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Politicians,Healthcare and Vested Interests

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Medical Care Should Not Be About Politics.

 

Stanley Feld M.D.,FACP,MACE

On May 30,2011, an article was published in the New York Times entitled “As Physicians’ Jobs Change, So Do Their Politics.”

This article has been reproduced multiple times in multiple blogs. The New York Times article leads readers to misleading conclusions based on inaccurate facts.  I felt the story was insignificant and passed it by. After I received a few comments about the story, I decided to critique it.

The author quotes a Maine State Senator who proposed a tort reform bill.

State Senator Lois A. Snowe-Mello offered a bill in February to limit doctors’ liability that she was sure the powerful doctors’ lobby would cheer. Instead, it asked her to shelve the measure.”

“It was like a slap in the face,” said Ms. Snowe-Mello, who describes herself as a conservative Republican. “The doctors in this state are increasingly going left.”

Tort Reform should not be a political issue. It is a medical care issue. I described the Massachusetts Medical Society survey on defensive medicine in the past. By extrapolation of the survey facts between 300 billion and 700 billion dollars is wasted on defensive medicine per year. This does not include the wear and tear of frivolous lawsuits on patients and physicians.

The Maine Medical Association does not have the position quoted by Senator Lois A. 

“We are a coalition of three Maine health care associations collaborating to protect the public’s access to quality care and to restrain the inflation of health care cost. We hope to accomplish what many other states have already done by reforming liability laws so that your physician remains in Maine and the best new doctors continue to come here to practiceVictims of negligence deserve compensation and it not our intention to deny these patients their rights. But the liability system must be restructured to be fare to all.”

The article goes on to say’ Doctors were once overwhelmingly male and usually owned their own practices. They generally favored lower taxes and regularly fought lawyers to restrict patient lawsuits.” 

But doctors are changing. They are abandoning their own practices and taking “salaried jobs” in hospitals, particularly in the North, but increasingly in the South as well. Half of all younger doctors are women, and that share is likely to grow.”

There are no national surveys that track doctors’ political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states.”

There are several implications is these few sentences that would lead readers to conclude that;

  1. President Obama is correct in ignoring Tort Reform because as physicians become more “liberal” they side with the plaintiff attorneys’ arguments about the value of litigation. The article ignores the increase in medical care costs resulting from defensive medicine and malpractice insurance.
  2. Physicians who are taking “salaried jobs in hospitals” have no interest in protecting themselves against frivolous lawsuits.  The implication is malpractice is now the hospital’s problem. It implies that defensive medicine will decrease.

(The reference sited under hospitals is inaccurate. It has nothing to do with physicians being salaried by hospitals.) There are many problems and conflicts between physicians and hospital starting to surface (previously discussed) with hospitals buying physicians’ practices and deciding on the value of physicians in the healthcare system.

  1. As more physicians become shift workers rather than owners they are becoming more liberal.

(There is no discussion about why many physicians are joining hospital systems.)

       4. It implies that women are lazy and do not want to own medical practices.

        5.  Since physicians are more liberal they therefore believe “Obamacare “ is    good for America. 

The Maine Medical Association does not believe in any of these implications. Its statements are clear. It understands that physicians are driven out of the state because of the lack of malpractice reform. It has a declining number of physicians practicing in the state and the cost of care is increasing while the quality of care is decreasing.       

Our coalition is seeking to advance medical liability reform to preserve access to physician services, improve the affordability of health care and ensure high quality care in Maine.

Across the country, America’s patients are losing access to care because the nation’s out-of-control legal system is forcing physicians in some areas of the country to retire early, relocate or give up performing high-risk medical procedures. There are now 21 states in a full-blown medical liability crisis — up from 12 in 2002. In crisis states, patients continue to lose access to care. In some states, obstetricians and rural family physicians no longer deliver babies. Meanwhile, high-risk specialists no longer provide trauma care or perform complicated surgical procedures.”

 These statements contradict the accuracy of the article. However, the media is the message. The New York Times represents the traditional media. With its bias it drives this disinformation or misinformation front and center. Readers accept the bias and do not think critically.

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

 

 

 

 

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Let Us Forget Demagoguery And Face Facts!

