the heavy lifting required for healthy living.

Why can’t someone create an anti-obesity hype that works as well as the megavitamin hype?

Increases in obesity lead to increased Type 2 Diabetes, hypertension, hyperlipidemia and the resulting Diabetic complications of stroke, heart attack, blindness, amputations, chronic renal disease and cancer.

Many schemes have been devised to decrease the increasing obesity rate. None have worked except eating less and doing more.

With the increasing obesity in children there is an increased incidence of Type 2 Diabetes in kids, teenagers and young adults.

Gastric bypass has become the rage for these young super obese people. To my dismay more and more insurance plans are paying for gastric bypass procedures. Even Medicaid is paying for the procedures.

Is the world going nuts?  I guess Medicaid’s logic is if the people become thinner it will decrease the incidence of Diabetes, decrease the complications of Diabetes and therefore decrease the cost of healthcare for these people.

To me it is like painting over rust. The rust will bleed through and the money for the paint will be spent already.

Americans do not get any help from society norms. We are flooded by manufactured foods with tons of calories and tons of salt. Mayor Bloomberg passed an educational law that fast food stores must publish calorie counts on foods.

This is helpful is the calorie count is accurate and people pay attention. 

Home cooking served in small portions is essential. The fat, calories and salt can be controlled. There is no need to have a home cooked meal anymore.

All you have to do is go to Costco or Sam’s and buy any precooked meal you want. Dinner is a 3 to 10 minute microwave pop away. Why would any busy person bother to prepare a home cooked meal? The harmful consequences prepared meals are in the distant future.

If you have dinner at a restaurant an average meal contains more calories than the average person burns in a day. My wife and I have been sharing for years.

Consumers want to be responsible but it is very difficult in the cultural milieu of our society. 

Ken Cooper M.D. created an exercise craze in the 1970’s. It has lasted until the present. He did not figure out how to get people to sustain their exercise program. He also did not figure out how to get people to decrease their intake in our sea of manufactured food and pre-cooked food.

The incidence of obesity is growing.

Most consumers are not stupid. They seek to be responsible in the easiest way possible.

Someone will come along and initiate a legitimate health craze.

The Ideal medical savings account (by providing financial incentives along with intense public education through appropriate advertising) can be as successful as the Dietary Supplement industry.

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

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A Wakeup Call About Individual Freedom

Stanley Feld M.D.,FACP,MACE

President Obama and congress have made major progress in increasing central power over individual freedoms during President Obama’s tenure in office.  Congress has done it by passing unpopular laws; President Obama has done it issuing unpopular by executive orders.

Two prominent examples are working their way through the governmental system right now.

The first is Obamacare with its many defects. The next congress and President will probably repeal Obamacare. President Obama’s Healthcare Reform Act has already damaged the economy, increased the budget deficit and is destroying the healthcare system.

The Supreme Court will not overturn Obamacare completely. The court is only judging the law on limited issues. The Supreme Court’s decision is going to take at least two years fro the time the bill was passed.

The real issue at stake with President Obama’s Healthcare Reform Act is should the central government have the power to control our lives and our choices.

The states are protesting that the federal government is taking power away from the states.

 Citizens are complaining that the federal government is limiting their rights and freedom of choice.

This conflict has existed throughout American history. America has struggled with the challenge of the balance of power between federal control, states rights and individual rights.

President Obama is a strong advocate of central control. In the process he is trampling states rights and individual freedoms.  He has bypassed congress and by executive order conferred absolute power to administrative appointees.

If the federal government can require people to purchase health insurance, what else can the government force Americans to do?  The government will be able to compel citizens to do any number of things by decree.

President Obama has ignored this basic issue.  Has congress and the executive branch overstepped their constitutional authority?

His administrations’ lawyers have had a difficult time providing a coherent response to the question in court appearances around the country.

