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A Big Idea For President Obama

April 17, 2011

inMedicine: Healthcare System, Patients Problems, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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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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Healthcare Is A Team Sport

April 26, 2009

inEMR, Medicine: Healthcare System, Patients Problems, Quality medical care measures

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Stanley Feld M.D.,FACP,MACE

Healthcare is a team sport. The patients are the most important members of the team. They are the players. Physicians are the coaches. They should be adjusting their recommendations after receiving maximum data from the patients. Patients must become the “professors of their disease”. In order to have a successful team, physicians need several assistant coaches. The physician extenders must not be physician substitutes. Physician extender are nurse educators, dieticians, psychologists, social workers and exercise therapists. Patients must be at the center of the healthcare team and relate to the entire team in order to have maximum knowledge about their disease. It requires a great deal of responsibility on the part of the patient.

I chaired the American Association of Clinical Endocrinologist Diabetes Guidelines in 2002 in which this team approach is outlined. The AACE diabetes guidelines also contains a patient/physician contract. It spells out the responsibilities of the patient and physician. The team unit cannot be successful if the assistant coaches act independent of physicians.

The internet can provide some infrastructure to aid the assistant coaches. So far, internet based information has not been an extension of physicians’ care (Healthcare 1.0). It has been a failure. The internet assets developed (some of which have been good) have proven to be ineffective in repairing the healthcare system.

Jennifer McCabe Gorman understands the problem. She is working diligently to promote the concept of connecting internet based patient centered information with physicians care (Healthcare 4.0). I believe she understands the concept of patient centered healthcare with healthcare as a team sport and physicians as the leaders of the team. I believe she has the passion and ability to translate this vision into reality.

Until now content on the internet has provided generic information about chronic diseases. Most of the information lacks context and nuance. Most of the internet content does not explain the pathophysiology of the disease process. Internet content out of context tends not to be helpful. Some of the content is inaccurate.

Jen McCabe Gorman describes Web 2.0 as a combination of content and social networking. Disease based social networking is growing rapidly and rightly so. We are all social beings starved for information. We need and seek disease based social interaction. Social networks give patients the opportunity to cluster by disease and share their experiences with a disease process. This can be helpful. However, its limits must be understood. Individual patient uniqueness and disease variation must be taken into account. It would be wonderful if the social network were an extension of the individual patient’s physician’s care. Physicians will gradually understand its value as a teaching tool to help patients become “professors of their diseases”. Presently disease based social networks act as physician substitutes. This use decreases both physicians’ and social networks’ effectiveness.

Patients live with their disease 24/7. If patients understand the dynamics of their chronic disease, they and their physician can be more effective in their decision making. Patients would have a better chance of controlling their disease and avoiding the costly complication of the disease.

I believe that repair of the healthcare system can be partially achieved with effective disease specific social networks as an extension of physicians’ care. Social networks are not focused on that goal yet(Healthcare 2.0). The goal is to get to Healthcare 4.0

Healthcare 3.0 is what Google Health and Microsoft’s Health Vault are trying to do with an internet based Personal Health Record (PHR). I predict they will fail. It is not connected to physicians care. My wife and I carry our PHR on a key ring flash drive. The PHR could easily be carried in an IPhone.

Patients must express outrage and force their physicians to utilize the medical records patients have gathered. Patients input into their own care, control of their own data, participation in the treatment decision making and being responsible for their care is the only way to reduce costs and avoid chronic disease complications.

Healthcare 4.0 will arrive. With the expansion of social networking we are developing more sophisticated patients who will become sophisticated consumers of healthcare. Patients will demand functional EMRs from their physicians. Only then will disease specific social networks become an extension of the physicians care and effectively decrease the complications of chronic disease.

The two primary stakeholders in the healthcare system are the patients and the physicians. All other stakeholders are secondary stakeholders. Additionally, it is essential that all the stakeholders align their collective vested interests in order to repair the healthcare system. With the development of internet based assets including a fully functioning EMR the alignment of vested interests will occur because patients will be empowered to demand it.

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

Dr. Davon Jacobson, MD • April 27, 2009

This is really a well laid out website. I like how you have presented the information in full detail. Keep up the great work and please stop by my site sometime. The url is http://healthy-nutrition-facts.blogspot.com
Stephen Holland • November 2, 2012

It looks like hospitals are marginalizing physicians. Cardiology practices are now mostly hospital owned. Hospitals are buying medical practices regularly. EMRs are being selected by hospitals, not physicians. The ownership of the EMR establishes the branding of the practice and creates defacto referral systems among specialities that share the EMR. We physicians are letting this happen. My colleagues tell me I’ll just have to get used to the EMR cause that’s the way it’s going. It so frustrates me to see hospitals choose winners and losers in referral patterns. It will become nearly impossible to form new medical groups when all groups essentially have become parts of multispeciality groups. Competing single specilaity groups, which is the basis for the quality drive in medicine today, will disappear, and the satisfaction of hospital administrators will determine if a group is viewed favorably. Of course, that means that groups that refer most to the hospital will be the most rewarded. Surgicenters will be hit, hospital outpatient care will cost more, less patients will be served, doctors will be less efficient, and patients will have to wait.
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President Obama; If You Really Want To Reduce Healthcare Costs, Effectively Reform The Medical Malpractice Tort System: Part 4