 

Stanley Feld M.D.,FACP,MACE

I understand that President Obama wants to win the election in 2012. He will do everything in his power to win it.

I understand politicians do everything to spin an issue in their favor to win an election. 

I know that politicians believe many issues are too complicated for Americans to understand. The reason we elect government officials as our surrogates is for them to understand the issues and vote for our vested interest. 

How many congressmen read President Obama’s entire healthcare bill and believe they voted for citizens’ vested interest? I bet the answer is not many.

I have pointed out how President Obama presented the CBO with false assumptions to manipulate budgetary conclusions. Appointed CBO officials and Medicare actuaries find President Obama’s conclusions difficult to believe.  

Finally, a congressman has stood up and said let us look at the facts, America must face where we are headed. It is his responsibility to the American people to explain these facts. Americans are capable of understanding these facts and the consequences of the facts. Paul Ryan believes in the intelligence of the American people.

The trick is to get Americans to listen. I used to worship the New York Times. It was the place to get the facts. It has become biased.

At a recent party politics became a hot topic. The discussion was about the Republicans not having a candidate able to beat President Obama in 2012. People quoted articles from the New York Times and Time Magazine as the ultimate authority.

I was very quite. I was quiet because I could not believe that intelligent people would believe the hogwash they were quoting. President Obama has had a terrible record. Just look at President Obama’s economic policy, foreign policy and healthcare policy. 

Here are a couple of examples in two recent New York Times editorials;

"Rep. Ryan’s Dubious Sales Pitch"

Published: May 29, 2011

"Representative Paul Ryan is rebutting critics of his plan to turn Medicare into a “premium support” program, pointing to two existing programs that he says prove 
his approach would be better for beneficiaries. Don’t believe it."

My immediate reaction looking at the editorial while eating breakfast was, “I got it.” “Paul Ryan’s plan is no good. The media is indeed the message. Forget about critiquing the details. 

The second article was more subtle.

Published: May 28, 2011

Republican leaders in the Senate have spent weeks gleefully deriding the Democrats who run the chamber for not producing a budget proposal in more than two years. It is a classic tactic, designed to deflect attention from their party’s toxic plan to privatize Medicare. 

In the second quote it is a given that the Ryan Plan is toxic. Again, no facts. If the New York Times said so, the Ryan Plan must be toxic. 

No one at the party I mentioned has yet to be affected by President Obama’s policies yet. I am sure they will start paying attention to his policies when his policies affect their life, standard of living, and freedoms.

President Obama is building the infrastructure to affect all of the above. As he is building the infrastructure he and the Democratic Senate are bankrupting the country.

I have not seen tremendous support by the Republicans for Paul Ryan’s budget.

Paul Ryan’s budget does not attack entitlements in the near term. It attacks the government waste President Obama’s own National Commission on Fiscal Responsibility and Reform pointed out.

It is best to hear from Paul Ryan himself. Paul Ryan’s goal is to help Americans become less dependent on government, not more dependent.

Government should make rules that level the playing field for all stakeholders in all areas and then get out of the way. It should enforce the rules equally and fairly. 

To my chagrin only 256 people watched this You Tube announcing the Ryan Plan. In announcing the budget Mr. Ryan points out the path to disaster President Obama is heading us into.  He then goes on to describe the path to prosperity we must take. 

If you want to hear what Paul Ryan really has to say rather than having it editorialized by the New York Times and the traditional media, it is worth watching this You Tube.



 
 

 

The facts are more important than hearsay.

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

 

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It Will Not Work!

 

 

Stanley Feld M.D.,FACP, MACE

“The media is the message.” It does not matter if the policy has failed previously.  All that is important is the effectiveness of the policy’s presentation and its ability to manipulate the polls. 

The government’s purpose is to work for the people who elected it. It does not seem to be working that way at present. Bureaucrats create rules or regulations as they interpret the laws made by congress and the president. Regulations are controlled by the administration’s ideology. Many times the regulations in one area nullify the intended effect in another area.  

Regulations and bureaucracy inhibit the use of common sense in policy making for the benefit of the people.

