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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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The Insured Are Feeling The Strain of Health Costs : Part 1

Stanley Feld M.D.,FACP,MACE

The United States economy is slowing down. Many employers provide healthcare coverage to their employees. As healthcare premiums rise employers are providing less coverage than previously in order to reduce their costs for providing the healthcare coverage. Employees are beginning to realize their healthcare insurance is not very inclusive and their out of pocket costs are high. In fact, many the out of pocket expenses are unaffordable. The result is a tendency to not seek necessary medical care. The avoidance of medical care leads to more serious and costly illness.

I have warned my readers about this problem earlier. I have received comments such as “The cost of healthcare does not concern me. I have a very good healthcare insurance policy through my employer. The inability to obtain healthcare insurance is the other guys’ problem and not mine.”

The other guys’ problem eventually becomes your problem either through higher taxes or other burdens on society. Individuals with healthcare insurance can not assume they have adequate coverage. The inadequate healthcare coverage is discovered when they become ill.

A basic economic fact is consumer spending defines the market place. Consumer spending also defines the economic well being of our society. An informed consumer can make or break a business. In Dallas, the new concept restaurant capital of the world, we see this market phenomenon daily. This week’s hot restaurant is next week’s dud because the consumer does not show up.

The economic slowdown has swelled the ranks of people without health insurance. But now it is also threatening millions of people who have insurance but find that the coverage is too limited or that they cannot afford their own share of medical costs.”

Many of the 158 million people covered by employer health insurance are struggling to meet medical expenses that are much higher than they used to be — often because of some combination of higher premiums, less extensive coverage, and bigger out-of-pocket deductibles and co-payments.
Our presidential candidates provide sound bite babble in the “so called” healthcare debate. The “debate” has nothing to do with the solution to our healthcare problems. Some politicians claim people are too dumb to take care of themselves. They claim the government needs to provide single party payer system for citizens healthcare needs.

The government is having a difficult time providing insurance for our senior citizens through Medicare. In fact Medicare is scheduled to be bankrupt before 2020. I cannot imagine how the government will insure the entire population.

The government should be figuring out rules that level the playing field for all stakeholders. All the stakeholders vest interests must be aligned. The basic principle should be the patient is first.

REED ABELSON and MILT FREUDENHEIM of the New York Times listed examples of the increased burden to consumers as healthcare premiums increase. The article does not present solutions. It simply confuses the consumer and intensifies the consumer feelings of impotence toward fixing the healthcare system.

Alan Shimel’s blog makes the problem clear from a consumer’s and executive decision maker’s point of view.

“My wife had minor surgery in September. It was ambulatory surgery where she went in the morning and went home that afternoon/evening. Even though we have full PPO coverage and it was participating doctors, hospital, etc. my out-of-pocket costs after insurance were almost $3000! The surgeon received a whopping $472 from the insurance company for the operation and the hospital billed like 17k! When I called the hospital they said they did not expect to get paid that much, but had to bill it so they could get as much as they could. I than had to negotiate what I would pay out of pocket beyond that. I also had to pay the anesthesia, the prescriptions, etc”.

The main issue in the healthcare debate is perfectly described in Alan Shimel’s next paragraph.

Here at StillSecure we had to switch providers again this year because United Health Care wanted another 15 to 20% raise in premiums. In fact that is about normal for health insurance, way above the cost of living and inflation. We pay a good chunk of our employees’ insurance premiums, but even so the 20% or so that we have the employee pick up gets bigger and bigger. Plus the insurance company covers less and less. This squeeze is frankly baffling. How can you pay more and get less.”

The problem is understood easily. The healthcare insurance industry is determining the premium as well as the access to care. The higher the premiums and the greater the restrictions on medical services the higher the healthcare insurance industry’s profit.

In the last few years employers have tried to get out of the business of providing healthcare to employees.
To my amazement, Mr. Nussbaum Director, Group and Healthcare, North America, Watson Wyatt Worldwide and other consultants say 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.”

Mr. Nussbaum dismisses Health Savings Accounts out of hand as a way to force the consumer to pay for their healthcare insurance.