April 19, 2009

inMedicine: Healthcare System, Patients Problems, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

President Obama, there are other consequences of the present malpractice liability system that cannot measured in dollars or impact. In order to avoid potential law suits physicians are avoiding high risk patients and high risk patient procedures. The result is a decrease in patient access to necessary care.

The measured costs of defensive medicine can be calculated from the Massachusetts Medical Society survey.

“Physicians practice defensive medicine because they don’t trust the medical liability system. This survey should provide a strong impetus for legislative, business, and health care industry initiatives promoting fundamental liability reform.”

It is essential to introduce effective and fundamental liability reform to reduce the practice of defensive medicine, decrease costs and improve access to care.

The Massachusetts Medical Society’s survey of physician concerning defensive medicine also point out the restriction of access to care as a result of the malpractice environment.

“The survey found that 38 percent of responding physicians reported they reduced the number of high-risk services they performed, with orthopedic surgeons (55%), obstetrician/ gynecologists (54%), and general surgeons (48%) reporting the highest frequencies.”

These actions by physicians’ specialties are a natural reaction to the malpractice environment. It also reduces the healthcare system’s capacity to care for sick patients.

“28 percent of physicians in the sample reported reducing the number of high-risk patients they saw, with obstetrician/gynecologists (44%) and the surgical specialties (37–42%) much more likely to reduce their number of high-risk patients.”

In many small or medium sized communities there is little or no access to medical or surgical specialists to take care of high risk patients. President Obama, rather than increase the quality of care, as you have promised, the quality of care in some communities will decrease.

Other surveys by the Massachusetts Medical Society confirm their survey.

“In its annual Physician Workforce Study over the last five years, the Society has found that an average of 44%-48% of physicians in the state reported that they are altering or limiting their practices because of the fear of being sued.”

The 2008 workforce study’s results were worse than the Massachusetts Defensive Medicine survey. More than half of physicians in seven specialties said they have progressively limited their practices, the fear of a frivolous malpractice suit being the primary reason. It is natural for people to adjust to their environment.

“Neurosurgery practices (76%), urology (75%), emergency medicine (66%), obstetrics/gynecology (57%), family medicine (53%), general surgery (51%), and orthopedics (51%).”

President Obama, what should you do to neutralize the negative impact of defensive medicine?

First, do not believe the arguments of the trial lawyers. The claim that malpractice reform will harm patients "by limiting their ability to seek compensation through the courts" is a smoke screen to protect their profitability in law suits.

The medical liability system is inefficient. It does not compensate patients experiencing medical errors very fairly. In fact more than 50 cents on every compensated dollar goes to pay lawyers and the courts. Patients may wait year to receive a single penny. The wear and tear of a malpractice suit on patients experiencing medical errors and physicians being sued is enormous.

The answer is not to leave it up to congress to work it out. Congress has a 30% approval rating. Congress is also composed mostly of lawyers. You are our leader. You are the one who must outline the change that is fair to patients, the government, and physicians.

The fundamentals of change should include the following:

Decrease the profitability of malpractice suits for attorneys.
Invest in a culture of patients’ safety at every healthcare enterprise.
Promote full disclosure to patients about adverse events quickly without legal consequences.
Promote apology to patients without legal consequences.
Provide fair compensation to patients for medical errors.
Professional mediation and arbitration to resolve disputes quickly and dismiss frivolous claims abruptly.
Create a body of judges immune from liability to adjudicate malpractice suits. The body should be composed of physicians and lay leaders. The best judge of physicians medical errors are other physicians if they were freed of adverse countersuit
Create a system of no fault malpractice insurance.
Place limits on patient compensation and expedient rate of compensation.
Eliminate the adversarial nature of the claims.
Build trust between patients and physicians.

Defense attorneys will hate most elements of this proposal because it threatens their vested interest and profitability. I suspect they will fight them with tooth and nail.

President Obama, if you implement these proposals to fundamentally change the medical liability system you would go a long way to reduce the practice of defensive medicine and a yearly wasted cost of $700 billion dollars to the healthcare system.

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

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President Obama; If You Really Want To Reduce Healthcare Costs, Effectively Reform The Medical Malpractice Tort System: Part 3

April 15, 2009

inMedicine: Healthcare System, Patients Problems, Physician's Problems, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

President Obama, the details of the Massachusetts Medical Society Defensive Medicine survey have profound importance in explaining trends in the delivery of medical care. Unfortunately, only meaningless sound bites have been given by the media. The survey’s significance has not had the impact on policy it should.