The people did not have an outlet to express their opinions or frustrations until blogging came into its own seven years ago.  

Americans do not like President Obama’s healthcare reform act. They also do not like Dr. Don Berwick’s apparent disrespect for their intelligence and his infatuation with the British healthcare system.

“I am romantic about the NHS (British National Health Service); I love it. All I need to do to rediscover the romance is to look at health care in my own country.”

 Dr. Berwick’s comments about redistribution of wealth and taking freedom of choice is scorned by many Americans.
 

“Dr. Berwick complained the American health system runs in the ‘darkness of private enterprise,’ unlike Britain’s ‘politically accountable system.’ The NHS is ‘universal, accessible, excellent, and free at the point of care – a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just’; America’s health system is ‘toxic,’ ‘fragmented,’ because of its dependence on consumer choice. He told his UK audience: ‘I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.’”

The NHS is failing. Prime Minister Cameron has declared he will change the system. The British healthcare system has resulted in long waits for treatment and rationing of treatment.  If past experience is any indication, generic drugs and expert commissions have done little to lower healthcare costs.

“As the United States prepares to introduce the massive new health-care program known as Obamacare, Britain’s Conservative Prime Minister David Cameron said on Monday that he plans to significantly reform his country’s state-run health-care system due to the program’s massive cost and lackluster performance”. 

Theodore Dalrymple wrote a critique of the British Healthcare system in the Wall Street Journal on April 16, 2011. Theodore Dalrymple is the pen name of  Anthony Daniels, an English physician.  

He is echoing the sentiments of many practicing physicians in Britain.

Dr. Anthony Daniels’ perception contradicts Dr. Don Berwick’s perception. One of them is wrong.  My bet is Dr. Berwick is wrong. 

Dr. Daniels’ practical experiences are:

“1. All attempts to reduce bureaucracy increase it, and the same goes for cost. Such, at any rate, has been my experience of the British health care system.”

“2. In Britain we have been prescribing generics for years; I cannot remember a time when I personally did not. Our National Institute for Clinical Excellence (NICE) has done cost-benefit analyses of drugs and procedures, often very sensibly, for years. But despite its best efforts, our system has been highly inventive in finding other ways of wasting immense quantities of public money.

I suspect this is a result of the administrative costs associated with the increased government bureaucracy and regulations.

“3. Don Berwick wants to move from a fee-for-service system, which gives doctors an incentive to perform expensive and doubtfully effective procedures, to one in which doctors are rewarded for preventing diseases that are so expensive to treat.”

“4. On paper, prevention always seems much cheaper than cure. Health-care economists prove it very elegantly and convincingly over and over again.”

“5. Unfortunately, the world always proves to be more complex and refractory than the theories of even the best economists”.

“6. For a long time, a physician was paid a capitation fee: He received a certain amount per patient per year from the NHS, irrespective of what the doctor did for the patient or how many times a year the patient was seen.  The physician could not increase his income except by private practice.”

“7. Needless to say, private practice was most extensive in the better-off areas, so that the system ended up reproducing the very social divisions in health care that it was designed to abolish.”

“8. In the poorer areas, doctors had no incentive—at any rate, no financial incentive—to improve their practice. It was rather the reverse. The worse the facilities they offered, the higher their income.”

“9. In the 1990s, Family doctors began to be paid to undertake preventive measures. The experts hoped that this would save money because the cost of preventing diseases would be more than offset by the savings from not having to treat the diseases that they prevented.”

“The costs of prevention were decidedly real, while the savings were inclined to be imaginary.”

a.     “The bureaucratic costs of setting and monitoring health-improvement targets—which were often highly arbitrary—were far greater than anticipated, bureaucracies having an inherent tendency to increase in size and spending power.”

b.    “Many doctors started to be paid for procedures that they were already doing for no charge, like taking their patients' blood pressure.”

c.     “Screening procedures turned out to be highly equivocal in their efficacy.”

d.     “Thus the overall benefit was much less than anticipated.”

e.     “Some of the more common ills that had been targeted, such as strokes and heart attacks, were in marked decline anyway because of increase in effective technology.”

f.      “Worse, much of the expenditure on the treatment of disease proved intractable.”

g.     “Technology inexorably increased costs; and even if the health of the population improved rapidly”

h.     “The increased proportion of older people in the population meant that the proportion of people ill with expensive chronic diseases increased.”

i.      “Procedures such as hip replacement have gone from being relatively new-fangled and exotic to being routine, precisely at a time when there are more people than ever who can benefit from them.”

j.      “ Osteoarthritis is no doubt hastened by obesity, but no medical means has yet been found for the prevention of that particular condition.”