It now becomes clear why many healthcare policy consultants for the healthcare insurance industry have bastardized the original Medical Savings Account and morphed it into the Health Savings Account. It looks like another example of telling the consumer you are providing something good but perhaps in reality providing an advantage to the healthcare insurance industry and the employers but providing something bad for the consumer.

I will discuss this point in greater detail next time.

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

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What Does Chronic Disease Management Mean? Part 2

Stanley Feld M.D.,FACP,MACE

The responsibility for the control of the onset of the complications of chronic disease is the responsibility of the patient. Patients live with their disease 24 hours a day and need to learn how to manage it.

There are 20 million patients with Type 2 Diabetes Mellitus in America. This number is growing every day because we are experiencing an obesity epidemic. As I have previously discussed, this epidemic is the fault of our cultural conditioning.

The physician’s responsibility is to teach the patient how to manage his chronic disease.

Imagine you were told you have Type 2 Diabetes Mellitus. Think about your potential emotional responses. Think of all the bad things you have heard about diabetes mellitus. Think about the fantasies you would have about your future morbidity and mortality. These fantasies are the result of the media information and free public service campaigns various organizations have to heighten awareness about Diabetes Mellitus.

The complications of Diabetes Mellitus cost the healthcare system at least $150 billion dollars per year. At a July 4th party, I spoke to a diabetic patient who has had diabetes mellitus for thirty years. He became a professor of diabetes mellitus 28 years ago and has had his blood glucose levels under exquisite control. He has not suffered one complication of diabetes mellitus. There are many patients like this patient.

How does one start to teach patients to be the professor of their disease? I believe it is important for readers of this blog to understand what patients need to learn. It is also important for readers to understand how this process of self-management is a continuous learning project for both the patients and the physicians. The patients’ effort and responsibility in controlling this chronic disease is enormous, and can be very difficult.

You have just been told you have Type 2 diabetes mellitus. If I describe what needs to be learned you can start understanding how this empowerment could result in better control of the blood glucose level. You could also understand how the information could extinguish your fantasies and anxieties about diabetes mellitus. The result would be a decrease in the complication rate of Diabetes Mellitus.

The teaching process has to be a coordinated effort between the physician and the Diabetes Care Team, the nurse educator, dietician, and exercise therapist. We start by teaching patients what Type 2 Diabetes Mellitus is,
why they got it, and how they can reverse Type 2 Diabetes or at least control the rising blood sugar. If patients understands the pathophysiology they know the enemy. They are not frightened about the consequences of the disease. Then a plan can be developed for patients to actively self manage their disease.

At least 20% of the population has the genetic tendency to develop Type 2 Diabetes Mellitus. The genetic defect is an underlying resistance to their own insulin. We have insulin receptors on every cell in our body. These receptors attract insulin. The insulin receptor/insulin combination permits our cells to absorb circulating blood glucose. Once in the cells the glucose gets metabolized to carbon dioxide and water. In the process, packets of energy (ATP) are stored in our cells.

Increasing weight, stress, decreasing exercise, and development of infection decrease the insulin receptors affinity to attack circulating insulin. In effect you have an increased resistance to your own insulin. These external factors are additive to the underlying genetic defect. The more weight gained, the less exercise done and the more stress one has the greater the insulin resistance. As the effective insulin receptors decrease (increased insulin resistance) our body produces more insulin to compensate for this increase in insulin resistance. Over time we can not compensate with sufficient output of insulin to overcome the insulin resistance and our blood glucose rises.

Diabetes Mellitus is defined as a fasting blood sugar of greater than 126mg% on two occasions. Patients can have fasting blood glucose of greater than 126 mg% for many years without symptoms. Many people, mostly men, do not have periodic blood glucose measurements.

High blood glucose levels are the cause of the complications of Type 2 Diabetes Mellitus. The complications are eye disease, kidney disease, neurological disease and heart disease. The average time from the onset to the diagnosis of Type 2 Diabetes Mellitus has been calculated as 8 years. The average time of onset of complications of diabetes varies with the height of the elevation in the blood glucose levels. If you do not recognize that your blood glucose is elevated because you are asymptomatic you can not appreciate that you are harming your body. Many patients first discover they have diabetes mellitus when they are in the Cardiac Care Unit after suffering the cardiovascular complication (heart attack) of Type 2 Diabetes Mellitus.