The authors state that the dollar estimates do not include the diagnostic procedures, hospital admissions, specialty referrals and consultations or unnecessary prescription by physicians in specialties not included in the study.

The eight specialties surveyed represent only 46% of the physicians in the Massachusetts. The real costs to the healthcare system from the practice defensive medicine in the state of Massachusetts are much higher. The authors estimate the real costs could be twice the $1.4 billion dollars per year they estimated.

I believe the costs of defensive medicine in many other states are much higher because the cost of litigation in many states is lower and the malpractice awards are higher encouraging litigation.

“This survey clearly shows that the fear of medical liability is a serious burden on health care,” said Dr. Sethi. “The fear of being sued is driving physicians to defensive medicine and dramatically increasing health care costs. This poses a critical issue, as soaring costs are the biggest threat to the success of Massachusetts health reform efforts.”

Defensive medicine is definitely a threat to the success of the Massachusetts healthcare reform efforts. President Obama, defensive medicine is a big burden nationally to the healthcare system. Its costs will undermine any attempt at healthcare reform unless you take medical malpractice liability reform seriously. There has to be a fundamental change in the structure of adjudication.

The survey’s findings must be studied carefully. The physicians surveyed estimated their percentages for defensive medicine testing to avoid law suit. I think their estimates are low. The real percentages must be studied objectively using data mining techniques. Nonetheless the current estimates reveal unsustainable waste in our dysfunctional healthcare system.

Radiological imaging is one tool overused by physicians defensively to avoid litigation. Physicians feel they must test everything even if the probability of a positive result is insignificant.

“Plain Film X-Rays: An average of 22% of X-rays were ordered for defensive reasons.”

“CT Scans: An average of 28% of CT scans were motivated by liability concerns, with major differences among specialties.”

About 33% of scans ordered by obstetricians/ gynecologists, emergency physicians, and family practitioners were done for defensive reasons.

The total number of unnecessary CT scans needs to be calculated along with its costs in order to understand the significance of the percentage presented. The health policy solution should not be to lower the reimbursement for CT scans. The solution is to fix the medical malpractice liability system.

MRI Studies: An average of 27% of MRIs were ordered for defensive reasons, with significant differences by specialty.

The highest rates were reported by obstetricians/ gynecologists, general surgeons, and family practitioners, with the lowest rates by neurosurgeons and emergency physicians.

Ultrasound Studies: An average of 24% of Ultrasounds were ordered for defensive reasons. Orthopedic surgeons (33%) and obstetricians/gynecologists (28%) reported the highest rates, with neurosurgeons (6%) and anesthesiologists (9%) the lowest.

I believe neurosurgeons are underestimating their use of radiologic procedures in order to look good. Neurosurgery is one of the specialties with the highest malpractice rates. Please note that obstetricians/gynecologists take no chances and order the most procedures for defensive purposes.

Laboratory Testing:

An average of 18% of laboratory tests were ordered for defensive reasons, with emergency physicians (25%) reporting the highest rates and neurosurgeons (7%) the lowest.

Specialty referrals, consultations and hospitalizations are overused the most for defensive reasons. No one wants to take a chance and send the patient home even if the indication for hospitalization is small. Hospitalization is also the most costly overused element in defensive medicine.

Specialty Referrals and Consultations:

“An average of 28% of specialty referrals and consultations were motivated by liability concerns, with significant differences by specialty. Obstetricians/gynecologists reported that 40% of their referrals and consultations were done for defensive reasons, and anesthesiologists and family practitioners said that 33% of their referrals and consultations were done for the same reasons.”

Hospital Admissions:

An average of 13% of hospital admissions were motivated by liability concerns, with surgical specialties reporting lower rates than the other specialties.

The percentages of defensive procedures are admitted by practicing physicians. The cost of defensive medicine is high and wasteful. President Obama, defensive medicine is not the minor problem that the malpractice attorneys want you to believe it is. It is time for definitive action now.

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

Medical Negligence • January 24, 2011

The doctor’s actions have caused or contributed to the plaintiff’s personal injury, his actions may not be deemed negligent if it can be shown that they were the ‘reasonable’ actions of a medical professional given the information the doctor had and the specific circumstances.
Tyler grey • July 11, 2012

I just stumbled upon your informative blog and wanted to say that I have really enjoyed reading your blog posts. I will be your frequent visitor.
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President Obama; If You Really Want To Reduce Healthcare Costs, Effectively Reform The Medical Malpractice Tort System: Part 2

April 12, 2009

inPatients Problems, Politicians,Healthcare and Vested Interests

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Stanley Feld M.D.,FACP,MACE

President Obama, as you know the real truth is elusive. Every vested interest has an agenda to protect. My agenda as a long time practicing Clinical Endocrinologist, now retired from active practice, has been to preserve the value of the profession of medicine and permit the delivery of the best clinical care possible to patients. Society has strayed from these goals. There are multiple problems with the healthcare system. They are interrelated and must be solved simultaneously.