Judge Laurence H. Silverman said, Let’s go right to what is your most difficult problem,”

 “What limiting principle do you articulate?” If Congress may require people to purchase health insurance, what else can it force them to buy? Where do you draw the line?

Would it be unconstitutional, to require people to buy broccoli?

Beth S. Brinkmann, the administration’s lawyer said, “No,” then “It depends.”

Judge Silverman asked the next logical question,

 “Could people making more than $500,000 a year be required to buy cars from General Motors to keep it in business?

Beth Brinkman’s response was “I would have to know much more about the empirical findings,”

Judge Brett M. Kavanaugh asked,

“How about mandatory retirement accounts replacing Social Security?”

Ms. Brinkmann replied. “It would depend.”

None of these ridiculous responses were published in the traditional media at the time of the testimony. The administration’s lawyers are trying to define its views of the limits of government power. The have not provided constitutional justification for their views.

 “They have said, for instance, that laws authorized by the Constitution’s commerce clause must be economic in nature, must concern interstate commerce and must address national problems.”

I do not think this should be done at the expense of states’ rights and individual freedoms.

The reason President Obama’s Healthcare law requires an individual mandate to purchase healthcare insurance is because Obamacare is not actuarially sound. It might work if everyone pays into the premium pool.

Rather than repairing the healthcare system and its inefficiencies President Obama is adding more revenue to a failing system by mandating everyone to pay into something they do not want. 

In reality, Medicare has failed economically even though seniors are satisfied with the insurance.

Medicare Part A mandates everyone to pay into the system through payroll taxes.  The reason the government had gotten away with the Part A mandate is because Americans had the right to opt out of Medicare Part B.

Another hollow argument President Obama’s lawyers have used is that the health care market is unique.

The administration’s lawyers have suggested,

 “Questions about constitutional limits can miss the point. The only question actually before the courts, they said, is whether the particular law under review was within Congress’s authority. Other cases, they said, can be decided as they arise.”

There are many unintended consequence of Obamacare already. Hopefully, the Supreme Court judges will understand these implications of these unintended consequences. Most important is the precedent the law set for other cases.

In 1995, when the court struck down a federal law that prohibited people from carrying firearms in school zones, Chief Justice William H. Rehnquist wrote that “we pause to consider the implications of the government’s arguments” in defending the law — that stopping activities that could lead to violent crime relates to interstate commerce because it affects “national productivity.”

Under that reasoning, Chief Justice Rehnquist wrote, “It is difficult to perceive any limitation on federal power,” adding that “if we were to accept the government’s arguments, we are hard pressed to posit any activity by an individual that Congress is without power to regulate.”

Many judges are reluctant to issue rulings without some sense of what their consequences will be in other cases.

The outcry about Obamacare has been loud and clear.  Our constitutional government should be government for the people by the people.

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

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President Obama Sneaks In Another Tax Increase: Means Testing for Medicare Part D

 Stanley Feld M.D.,FACP,MACE

 

I must interrupt the development of my theme, “Managing Complexity In Order To Repair The Healthcare System,” to bring you this special announcement.

Starting in 2011, Part D enrollees whose incomes exceed $85,000 (for individual tax returns) or $170,000 (for joint tax returns) will begin paying more for Medicare Part D (Drug Prescription Benefit Plan). These “super rich?” seniors will be paying up to 60% more for Medicare Part D per person.

Some really rich seniors who receive a total income from all sources, including retirement benefit, social security, capital gains and dividend will pay the government up to an additional 500% more than their Medicare part D premium costs.

The government should fix the Medicare Part D program by negotiating the drug costs with drug companies directly as they do in the Veterans Administration. The healthcare insurance companies lobbied hard for this concession.

President Obama has chosen to tax seniors for the outrageously constructed drug benefit rather than putting seniors first.

President Obama slipped the means testing regulation for Part D into last years budget. Means testing went into effect on January 1,2011. I missed the regulation and its implementation completely.

Congress and the mainstream media also missed this rather historic regulation. Some would say the regulation was in plain sight but congress did not bothered to see it.

