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

 

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 

    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

    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

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

 

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

 

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

    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

    Lorne: What are you smoking?
    Steve MD

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Did You Know The United States Could Have A Prescription Drug Shortage!

 

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

 

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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Do You Think Politicians Want To Hear From You?


Stanley Feld M.D.,FACP,MACE

The answer is “NO”. Cecelia and I wanted to contact John Cornyn and Kay Baily Hutchison about their vote on HR 6331. Their two votes defeated the House of Representatives proposal to cancel the Medicare cuts.

It is an impossible task to send them an email. Just try to find an email address. We have concluded the best way to contact a congressperson is to send him or her a fax. Actually, many fax’s and break their fax machine. Maybe then you will get their attention.

The next time I hear that a politician wants to hear from his/her constituents, I know he/her wants to seduce us to vote for him/her. He/her has no intention of listening to us.

  • Mark

    I think you are right . . . they tell how much they want to do for us and then they pretty much do what they REALLY wanted to do all along.
    We need to pray for all of them because I believe that the Lord can get through to them better than we can.
    Cheers,
    Mark

  • Sandra Smith

    Dear U.S. Senator John Cornyn,
    I am writing to you because I am very fed up with Washington right now. I have spoken to many people in my area that feel the same way that I do. I have not spoken to anyone that is in favor of this health care bill.
    1. Where did the money come from for the bank bailouts???
    2. Where did the money come from for the auto bailouts???
    3. Where did the money come from for the aid to Haiti???
    4. Where did the money come from for the aid to Chile???
    5. Where is the money supposed to come from for the health care bill???
    I am (along with many people in my area) totally opposed to the health care bill. I hope you strongly oppose this bill. I also hope that you get as many congress people to also oppose this bill. Only our representatives can do as their constituent’s want, so I am counting on you and others to fight this bill every way that you can.

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It Is Not Only Older Physicians Who Are Discontent: Part 1

Stanley Feld M.D.,FACP,MACE

It has been said that the older physicians are the only physicians upset by the way they are being treated by the healthcare insurance industry. The claim is older physicians are spoiled by the golden days of medicine. My reply to that statement is nonsense. When a professional is treated as a commodity no matter what his age discontent is generated. The older physicians are products of the silent generation. When the younger physicians are pushed to the edge we will hear lots of noise and have lots of rebellion. The rumblings have started.

“I love being a doctor but I hate practicing medicine,” a friend, Saeed Siddiqui, told me recently. We were sitting in his office amid his many framed medical certificates.

Uwe Reihardt said it all to my surprise in a letter to the editor of the New York Times in May 2008.

“Any college graduate bright enough to get into medical school surely would be able to get a high-paying job on Wall Street. The obverse is not necessarily true. Against that benchmark, every American doctor can be said to be sorely underpaid.

Besides, cutting doctors’ take-home pay would not really solve the American cost crisis. The total amount Americans pay their physicians collectively represents only about 20 percent of total national health spending. Of this total, close to half is absorbed by the physicians’ practice expenses, including malpractice premiums, but excluding the amortization of college and medical-school debt.

This makes the physicians’ collective take-home pay only about 10 percent of total national health spending. If we somehow managed to cut that take-home pay by, say, 20 percent, we would reduce total national health spending by only 2 percent, in return for a wholly demoralized medical profession to which we so often look to save our lives. It strikes me as a poor strategy.

Physicians are the central decision makers in health care. A superior strategy might be to pay them very well for helping us reduce unwarranted health spending elsewhere.”

Many examples of discontent from younger physicians can be sited. As these physicians gain experience and understand that the healthcare system is a business to the facilitator stakeholders whose only concern is the bottom line the patient-physician rebellion will pick up steam. The facilitator stakeholders account for 80% of the healthcare dollar and add little value.

A doctor in his late 30s, he has been in practice for six years, mostly as a solo practitioner. But he told me he recently had decided to go into partnership with another cardiologist; “Your days aren’t busy enough already?” I asked.

The waiting room was packed. He had a full schedule of appointments, and after he was done with his office patients, he was going to round at two hospitals.

He smiled wanly. “Just look at my eyes.” They were bloodshot.“This whole week I haven’t slept more than about six hours a night.”I asked when his work usually got done. “It is never done,” he replied, shaking his head. “See this pile?” “He pointed to five large manila packages on a shelf above his desk.” “These are reports I still have to finish.”

“As a physician, I could empathize. I too often feel overwhelmed with paperwork. But my friend’s discontent seemed to run much deeper than that. Unfortunately, he is not alone. I have been hearing physician colleagues voice a level of dissatisfaction with medical practice that is alarming.”

The discontent is building. Physicians are fed up with what they perceived as a loss of professional autonomy. They can not stand the unwarranted restrictions on their medical judgment. As demand for physician services increase we are experiencing larger and larger physician shortages.

Another physician complained. “I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.” Managed care is like a magnet attached to you.

A 42 year old physician complains that he continues to be frustrated by payment denials. “Thirty percent of my hospital admissions are being denied. There’s a 45-day limit on the appeal. You don’t bill in time, you lose everything. You’re discussing this with a managed-care rep on the phone and you think: ‘You’re sitting there, I’m sitting here. How do you know anything about this patient?’ ”

The endless abuse on professional integrity amazes me. A high school graduate sits in front of a computer screen deciding on what a physician can or can not do. Another healthcare insurance company assistant sits in front of a computer billing screen reducing reimbursement on questionable computer programming decisions. The appeals process is difficult and time consuming for physicians.