The present malpractice liability problem leading to the practice of defensive medicine is a huge problem for the healthcare system. It is essential that this problem be solved before meaningful cost savings and increased quality of care are realized

Malpractice attorneys dismiss the system of adjudicating malpractice liability as the cause of significant defensive medicine costs. They claim that they are the protectors of mistreated patients. You will soon receive a 29 page document defending their claim and dismissing the significance of defensive medicine.

“Trial lawyers are preparing for a fight, starting with a 29-page research document they will send to Capitol Hill in an attempt to convince lawmakers that lawsuits have very little to do with healthcare costs.”

The malpractice attorneys will attempt to make a compelling argument. I suspect they will have little real scientific evidence to prove their point in the 29 page document.

Donald Berwick Professor in the Department of Health Policy and Management Department of Health Policy and Management has never been a friend of practicing physicians. He has frequently pointed out the defects in the practice of medicine. Recently Don Berwick made the following off the cuff comment in response to a question after he addressed the American Medical Association (AMA) meeting.

"What about malpractice reform?" the first questioner asked when Berwick opened up the discussion to attendees. He was a physician, and murmurs of approval rippled through the crowd.”

Berwick’s answer didn’t please the questioner and many of his colleagues. “The data just doesn’t back up the claim that malpractice lawsuits are one of the top drivers of healthcare costs, he replied.”

No one was brave enough to ask Dr. Berwick to show them the data for this conclusion. I have read Fooled By Randomness twice. I am starting to understand that all expert opinions are noise unless they are confirmed scientifically. Even then conclusions can change as the knowledge base changes.

In November 2008, the Massachusetts Medical Society published a survey of practicing physicians. The purpose of the survey was to get a sense of what practicing physicians (the generators of defensive medicine) thought the incidence of defensive medicine was in their practice. I was surprised it was not published in the New England Journal of Medicine.

“A first-of-its-kind survey of physicians by the Massachusetts Medical Society on the practice of “defensive medicine” – tests, procedures, referrals, hospitalizations, or prescriptions ordered by physicians out of the fear of being sued – has shown that the practice is widespread and adds billions of dollars to the cost of health care in the Commonwealth.”

The devil is usually in the details. The details found were the details at ground level. It was not speculations by experts or secondary measurement. The defect in the survey was the fact that was a survey (surveys have its scientific defects) even though 900 practicing physicians in eight specialties in Massachusetts completed the survey. Its strength is the survey links practice to costs.

“The Investigation of Defensive Medicine in Massachusetts” is the first study of its kind to specifically quantify defensive practices across a wide spectrum and among a number of specialties. The study is also the first of its kind to link such data directly with Medicare cost data.”

Physicians self reported on seven tests that might be used in defensive medicine. They were plain film X-rays, CT Scans, Magnetic Resonance Imaging (MRIs), ultrasounds, laboratory testing, specialty referrals and consultations.

Based on Medicare reimbursements rates in Massachusetts for 2005-2006 the eight specialties surveyed generated 281 million dollars in defensive medicine costs in outpatient clinics. Their practice of defensive medicine also generated $1.1 billion in unnecessary costs for hospital admissions. The big winner here was the hospitals. Hospitals might not be motivated to fight as hard as physicians to eliminate defensive medicine because defensive medicine serves its revenue generating agenda well.

The estimate of a total of $1.4 billion only includes 7 tests and 8 specialties in a 900 physician sample. Massachusetts is a small state. If we assume all the states are the same size and multiple by 50 states we are talking about $70 billion dollars wasted on defensive medicine.

If the survey included all specialties, all physicians, and all costs including the cost of malpractice premiums and physician practice time lost in litigation in all states, my guess would be the cost of defensive medicine would be ten times the 70 billion dollars. A $700 billion dollar cost for defensive medicine is an unnecessary cost to the healthcare system. This cost can be dismissed lightly or yield to unscientific expert opinion. The result does not include the emotional toll on physicians being sued and the lawsuits effect on their ability to practice medicine.

The legal system for handling malpractice claim is very costly. A more logical and cost effective system for adjudicating patients harmed by medical error needs to be instituted.

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

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Is Barack Obama Any Different Than Other Politicians? Part 6

August 26, 2008

inMedicine: Healthcare System, Patients Problems, Politicians,Healthcare and Vested Interests

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Stanley Feld M.D.,FACP, MACE

Some of the ideas in Barack Obama’s healthcare plan are good. However, some of the ideas have defects. The defects will render execution of his healthcare plan impossible. The complexity of his bureaucratic machinery will make his plan inefficient and costly.

Quality and efficiency are important bullet points in Barack Obama’s healthcare plan

· Quality and Efficiency.