It was also astonishing to slip this into law when President Obama specifically promised he would not change Medicare benefits for any seniors. 

President Obama cannot be trusted.

It reminds me of President Reagan’s famous line. “I am from the government and I am here to help you.” 

President Obama’s plans to collect more than $8 billion a year from “wealthy seniors” for Medicare Part D drug prescription benefit by “means testing” seniors for all sources of income.

Major Democratic members of the House and Senate have been opposed to means testing for Medicare Part D. President Bush tried to get congress to pass means testing for Part D in 2006. It was quickly rejected by the Democratic controlled congress.

The Democrats arguments were consistent with liberal dogma.

“Social Security and Medicare are participatory programs, designed for all Americans—rich and poor alike. You work hard, kick a portion of your income into these two retirement funds, and are guaranteed a payout in your golden years. This gives these programs broad popular support—they are not welfare for the poor, they are guaranteed retirement benefits for all.”

“Liberals fumed. Means-testing of entitlement programs would send us down a dreaded "slippery slope," they argued. Soon Medicare, and then Social Security, would lose their broad-based popular support, and be merely costly welfare programs! Both Obama and then-Sen. Hillary Clinton voted against a Republican proposal to means-test Part D last year.”

President Obama’s regulation has not gotten very much media attention.  Liberals declare the goal is to preserve Medicare's status. Wealthy seniors (earning retirement income from all sources of over $85,000 per year) did not recognize the increase in 2011. The tax is deducted from their electronically paid Social Security benefit.

This tax was another President Obama trick play.

Pete Stark must be fuming about the means testing. It contradicts his liberal philosophy.

“Requiring some seniors to pay more for Medicare is a red herring from Republicans who want nothing more than to end Medicare as we know it,” said Rep. Pete Stark, ranking Democrat on the Ways and Means Health Subcommittee. “Upper-income seniors paid more into Medicare when they worked. Applying a new surcharge is essentially double taxation and should be rejected.”

Charlie Rangel’s reaction to means testing for Part D was expressed in 2006.

“The beauty of Medicare is that we’re all in it together, whether you are rich or poor, healthy or sick,” commented Rep. Charles B. Rangel, senior Democrat on the Committee on Ways and Means. “Charging certain people more is the first step toward destroying Medicare’s universality and turning it into a welfare program.”

Nancy Pelosi’s take on means testing for Part D in 2006 was harsh.

“It is simply unacceptable that nearly 2 million Medicare premiums will double beginning this January,” House Democratic Leader Nancy Pelosi said. “Seniors, who are already struggling to make ends meet, should not pay the price for failed Republican policies. With further premium increases slated in the future for even more beneficiaries, we must act immediately to protect America’s seniors.”

The Part D premium increases, known as means testing, are based on the same income thresholds as Medicare Part B means testing.

2011 Income thresholds are as follows:

2011 Income Thresholds (single)

Joint per person

Less than $85,000

Less than

$170,000

$85,000 – $107,000

$170,000

to $214,000

$107,000 – $160,000

$214,00

to $320,000

$160,000 – $214,000

$320,00

to $428,000

$214,000 or more

$428,000

or more

2011 Part D Additional Premium (monthly)

$0

$12

$31.10

$50.10

$69.10

2011 Part B Premiums

(monthly)

$115.40

$161.50

$230.70

$299.90

$369.10

Part D plan members will continue to pay their regular premium to their Part D plan, but the income-related adjustments shown above will be paid to Medicare. It will be deducted from their monthly Social Security check.

These additional charges are sure to catch some seniors’ off-guard. Some who might be subject to the additional charges are those who own a business, those who are earning farm or investment income, seniors who are taking installments from their 401(k), or those selling a home for a profit.

This potentially historic change (and others like it) will slide right through, and serve as a model for further means-testing of entitlement programs”.  