Dr. Mark Linzer, an internist at the University of Wisconsin who has done extensive research on physician unhappiness, told me. “Fortunately, the data show that physicians are willing to put up with a lot before giving up.””

How long do you think young intelligent physicians will tolerate this abuse? How long do you think it will take to train another compliant work force? America has a physician shortage that is about to accelerate.

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

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The Insured Are Feeling The Strain of Health Costs : Part 2

Stanley Feld M.D.,FACP,MACE

I could never understand why my understanding of the original Medical Savings Accounts presented by John Goodman in 1994 slowly got changed to a Health Savings Accountsounding the same but using a different formula for payment and savings.

Many consulting firms worked hard to change the structure of the original Medical Savings Account to the structure of the Health Savings Account. They also convinced congress to pass a bill permitting the structure of the HSA instead of the MSA.

To my amazement, Mr. Nussbaum Director, Group and Healthcare, North America, Watson Wyatt Worldwide explained the reason for the change clearly, saying it is unlikely that significant numbers of employers will simply drop coverage for their workers.

The weak economy could prompt more of them to push for so-called consumer-driven plans. Such plans tend to offset lower premiums with higher annual deductibles. And when a weak economy undermines job security, he said, workers may simply have to accept reduced benefits. Even so, more companies may see themselves as having little choice but to require employees to pay even more of their health expenses.” 04insure.html?_r=3&th&emc=th&oref=slogin&oref=slogin&oref=slogin

Mr. Nussbaum dismisses Health Savings Accounts out of hand as a way that forces consumers to pay for their healthcare insurance.
I believe the consulting firms figured out a way for the healthcare insurance industry to remain in control of the healthcare system and relieve the employer of the responsibility of paying for the healthcare insurance needs of their employees.

“And while these plans often allow employees to put pre-tax savings into special health care accounts, they typically end up forcing the worker to assume a bigger share of overall medical costs. About six million people are now enrolled in these medical plans.”

The director of a major health benefits organization (Watson-Wyatt) revealed the subtext purpose of the Health Savings Accounts. These plans seem to be evolving into plans that take the burden of payment out of the employers’ hands and into the employees’ hands with the control of the money remaining in the healthcare insurance industry’s hands. That was a neat trick. It will probably do little to Repair the Healthcare System.

The Consumer Driven Healthcare movement is an exciting movement to me because it promises to put consumers in control of their healthcare dollar and not the healthcare insurance industry.

Politics and powerful stakeholders’ agenda always seem to contaminate solutions to problems in order to protect its vested interest. The healthcare insurance industry has done and is doing just that to the consumer driven healthcare movement. I believe its goal is to destroy the consumer driven healthcare movement. The healthcare insurance industry has not been pushing HSA’s . because, I suspect because the net profit is less than traditional plans.

Health Savings Accounts do not motivate patients to save money. The healthcare insurance industry still controls the premium rates, and designs the patients’ deductibles and co-pays. The healthcare insurance industry can manipulate deductibles and deplete the HSA. If there is less money in the HSA out of pocket expenses will be higher.

The original concept of consumer driven health care was to provide the consumer with the purchasing power to control the costs of healthcare. Most other consumer driven purchases such as automobiles, computers, houses, and food control the costs using purchasing power and forcing providers to compete.

Wal-Mart and Target are really consumer extenders that drive down the costs to consumers utilizing their companies’ purchasing power. The purchase remains the consumers’ choice.

The original Medical Saving Account and my Ideal Medical Saving Account
accomplish the same using Patient Power. in a consumer driven healthcare model.

In the process it eliminates much of the non transparent 150 billion dollar skimming off the top of the healthcare insurance industry for “expenses”.. It also eliminates the control the healthcare insurance industry has on the consumer. The consumer has control over the first $6,000 and pays the first $6,000 of services. Anything he does not spend goes into his retirement fund. The money is out of play for the insurance company of other vendors.

If the consumer spends the $6,000 appropriately he gets first dollar coverage without deductibles. The consumer is by true insurance for risk. If he has a chronic disease and it is determined that certain amount of money would have to be spent to avoid complications of that disease he should be eligible for a bonus since he has saved the system a great deal of money. This is an example of the incentive I have described previously. As an example a Type 2 Diabetic should spend $4500 a year to prevent complications of his disease. If he does he keeps the remaining $1500 and gets a $2250 reward totaling $3750. This is the financial reward for losing weight, exercising, maintaining a normal blood sugar and functioning in the work place at a high level.

Healthcare insurance should be available to everyone regardless of pre-existing illness. It should be paid with pre-tax dollars regardless of the payer. It should be community rated and not individually rated.
Who pays for the premium? It could employer, the government with subsides, or the patient himself. All would pay with pre-tax dollars. All consumers would be automatically eligible without penalty. Monies not spent or monies for performance would accrue in a tax free retirement account until withdrawn.
Medicare and Medicaid entitlement programs would be eliminated. The government could get out of the way after making the rules and providing effective subsidy programs. The government would guarantee and enforce the requirements for real price transparency from insurance carriers, hospitals, physicians and drug companies.

The New York Times article simply confuses the issue. It does not clarifying anything. It presents war stories that we have no way to cure.

Let us stop complaining. Let us start demanding positive constructive action from our local, state, and national government.

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

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