“ Participating insurance companies in the new public program will be required to report data to ensure that standards for quality, health information technology and administration are being met.”

I have stated that measuring quality medical care has not been accurately defined. Quality medical care should be measured by positive medical outcomes at the least cost. Successful medical outcomes have to be linked to successful financial outcomes.

Inaccurate quality measurements are presently being used to judge physician performance. The system is called Pay for Performance (P4P).

Hemoglobin A1c testing is an example of a presently used quality measure. Does the physician do four hemoglobin A1c’s per year in treating his diabetics? HbA1c is a measurement of glucose control over a 3 month period of time. The result is a valid measurement of glucose control.

The four measurements of HbA1c are in itself meaningless. The importance of the measurement is to track patients’ HbA1c improvement over the year? How much of the improvement was due to the physician’s treatment? How much of it was due to the patient’s effort to improve his HbA1c? Did the improvement in HbA1c prevent the patient from developing a complication of Diabetes Mellitus?

Did the improvement keep the patient out of the hospital? The results and cost savings from these results are the parameters that should be measured to make the judgment of the quality of care and not the measurement of HbA1c itself. The dual fulfillment of the responsibility of the physician and patient should be measured. None of these goals are included in the definition of quality measurements at this time. Until they are we do not have an accurate measurement of quality medical care.

Before the government can demand that participating insurance companies in the new public program can ensure that standards of quality are met quality has to be defined. If the healthcare insurance companies are determining quality the government is essentially putting the fox in the hen house to have a feast.

Lowering costs by modernizing the healthcare system is an essential idea. The responsibility for the cost of care should not be a burden of the government. It should not be a burden on the employer who is providing the benefit. It should be a burden of the consumer (patient). It should be the consumer’s responsibility to take care of him. The employer and government should aid the consumer in his ability to fulfill his responsibility for his wellness and effective and efficient care if he is sick.

Lower Costs by Modernizing The U.S. Health Care System

Reducing Costs of Catastrophic Illnesses for Employers and Their Employees:

Catastrophic health expenditures account for a high percentage of medical expenses for private insurers. The Obama plan would reimburse employer health plans for a portion of the catastrophic costs they incur above a threshold if they guarantee such savings are used to reduce the cost of workers’ premiums.

Many of the chronic diseases are the result of our social behavior and environment. Obesity, pollution, drug addiction, smoking, and public hygiene generate many chronic diseases. Who should be responsible for our social behavior and environment? Should it be the government, our employer, the state, or our neighbors?

I believe the government should be responsible for developing programs to eliminate pollution as it did in the past with smoking. Our government has dropped the ball with its public service campaign against smoking. It can be done if Congress and the President had the courage to do it.

The government could also do much to reduce obesity and drug addiction. However, it must be up to the consumer to be responsible for himself. Obesity and drug addiction are tinder box problems for our healthcare system. Coal burning electricity plants are another problem. It increases our carbon footprint but this impact is not even a required measurement for license. The indiscriminate use of antibiotics in cattle feed lots is another tinder box problem. The problem could be a mutation of an antibiotic resistant infectious disease epidemic. Barack Obama should be talking about solving these problems and not providing a rebate for employers who have employees with catastrophic illness.

Helping Patients:
1. Support disease management programs. Seventy five percent of total health care dollars are spent on patients with one or more chronic conditions, such as diabetes, heart disease and high blood pressure. Obama will require that providers that participate in the new public plan, Medicare or the Federal Employee Health Benefits Program (FEHBP) utilize proven disease management programs. This will improve quality of care, give doctors better information and lower costs.

This is a great idea. Presently these programs are not supported by the government or healthcare insurance companies.

Traditionally the government sets up pilot programs to test every concept. However, when the pilot study for the effect of managing chronic disease failed, it failed not because the concept of chronic disease management was wrong but because the design of the pilot was defective.

· Coordinate and Integrate care.

Over 133 million Americans have at least one chronic disease and these chronic conditions cost a staggering $1.7 trillion yearly. Obama will support implementation of programs and encourage team care that will improve coordination and integration of care of those with chronic conditions.

This is another great idea. The emphasis for reimbursement has to shift from procedural medicine to cognitive medicine. Since cognitive medicine has not been well supported with reimbursement, physician care has migrated to procedural medicine. Diabetes education is an essential element in teaching the patient how to become a “professor of their disease”. It is essential that patients know how to self manage their diabetes. Diabetes education program must be supported so that physicians can afford to develop diabetes education centers in their office. The diabetes education must be an extension of the physicians care. It does not work in a free standing clinic that is uncoordinated with the physician. It has to be a team management effort with the patient in the center of the team and the physician the captain of the team. It must be a team effort so the patient feels connected and cared for.

None of the infrastructure for chronic disease management is in place presently. I am happy that in Barack Obam
a’s healthcare plan there is awareness of this essential element to repair the healthcare system. However legislative regulation must occur for this to become a reality.