“It is true that in Britain we have had our own peculiar reasons for the spectacular rise in the cost of our health-care system.”

“The British system is now capable of absorbing infinite amounts of money with minimal benefit to the health of the population, though with great benefit to the pocketbooks of those who work in it.”

“It is an occupational hazard for politicians to think that they and their ilk know best.”

“I have seen a hundred schemes of cost reduction.”

“ I have never seen any reduction in costs, or at least any that lasted more than a few months. I can't remember a single health minister who did not promise more efficiency at less cost, or a single one who actually managed to achieve it.”

“The long-term solution, I imagine, is the same for health care as it is for pensions: to pay for it with the income generated by dedicated savings accounts, which can be transferred to the next generation after death.”  

President Obama is setting up a healthcare system in America that has been proven not to work in Britain. The healthcare reform act should be reconsidered.

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

 

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It Is Easy To Forget

 

Stanley Feld M.D.,FACP,MACE

President Obama’s healthcare reform act is a little over one year old.

It is easy to forget the negative components and unintended consequences of the bad legislation. It will not solve our healthcare systems problems. It is making the problems worse. 

America is facing a tremendous budget deficit. There are many causes for the deficit. The Medicare and Medicaid entitlement programs are two of the principle causes of the mounting deficit.

President Obama’s goal is to provide universal healthcare coverage at an affordable price with an increase in quality. The healthcare reform act is going to change the payment structure without changing incentives for consumers of healthcare.

The result will be a disaster for everyone.

John Fleming is an M.D. and a member of congress. He wrote a note to his constituents revealing how the President Obama’s healthcare reform act has failed to deliver on costs, premiums, spending and preserving American’s existing healthcare coverage. He wants to repeal the healthcare reform law.

 

Several of the law’s initial provisions have taken effect. The effects of newer provisions are being anticipated. This anticipation has created havoc. Waivers granted to unions have generated cries of favoritism. The law’s initial provisions have already resulted in American families and businesses facing higher costs, economic uncertainty, and loss of their current healthcare insurance coverage. 

None of these effects has been helpful to our fragile economic state. 

Dr. Fleming has listed some of the issues and unintended consequences that will cause President Obama’s healthcare reform act to fail.

 

1.  In 19 states parents can no longer buy child-only insurance policies as a result of the law.

2.  30 states suing to block the law from taking effect, or requesting waivers from its requirements

3.  51 percent of American workers who will lose their current health coverage by 2013, according to the Administration’s own estimates.

4. A $2,100 increase in individual insurance premiums due to Obama care, according to the Congressional Budget Office.

5. $2,500 premium reduction promised by candidate Obama “by the end of my first term as President” will not occur. 

6.  7,400,000 reduction in Medicare Advantage enrollment as a result of Obamacare, resulting in a loss of choice for seniors and millions of beneficiaries losing their current health plan.

7. $118,000,000,000 in new costs imposed on states to implement Obamacare's budgetary costs that will lead to reduced services for other state programs like education or to higher state taxes

8. $310,800,000,000 projected increase in health costs due to Obamacare, according to the independent Medicare Trustee.

This list is only the tip of the iceberg. There are many effects of the legislation that will add waste and increase cost to the healthcare system.

It is hard to keep track of these effects. Painful consequences are “easy to forget” as President Obama’s spin machine keeps telling us how wonderful his healthcare reform act will be for America.

The massive bureaucracy being formed with all its waste and paperwork is discounted by the administration.