What bothers me most is that there was no public discussion or political debate on the issue that I recall. President Obama simply hid the increased senior tax in his budget. He has often promised to make the drug plan more affordable.

President Obama’s means testing regulation is really an assault on the retired middle class seniors of modest retirement income.

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

 

 

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Healthcare Costs Are All About Chronic Disease Management

 

Stanley Feld M.D., FACP,MACE 

The National Institute for Healthcare Management Foundation is a nonprofit, nonpartisan organization focused on healthcare. The foundation just published an excellent report on the distribution of  healthcare costs in the population.

The results indicate that reducing healthcare cost is all about reducing and managing chronic diseases.

U.S. healthcare spending has sharply increased between 2005 and 2009 by 23 percent from $2 trillion to $2.5 trillion per year.

This is a result of a combination of factors. Chief among them is the increasing incidence of obesity. 

Who spends the money?

 Five percent of the population is responsible for 47% of all health care spending in the United States. Ten percent of the population accounted for 63.3% of the expenditures.

Fifty percent (50% percent) of the population accounted for only 3% of the healthcare expenditures.

The low cost person spent $233 in 2008 for healthcare services. Those in the top half of spending cost insurers, the government, or themselves $7,317 a year. The top 1 percent cost $76,476 per year. These are discounted fees not retail fees.

Healthcare expenditures were concentrated among a small group of high-cost patients. These high cost patients were older patients (over 55 years old) with one or more chronic diseases. If they were young and they had one or more chronic diseases healthcare expenditures increased. The more chronic diseases a patient had, the higher the likelihood the patient would be in the top 5% of healthcare dollar utilizers.

Fifty percent of the top 5 percent of healthcare spenders had high blood pressure, a third had high cholesterol, and a quarter had diabetes. The incidence of hypertension, hypercholesterolemia and adult onset type 2 Diabetes Mellitus is directly proportional to the presence of obesity.

It is logical to conclude that as the incidence of obesity and its severity increases the complications of obesity (hypertension, hypercholesterolemia, and Type 2 Diabetes) will increase.

It follows that healthcare costs will increase as a result of the increasing incidence of obesity. America must control the obesity epidemic.

Little progress is being made to decrease the increasing incidence of  obesity or Type 2 Diabetes.

In a perfect world, if obesity could be decreased, the incidence of chronic disease would be decreased.

In a perfect world, if the patients with chronic diseases could be taught to self-manage their disease, healthcare costs would decrease because the incidence of complications of chronic disease would be decreased by at least 50%.

 The treatment of the complications of chronic diseases is the most costly healthcare expenditure.  

President Obama’s Healthcare Reform Act mentions prevention and chronic disease management. There are no concrete incentives for patients to learn how to manage their chronic diseases. There are no specific financial incentives for physicians to develop facilities to teach patients to mange chronic diseases.

Americans are in for a long and costly dysfunctional healthcare system to the disadvantage of consumers and physicians.

President Obama’s Healthcare Reform Act puts consumers in a passive dependent position. Consumers need to be put in a proactive position to care for and be responsible for their health and healthcare needs.

Physicians have to have incentives to teach consumers to be self-reliant.

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

 

 

 

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A Big Idea For President Obama


Stanley Feld M.D.,FACP,MACE

President Obama has been disingenuous during his entire time in office.  He has publicly asked for ideas on Repairing The Healthcare System before and after he took office. I will repeat the advice that he has ignored in the next few blog post.  

He has been influenced by the ideas of Tom Daschle and Don Berwick to the exclusions of ideas that might actually be effective. Both men are convinced that the healthcare system would be repaired if there were a complete government take over.

President Obama has been extremely cunning in working his way toward a complete government takeover of medicine. Some of Mr. Daschle and Dr. Berwick’s ideas are good. Most of their ideas will not fix the defects in the healthcare system. There is a total disregard of citizens in their program.  

President Obama is expanding the bureaucracy and creating a wasteful morass of new agencies. Those agencies are generating incomprehensible and non-enforceable regulations. The regulations are trying to commoditize medical care  in America. 