Why does a high blood glucose level cause eye disease, kidney disease, neurological disease and heart disease? I have observed that once people understand the concept they become motivated to control their blood glucose levels.

Understanding causality is simple. A graphic way of understanding the process is to know that sugar helps alter proteins. The process of converting cucumbers to sour pickles comes to mind. You mix water, vinegar, salt, spices and sugar together. Then add cucumbers to the liquid and put the container in the closet for two weeks. The cucumbers have turned to sour pickles because the proteins in the cucumber have been deformed.

One can think of a person with a high blood glucose level deforming all the proteins in their body. They are essentially pickling all the cells and vessels in their body. The blood vessels narrow because the cells lining the blood vessels are deformed. For example, If there is not enough blood supply to the eye, the body tries to compensate by making more vessels. These new blood vessels (neovascularization) float on the surface of the retina and are fragile. If they bleed, patients can become blind. This narrowing applies to the blood vessels around nerves resulting in neuropathy. As blood vessels narrow, nerve endings will fire ineffectively. Many times these nerve ending misfires are painful. Many patients lose feeling in their extremities as a result of misfiring of nerve ending.

The hemoglobin molecule carries oxygen to the cells of the body. Each red blood cell has a 120 day life cycle. If a red blood cell is born in a high glucose environment it gets deformed or pickled and rather than being a simple Hb molecule it is now a HBA1c molecule. The higher your HBA1c level is, the higher your average blood glucose level has been over the three month period of time. A normal HbA1c level is under 6%. The HbA1c is that high in normal people because after a meal a normal blood glucose can go as high as 160mg%. National laboratories have calculated that the average Type 2 diabetic has a HbA1c of 9.2%. This finding means that neither patients nor physicians are doing a very good job in lowering the HbA1c to normal.

The patient I referred to earlier with diabetes for 30 years has a HbA1c level of 5.5%

Next time I will describe how that goal of a normal HbA1c can be achieved by the patients. It is the essence of the principle of chronic disease management. Normalization of the HbA1c levels can reduce the complication rate of Type 2 Diabetes Mellitus by at least 50%. It can theoretically reduce the complication rate of Type 2 Diabetes Mellitus by 100%. Fifty percent of $150 billion dollars is not a shabby dollar amount toward the repair of the healthcare system. However, the necessary education process to empower the patients to control their blood glucose levels and prevent obesity is not supported by society, the insurance industry or the government.

  • Electronic Medical Records

    Gaining favor with employer groups, health-care organizations and health payers, these programs are being increasingly questioned

  • Keranamu Gula

    Interesting and valuable post. I believe those with diabetes will appreciate your post. Thanks.

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What Does Chronic Disease Management Mean? Part 1

Stanley Feld M.D.,FACP,MACE

Ninety percent (90%) of the Medicare dollar is spent on the complications of chronic diseases according to CMS. Eighty percent (80%) of the healthcare dollars for all age groups is spent on the complications of chronic diseases.

I have stated that our medical care system is great at fixing things that are broken. Our healthcare system has not been good at preventing things from breaking. The medical care system has not been good at preventing the complications of chronic diseases once the patient is afflicted with the disease.

There are two reasons for our inability to prevent things from breaking. One, is that most of the abuse to the human body is a result of the patient’s behavior and lifestyle. An additional factor is the genetic predisposition patients have for a particular chronic disease. Physicians can do little to control genetic predisposition presently. Genomics represents a great hope for preventing the onset of chronic disease in the future. Inhibiting stem cell research seems foolish in the face of its potential benefit. Prohibiting the use of embryonic material that is going to be destroyed anyway to me is illogical. The controversy is a result of the science wars presently going on between theology and science. It is my belief once the public understands the potential of genomics and the illogical nature of the controversy, public opinion with turn on the foolishness of the argument and the controversy will evaporate. This is for the future and the prevention of the onset of chronic disease.