1.   1,270 for new bureaucrats requested by the Internal Revenue Service to implement the law this year

2.   6,578 pages of new regulations issued implementing Obamacare through March 14, 2011

2. 800,000 reduction in the American labor force due to Obamacare provisions that “will effectively increase marginal tax rates, which will also discourage work,” according to the CBO

3. 2,624,720 total individuals in 1,040 plans granted waivers thus far exempting them from the law’s insurance mandates; nearly half of whom participate in union plans

4. 40,000,000 firms subject to the health law’s new 1099 reporting requirements, which the National Federation of Independent Business called a “tremendous new paperwork compliance burden actuary", who called its promise of lower costs “false, more so than true”

5. $552,200,000,000 is the amount of higher taxes Americans will pay if Obama care remains in place, which will be imposed on all Americans in varying degrees.

6. A  $1,390,000,000,000 increase in federal spending on new entitlements during fiscal years 2012-2021 according to the CBO, a 48 percent increase from an earlier estimate

Dr. Fleming’s  DIAGNOSIS:

 The new health care reform law is the prime example of how the Democrats’ tax hikes, spending spree, and heavy-handed government policies are hurting our economy and making it harder for small businesses to create jobs. 

 

 Removing these barriers will provide the businesses that create new jobs with the certainty they need to hire new employees and get our economy back on track. I remain committed to reducing healthcare costs by providing access and choices for every American, protecting the patient-doctor relationship, and keeping the government out of the exam room.  I will work aggressively in Congress to repeal what I firmly believe to be an onerous and unconstitutional health care reform law and support market-based solutions to our health care needs.
Sincerely, 


JOHN FLEMING, M.D.
Member of Congress

Bravo Dr. John Fleming. More congressmen should be repeating the facts about President Obama’s undeclared waste and hidden taxes. It is hard for the public to remember all the facts.

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

 

 

  • Jo edwards

    I am a RN. I am disgusted in those who support the Health care reform law.

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Why Will Accountable Care Organizations (ACOs) Fail?

 

Stanley Feld M.D.,FACP,MACE


In an ideal world ACOs should work. There is no evidence that  untested and complex organizational structure of ACOs developed by Dr. Don Berwick (head of CMS) will improve quality of care and reduce costs

ACOs are supposed to provide financial incentives to health care organizations to reduce costs and improve quality. There are too many defects in the ACOs infrastructure to improve the financial and medical outcomes.

At a conceptual level, the incentive for ACOs would be to increase efficiency and avoid overuse and duplication of services, resources, and facilities. In this model, ACO members would share the savings resulting from the increased coordination of care.

I have said over and over again that excessive administrative fees and ineffective management of chronic disease is the main source of waste in the healthcare system. ACOs do not deal with these main drivers of costs.

The only stakeholders who can demand that this waste be eliminated are consumers/patients. Patients must control their healthcare dollars.  They will make sure there are competitive prices and will not permit duplication of services.

ACOs are not a market-based system. They do not put patients at the center of their medical care or permit them to choose their medical care. The government controls the healthcare dollars and is at the center of patients’ medical care decisions directly and indirectly.

In order to truly repair the healthcare system a system of incentives for patients and physicians must be created. There is no question that the processes of care for chronic diseases must be improved. More importantly, the medical and financial outcomes must be measured and not the process changes.

In theory, ACOs provide financial incentives to health care organizations to reduce costs and improve quality. In reality, given the complexity of the existing system, ACOs will not only fail; they will most likely exacerbate the very problems they set out to fix.”  

ACOs are merely the latest in a long history of unsuccessful health policy innovations. Since the 1970s, Congress and successive administrations have tried a number of tactics to control rising health care costs.  The tactics tried have been:  

  1. Payments for diagnostic related groups of services, or DRGs.
  2. Health maintenance organizations (HMOs).
  3. Preferred provider organizations (PPOs). 

They all failed. Consumers reacted negatively to the care provided. Healthcare costs continued to rise. ACOs are being promoted as the new structure that will address the lack of success of the past tactics.

Under Obamacare, the Secretary of the Department of Health and Human Services (HHS) is charged with developing a method to assign Medicare beneficiaries to ACOs.”

“ Because the statute is unclear about the resolution of many vital issues, the crucial details will be supplied and refined by federal regulators—as is the case for so many other provisions of the new health law.” 