Our healthcare system is a mess. Medicare and social security in its present form will result in a 100 trillion dollar a year deficit in 75 years. The solution to Repairing the Healthcare System is relatively simple. The key to the solution is social responsibility by all stakeholders involved in the healthcare system and individual responsibility by the consumers and potential consumers of healthcare.

Neither political party is getting behind a big idea that’s bold enough to actually solve major problems.  

Unfortunately, secondary stakeholders (the healthcare insurance industry, hospital systems and government) have not become socially responsible toward the best interests of consumers. Consumers will assume responsibility with significant incentives and appropriate education.

 One big idea is to reform the food industry. The food industry’s products and advertising undermine Americans eating healthy. The food industry’s advertising has to be redirected to consumer education and not consumer self-destruction.  President Obama’s approach to healthy eating has been tokenism.

He has ignored appropriate input on how to fix the food industry in an effort to decrease obesity in America.

  No one has asked for the opinion of practicing physicians. The focus of all healthcare policy “experts” is economics.

Here is a big idea.

Obesity leads to chronic diseases such as Type 2 Diabetes Mellitus. Walk into any Coronary Care Unit in the nation and 80% of the patients with myocardial infarctions are obese and have Diabetes Mellitus. The complications of Diabetes Mellitus cost the healthcare system $160 billion dollars a year. Eliminating obesity will reduce the incidence of Diabetes Mellitus by at least 50%.

Cheap manufactured food subsided by the government results in 19% of America’s fossil fuel use. It also results in more than 75% of the obesity in this country.

Eighty per cent of the healthcare dollars are spent on the complications of chronic diseases. The eighty percent cost to the healthcare system is one trillion six hundred million dollars a year.

The obesity epidemic is interconnected with our energy policy and energy subsidies, farm policies and subsidies, environmental policy and conditioned attitudes toward fast food.

 Michael Pollan points out the problem with our entire food supply system and the impact it has on healthcare, the environment and energy.

“Which brings me to the deeper reason you will need not simply to address food prices but to make the reform of the entire food system one of the highest priorities of your administration: unless you do, you will not be able to make significant progress on the health care crisis, energy independence or climate change

The three problems are tightly connected. The repair of each problem has to must be done in a creative way that aligns all the stakeholders’ incentives with consumers’ health and wellness.

Michael Pollen goes on to tell President Obama “Unlike food, these are issues you did campaign on — but as you try to address them you will quickly discover that the way we currently grow, process and eat food in America goes to the heart of all three problems and will have to change if we hope to solve them.

Mr. Pollan’s point is the way we grow food and manufacture food stuff is a major reason for obesity and pollution leading to the complications of chronic diseases (Type 2 Diabetes Mellitus and chronic lung disease). This results in a 1.6 trillion dollar cost to the healthcare system. All American’s needs is the will to change.  

It is going to require a lot of public and congressional education. It will be harder to educate congress than the public. Vested interest lobbying drives Congress.  President Obama must help the public create a greater voice than the special interests. The public will then lobby the congress.

Michael Pollan says “the 20th-century industrialization of agriculture has increased the amount of greenhouse gases emitted by the food system by an order of magnitude; chemical fertilizers (made from natural gas), pesticides (made from petroleum), farm machinery, modern food processing and packaging and transportation have together transformed a system that in 1940 produced 2.3 calories of food energy for every calorie of fossil-fuel energy it used into one that now takes 10 calories of fossil-fuel energy to produce a single calorie of modern supermarket food. Put another way, when we eat from the industrial-food system, we are eating oil and spewing greenhouse gases.  

The reformatting of the payment system for physicians with the theoretical effectiveness of Accountable Care Organizations (ACO’s) will not work. It will only waste money. It will only dispirit the medical profession and diminish the effectiveness of a necessary workforce. Physicians are not the villains.

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

 

 

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