· Require full transparency about quality and costs.

“Obama will require hospitals and providers to collect and publicly report measures of health care costs and quality, including data on preventable medical errors, nurse staffing ratios, hospital-acquired infections, and disparities in care. Health plans will also be required to disclose the percentage of premiums that go to patient care as opposed to administrative costs.”

Real price transparency is another big idea.

It must occur if there is going to be any improvement in the costs of the healthcare system. However, if all we have is a single party payer (the government) with the administrative services outsourced to the healthcare insurance industry price transparency will not occur. There will be no competition for healthcare insurance coverage. The lack of competition means the lack of innovation.

Barack Obama has some good ideas.The ideas will fail because big government is king. It is big government’s role to control the lives of the people rather than creating programs which promote people to control their own lives? Most people can be trusted. If they can not control their own lives under proper incentives and supervision they should be penalized. The government should not try to control the lives of the people.

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

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Is Barack Obama Any Different Than Other Politicians? Part 1

August 17, 2008

inMedicine: Healthcare System, Patients Problems, Physician's Problems

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Stanley Feld M.D.,FACP, MACE

No! He is not.

In the weeks to come I am going to point out the deficiencies in both
candidates thinking about healthcare. It is clear that neither has received
input from practicing physicians. Please click on the highlighted phrases for
more details on each subject.

I will start with Barack Obama because the Democratic convention is first.

I am astonished by the lack of scholarship and thoughtfulness on the part of
either Presidential candidate. The issues have been reduced to sound bites. The
pronouncements are picture words that generate false hope. Neither political
party is confronting the real issues and the necessary repairs. If any of their
proposals are passed into law it will simply be a patch. In the process the
proposals will destroy the vital and good elements of our entire healthcare
system.

Both the Medicare and the Private Healthcare Insurance system have failed.
They have neither decreased costs nor improved medical outcomes. They have been
both economic and medical care disasters. The United States can no longer afford
the present course. Academically the reasons for the disaster are clear.

1. Price
controls do not work!

2. Price
transparency is essential to create a free market economy!

3. There are too
many monetary incentives in the healthcare system to maintain an inefficient
system for all stakeholders. (primary and secondary stakeholders)

4. Punitive
measures directed at the weakest stakeholders (primary stakeholders) to
correct inefficiencies do not work and lead to greater inefficiencies.

5. The healthcare system must be constructed and run
for the benefit of the primary stakeholders.

6. The
primary stakeholders must drive the healthcare system for their medical and
financial benefit. (Consumer driven healthcare).

7. Secondary
stakeholders should be facilitators for the primary stakeholders.
(patients).

8. Profit
derived from the system should be the result of efficiency and not the result of
political influence to protect secondary stakeholder vested interests.

9. Consumers
as the primary stakeholders must be responsible for their health, and medical
care. Appropriate government subsidy must be provided, if warranted.

10. The
government must set up rules to protect the consumer from the healthcare
insurance industry, hospital systems, drug companies and physicians

10. Actions should be taken by government across all areas of society (War
on Obesity) to educate
consumers to decrease the incidence of chronic disease.

The consumer must fix the healthcare system. None of the other stakeholders
has been successful. In fact, in the last 30 years the healthcare system has
been made worse by the insurance industry, government and policy makers.

All their systemic changes have failed because they have, for the most part,
been to the advantage of the facilitator stakeholders and not the primary
stakeholder, the patient. Facilitator stakeholders’ profits have soared,
insurance premiums have skyrocketed while access to care has plummeted.
Patients, physicians, hospital systems and the government have adjusted to
changes to the detriment of patients. The facilitator stakeholder adjustments
have resulted in further dysfunction in the healthcare system.

Presently, employers and all the stakeholders except for the insurance
industry are in pain. However, the stakeholder most at risk is the consumer.
Only 20% of the population is sick and interacts with the healthcare system at
any moment in time. 80% of the population does not interact with the healthcare
system. They think everything is fine. However, the entire populations’ health
and well being is at risk! If we stay on the present course, I predict the
system will break down completely. Access to care will be limited and rationed.
Access to life saving medical advances will vanish. Future advances in medical
care will disappear.