Congress has relinquished its power to the unelected portion of the executive branch of government to construct a system that will reduce the rising costs.

ACOs create a new organizational structure to remedy problems inherent in the existing healthcare system.  The complexity of the structure of ACOs will result in the same or similar types of unintended consequences that led to earlier failures. 

There will be consolidation of providers. ACOs will result in increased costs rather than decreased costs.  It might decrease duplication of testing. The resulting savings will be small. There is no evidence that ACOs will provide improved medical and financial outcomes. I believe it is Dr. Berwick’s naïve wish that it will improve medical and financial outcomes. 

The are at least 7 key deficiencies with ACOs

  1. ACOs do not empower consumers to be responsible for their own medical care.  Healthcare should be consumer driven with consumers controlling their healthcare dollars. They will then make informed choices about their care and insurance coverage.

      2.ACOs create artificial incentives to improve quality and provider performance. Consumer driven           healthcare creates real incentives to promote price completion. Competitors are constantly           working to improve their products, attract consumers, and ultimately increase market share.  

Consumers have no part in driving that competition in an ACO system.

           3.Most physicians are reluctant to assume accountability for patient outcomes.  Physicians                           recognize that much of the outcome is directly under the consumer/patient behavioral control.

            4. ACOs remove the patient/consumer from being responsible or accountable for their medical                   care. ACOs undermine any attempt to create a truly accountable healthcare system that can                   drive down costs.

            5.ACO do not encourage provider accountability even though it seems that provider buy-in would            be integral to an ACO’s success with its shared savings incentive.  Many physicians believe the                  share savings incentive is bogus. 

            Providers continue to be paid for each service they perform until the government provided funds             run out. There are also grave uncertainties and practical complications of distributing production             and savings between the hospital system and physicians.

             6. ACOs create an unfair competitive advantage for large organizations that are hospital                 centric. Eligibility requirements are vague and ambiguous. The eligibility requirements                 suggest that larger organizations have an unspoken eligibility advantage.

                This is the reason hospital systems are trying to form ACOs. Hospital systems think they will                 make money. I think they will fail. Hospital systems will lose a lot of money. They will fight                 with their physicians over the distribution of government reimbursement. The cost of hospital                 care will then increase. The consumer will lose.

                7. Groups of independent practitioners as well as other types of small and mid-sized practices                     may lack the infrastructure, Internet technology, or other resources needed to qualify for                     ACO eligibility. They will be forced to join hospital systems. Hospital systems have a                     history of taking advantage of physicians and their skills and intellectual property. More                     tensions will be created. Hospital systems’ ACOs will crumble. The cost of medical care                     will continue to increase further.

I have presented some common sense observations. Common sense does not seem to prevail in the difficult world of repairing the healthcare system.

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

 

 

 

 

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The Accountable Care Organizations (ACOs) Plot Thickens.

 Stanley Feld M.D., FACP, MACE

Thousands of articles have been written about forming ACOs. Millions of dollars have been spent by hospital systems to try to form an ACO. Healthcare policy consultants have discovered a new cash cow.

Hospitals systems are wasting their money. They think the return from owning salaried physicians’ intellectual property will be more than worth the cost.

  1. Thousands of physicians have been confused by the concept of ACO.
  2. Many have felt ACOs are an attack on their freedom to practice medicine the best they can.
  3. Many have rejected the concept because they feel they will have to be salaried by hospital systems.
  4. Many physicians do not trust President Obama or Dr. Don Berwick.
  5. The Stage 2 ACO regulations are not easy to understand. They are more ominous than the stage 1 regulations.

The two core stated objectives for ACOs are:

(1) Reducin healthcare costs.

(2) Preserving and improving quality. 

The stated objectives are laudable. The government regulations and controls are confusing. They are a threat to physician autonomy. There are many unwritten rules pending. Physicians are being asked to accept the unwritten rules on blind faith and trust them.

ACO requirements are;

 1.     Agrees to participate for three years.

2.     Cares for 5,000 Medicare patients

 3.     Is prepared to receive and distribute shared savings.

4.     Is prepared to repay shared losses (if it takes economic risk).

5.     Establishes reporting, and ensures ACO participant and ACO provider/supplier compliance with program requirements, including the quality performance standards.