Once the patient has a chronic disease, there is much that can be done for each disease to slow or halt its progression and slow or halt the onset of devastating complications. If we were effective in preventing the complications of chronic disease after its onset, this would result in an improved quality of life for patients and a marked reduction in cost to the healthcare system. The present costs of the healthcare system are leading to an increasing number of uninsured as well as bankrupting the nation.

Presently, most studies demonstrate that, with adequate treatment, we can reduce the complication rate of most chronic diseases by 50%. The reduction to the cost of the healthcare system would be 800 million dollars. Theoretically, with perfect control of the chronic disease and perfect medical therapy we could reduce the complication rate by 100%. The result would be a 100% reduction of the 90% of the money spent by the healthcare system on the complications of the diseases.

Most healthcare economists, “healthcare policy experts” and politicians are starting to understand the math. What I have discovered is that they do not understand the process of chronic disease management and the importance of the patient physician relationship. They do not understand the pathophysiology of the chronic diseases or the origin of the complication of the diseases.

The chronic diseases we are talking about are cardiovascular disease and hypertension, diabetes mellitus, osteoporosis and muscular skeletal disease (arthritis and collagen vascular diseases, lung disease, AIDs, and cancer. We have a $2 trillion dollar annual healthcare system. The total cost of all chronic disease complications to the healthcare system is $1.6 trillion dollars per year.

A lot of brain power is going into trying to do something to reduce the healthcare system costs because we simply can not go on with ever increasing costs and ever increasing opportunities for facilitator stakeholders to increase there profitability while there are ever increasing number of uninsured persons.

We must have a universal healthcare system. However, universal healthcare does not mean a single party payer. I believe a single party payer system will add bureaucracy and impose rules that will stifle and inhibit innovation. The result will be increased inefficiency and increased cost. We all agree that what has made America is innovation by entrepreneurs and not rules by bureaucrats. I know that the physicians are not the problem. They are part of the problem. There is no reason to create a healthcare system that will methodically inhibit physician innovation. Even worse, drive a skilled labor force (physicians) out of business whose education we as a society subsidized.

Who is responsible for the complications of chronic diseases? It is the patient who lives with his disease and lifestyle 24 hours a day. The patient must learn how to control his disease to avoid the complications of the disease. The physicians can only be the coach or manager of the patients and modify their treatment plan through his experience and clinical judgment. Physicians must teach patients how to adjust to changes in the course of their disease. Physicians have to do this with their healthcare team with the patient being the most important person on the team.

Patients must be provided with education, incentive and financial reward for their successful adherence to treatment regimes. The promise of good health does not seem to be enough of a reward. Once patients understand that they are responsible for their self-management and the management of their health care dollar adherence to treatment will improve and outcomes of chronic diseases will improve. Physicians also have to be compensated for their effort. To help make the patients the professors of their disease is a very hard process. It is much easier for a physician to set a broken arm, fix a hernia, or even do bypass heart surgery. Yet the insurance industry does not value or reward this effort.

If patients owned their healthcare dollar and needed to spend their money wisely, they would become intelligent consumers of healthcare. This would force innovation by physicians and hospitals. They would force and increase the quality of chronic disease management at decrease the cost. This would also create a competitive environment for hospitals to control prices. They would produce a market driven economy as occurs in other areas of commerce. Healthcare is a not marketplace presently. Hospital prices presently have nothing to do with hospital costs. This is why we need the ideal medical saving account owned by patients and not the insurance industry. The Ideal Medical Savings Accounts would align all the stakeholders incentives to enable the best product at the best price in a truly consumer driven healthcare system.

In order to understand its complexity I will discuss the disease management concept of several diseases. Obesity is the worse epidemic we are experiencing at the moment. It leads to diabetes, heart disease and hypertension, each of which has devastating and costly complications. In my “War on Obesity” I have discussed some of its problems. I will integrate obesity into the disease management process.

  • Aiams1

    I’m curious as to what type of care and treatment patients with Cronic illness will receive if we have universal healthcare. Not those who can prevent symptoms etc but those who need continual aggressive treatments?

  • 2012 moncler coats

    Don’t know what is wrong what is rite but i know that every one has there own point of view and same goes to this one

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