The goal of the healthcare system should be;

1. To provide patients

a. with access to good quality care
b. with
education to judge quality care
c. with incentives
to be motivated to be responsible for their medical care
d. with the freedom
to judge and select the physician of their choice
e. with the information
from their healthcare providers that is truly portable
f. with choice
of healthcare insurance vehicles that are affordable
g. with education
vehicles to become “Professors of their Chronic Disease” and be truly
responsible for their care
h. effective
and affordable drug coverage designed to enhance patient compliance with
treatment

2. To provide physicians

a. with a precise definition of the meaning of quality care for various
chronic diseases
b. with incentives to provide quality care for both acute
and chronic disease
c. with the educational opportunity and motivation to
improve the quality of care they deliver.
d. with an actual vehicle developed
by their peers to prove that they are delivering quality care.
e. with a
mechanism for delivering care at a transparent price
f. with the ability to
effectively
communicate with patients electronically.
g. with the
ability to improve the patient physician relationships
h. with the
ability to enable patients to practice effective self-management techniques to
prevent costly complications of chronic disease
i. with the ability to
improve communication and access to patient information so as to reduce the cost
of redundant evaluation and treatment

3. To decrease the overall cost of the system

4. To eliminate the 47 million uninsured

5. To align stakeholders’ incentives

6. To provide satisfactory profit margins for hospitals, pharmaceutical
companies, insurance companies, and physicians.

These are ambitious goals. Processes must be changed in order for the United
States to deliver effective health care to the population now and in the future.

Consumers can not leave it up to the facilitator stakeholders and policy
wonks to fix the system. Their policies have distorted the healthcare system in
the past to serve their vested interests. Patients today and in the future must
drive the process of change through appropriate demands on our politicians in
order to repair our healthcare system and install an effective consumer driven
healthcare system.

Toronto life insurance broker • August 18, 2008

I believe Obama offers simple solution for a very complicated problem. And that’s it – there are no easy, painless solutions, no Alexander the Great to cut the Gordic knot…but voters don’t want to see it, in USA, or here in Canada…I think the biggest problem are tremendous costs of your health system. but how to cut those hundreds of billions???
Lorne
Stephen Holland • November 2, 2012

Lorne: What are you smoking?
Steve MD
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Did You Know The United States Could Have A Prescription Drug Shortage!

August 5, 2008

inMedicine: Healthcare System, Patients Problems, Physician's Problems

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Stanley Feld M.D.,FACP,MACE

China is determined to present a favorable impression to the world during the Olympic Games. Beijing is extremely polluted. It is desperately trying to decrease the pollution in the city and its surroundings. The pollution could affect the athlete’s performance and health. Many countries have expressed concern.

In order to clean up the air quality for the Olympic Games athletes, Beijing has taken extreme measures shunting down many large commercial plant operations in its vicinity. Many chemical plants in and around Beijing produce ingredients for both generic and brand named drugs. These plants are dirty plants producing significant pollution. The closing of these chemical plants before and after the Olympics will result, at least, in large increases in drug prices globally and, at most ,in life threatening shortages of vital medications throughout the world.

“The expedience of reducing particulate pollution has prompted officials to temporarily shut down chemical production in and around Beijing prior to the Olympics. This crackdown is likely to include pharmaceutical production.”

The Chinese government has been trying to relocate polluting industries and power generating plants away from its large cities. Cleaner plants have already been built in less populated areas. However, the production of particulate matter (microscopic particles toxic to lung tissue) is still twice the admissible level recommended by the World Health Organization. Pollution from particulate matter produces both acute and chronic pulmonary disease. Chinese government officials have temporarily shut down chemical production for two months prior to the Olympics and one month post Olympic Games to decrease particulate matter in the air.

This crackdown affects pharmaceutical production. China is the largest producer in the world of bulk pharmaceuticals known as active pharmaceutical ingredients (API)

“China is the largest producer of bulk pharmaceutical chemicals, also known as active pharmaceutical ingredients (APIs), which are made into drugs that supply the world. With India it supplies 40% of the API used in U.S. pharmaceutical production, an amount predicted to increase to 80% by 2020. China provides at least 20% of the APIs used in making Indian generic drugs, as well as about 75% of the intermediate products Indian firms require to synthesize the final products they sell.”

These APIs are used for the production of both brand named and generic drugs. The U.S. press has not discussed the source of production of U.S. brand named drugs.

“For the next two months Western and Indian companies will find it difficult to import most chemical substances including bulk drugs and intermediates from China. This could prove costly to patients and especially costly for the Indian generics industry, because their companies are so reliant on Chinese inputs.”
The price of APIs has increased at least 50% over the past six months.”

This is putting pressure on the pharmaceutical industry’s profit. The increase in price for APIs has been blamed on the increase in the price of oil as well as the decrease in China’s production. This is certainly going to be reflected in the increase in drug prices shortly at all levels.

“Given that many of China’s bulk API manufacturers operate around Beijing product prices will still increase drastically over the next few weeks as supply is constricted from Beijing alone.”

I predict we are going to see the impact of China’s decreased production on the United States drug supply in the next few weeks. I suspect we are going to see life threatening shortages.

One must wonder about this perverse effect of “globalization” on our ability to deliver appropriate medical care if it results in significant shortages of vital medication.

The other perverse effect of globalization is the inability or lack of desire on the part of multinational companies operating throughout China in joint ventures with the Chinese government to protect the environment of the country to the detriment of its citizens in order to product “cheap” medication for the United States and the rest of the world.

“It is impossible to calculate how many lives will be lost because drug prices are rising,”

It is easy to feel that the wheels are coming off the global economy as indiscretions are being tolerated by government. As these indiscretions are revealed one has to wonder if the present direction of globalization is a good idea.

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

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It Is Not Only Older Physicians Who Are Discontent: Part 2

July 9, 2008

inMedicare, Medicine: Healthcare System, Patients Problems, Physician's Problems, Politicians,Healthcare and Vested Interests

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Stanley Feld M.D.,FACP,MACE

The administrative difficulties in the physicians’ work environment are increasing physician discontent.

“In a survey last year of nearly 2,400 physicians conducted by a physician recruiting firm, locumtenens.com, 97 percent said they were frustrated by nonclinical aspects of medicine. The level of frustration has increased with nearly every survey.”

The important point is that it is our younger physicians who are complaining about the burdens of medical practice.

“Dr. Bhupinder Singh, 42, a general internist in New York, sold his practice and went to work part time at a hospital in Queens. When he decided to work in a hospital, he figured that there would be more freedom to practice his specialty.”

Recently, he confessed, he has been thinking about quitting medicine altogether and opening a convenience store. “Ninety percent of doctors I know are fed up with medicine,” he said.

Many healthcare policy makers dismiss these complaints as the failure of managed care. Managed care was a system policy makers developed to manage costs. It is a system that has failed to manage care and manage costs as well.

“It is not just managed care. Stories of patients armed with medical knowledge gleaned from the Internet demanding antibiotics for viral illnesses or M.R.I. scans for routine symptoms are rife in doctors’ lounges. Malpractice worries also remain at the forefront of many physicians’ minds, compounded by increasing liability premiums that have forced many into early retirement.’

Physicians are discouraging their children and their friends’ children from becoming physicians. The opposite was true in past generations.

In surveys, increasing numbers of doctors attest to diminishing enthusiasm for medicine and say they would discourage a friend or family member from going into the profession.

Practicing physicians are not stupid. They are adjusting their practice to decrease practice burdens. Some Ob-Gyn physicians have stopped delivering babies because of the malpractice burden and decrease in reimbursement. They are only practicing gynecology. The adjustments in medical practices are to the detriment of patient care.

“Doctors are working harder and faster to maintain income, even as staff salaries and costs of living continue to increase. Some have resorted to selling herbs and vitamins retail out of their offices to make up for decreasing revenue. Others are limiting their practices just to patients who can pay out of pocket.”

“There are serious consequences to this discontent, the most worrisome of which is that it is difficult for doctors who are so unhappy to provide good care.”

I have said over and over again that healthcare policy makers do not listen to or ask physicians for advice. The end result will be a severe physician shortage. Physician shortages are here already. The central problem is quality care for patients and not the healthcare insurance company’s bottom line. I hope policy makers are listening.

“Another is a looming shortage of doctors, especially in primary care, which has the lowest reimbursement of all the medical specialties and probably has the most dissatisfied practitioners.”

Last year, residency programs in family practice took only 1,096 graduating medical students, the fewest in the last two decades. The number increased just slightly this year. “For me it’s an endless amount of work that I can never get through to do it properly,” said Dr. Jeffrey Freilich, 38, a primary-care physician on Long Island. “I’m a bit compulsive. There is no time to do it all in a day.”

“On top of all that, there are all the colonoscopies and mammograms you have to arrange, and all the time on the phone getting preauthorizations. Then you have to track the patient down. And none of it is reimbursed.”

The only services primary care physician have to sell is their time and clinical judgment. Both services are undervalued in the present healthcare system.

Once a patient is hospitalized the primary care physician loses track of the patient. Hospitalists take over. Hospitalists call many specialists for consultation and advice.

“The upshot is that the doctor who knows a patient best is often uninvolved in her care when she is hospitalized. This contributes to the poor coordination and wanton consultation that is so common in hospitals today.”

“Years ago you had one or two doctors,” a hospitalized patient told me recently. “Now you’ve got so many people coming in it’s hard to know who’s who.”

Medicare is going to cut payments to physicians 10.6% in July. Why? It is easier to cut physicians who utilize 20% of the healthcare dollar than to cut the stakeholders that absorb 80% of the healthcare dollar. Why? Physicians are not organized! They are also cheapskates and do not support lobbyists. They do not have the powerful a lobbying infrastructure that the healthcare insurance industry and the American Hospital Association.

A 10.6 percent cut in Medicare payments to physicians is scheduled to take effect on July 1. Further cuts are planned in coming years. Many doctors have told lawmakers that if the cuts go through, they will stop seeing Medicare patients.

Unfortunately, politicians do not understand the problems physicians and patients have in the healthcare system. It is going to be up to patients and physicians make these problems clear to politicians in order to Repair the Healthcare System.

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

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