6.     Has shared governance that provides all ACO participants proportionate control over the ACO’s decision making process and includes Medicare patient representatives.

7.     Is operated and directed by Medicare-enrolled entities that directly provide health care services to Medicare patients. ACO participants (e.g. physicians, hospitals) must have at least 75 percent control of the ACO’s governing body.

8.     Has sufficient primary care physicians to meet the primary care needs of the ACO patients.

9.     Has administrative and clinical organization and leadership.

10.  Is patient-centered though the use of such things as patient assessments and individualized care plans

11.  Is subject to substantial monitoring and reporting requirements, including public reporting of quality data to ensure transparency.

The rules get complicated. They will be difficult to execute and enforce.

 

Those who can participate include,

  • Group medical practices
  • Networks of group practices (e.g. IPAs)
  • Partnerships of joint ventures between hospitals and physicians (e.g. PHOs)
  • Hospitals employing physicians
  • Anything else that accomplishes the objectives of the Act

Group practices are placed at the top of the list intentionally. It is to decrease physicians’ anxiety and sense of losing control.

 The only way ACOs have a small chance of succeeding is if physicians are hired by the hospital systems and the hospital systems divide the money. The fight will then be between hospital systems and their physicians.

Two questions immediately come to mind:

  1. How is the calculation done to divide the money by the hospital system? What money is taken off the top for hospital systems’ salaries and expenses before the savings is shared with physicians?
  2. If there is a loss rather than a cost saving, and the government reduces the ACO’s compensation, how is the distribution of the loss calculated? Let us say four physicians in the system were responsible for 90% of the loss.  Should everyone be responsible? I do not think any of this has been thought out.

The legal issues involved with ACO’s are vast and expensive. One issue revolves around the Stark law and the anti -kickback statutes in the law. How can an ACO participate in the proposed Medicare Shared Savings and not violate the Stark law provisions? Easily say the OIG and CMS. They will issue waivers from the Stark law. The implication is these agencies will bypass congress once more. 

The provisions listed to get an anti-kickback waiver are complicated. It will require expensive compliance. There will be issues which will require expensive legal action by the hospital systems and physicians as a result of a net decrease in reimbursement.

“Conceptually speaking, DOJ has publically stated that they will seek to support organizations which accomplish the law’s two core objectives—lower cost and improve quality. More specifically, DOJ has said “[they] will not challenge an ACO that otherwise meets the CMS criteria to participate in the Shared Savings Program if ACO participants that provide the same service (common service) have a combined share of 30 percent or less of each common service in each ACO participant’s Primary Service Area (PSA), wherever two or more ACO participants provide that service to patients from that PSA.”

 Does anyone understand this? It gets worse.

 “DOJ have even allowed for the possibility of ACOs where the combined PSA share would exceed 30 percent in saying “an ACO outside the Safety Zone may proceed without scrutiny by the Antitrust Agencies if its combined PSA share for each common service, wherever two or more ACO participants provide that service to patients from that PSA, is less than or equal to 50 percent. An ACO in this category is also highly unlikely to present competitive concerns if it avoids certain specified conduct.”

As we get further into the weeds the Stage 2 ACO regulations become even more confusing.

“The Justice Department has stated that they will use the more malleable “rule of reason” analysis when reviewing ACOs. The Antitrust Policy Statement explains, however, that for ACOs that do not meet the Rural Exception, a combined PSA share for common services of more than 50 percent provides a valuable indication of an ACO’s potential for competitive harm.” DOJ is proposing an expedited review process for ACOs; and we can expect many ACOs to line up for the review process.”

My reflex is that you have to trust that President Obama will do the right thing for physicians and their patients.

You also have to trust that the hospital systems that salary physicians will be looking out for their physicians and not themselves while owning physicians’ skills and intellectual property.

It will be a very difficult task!

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

 

 

 

 

 

 

 

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The Will Of The People

 

Stanley Feld M.D.,FACP,MACE 

I have struggled to understand why President Obama is ignoring the will of the people. I have also struggled to understand why the traditional media ignores the important stories.

The media deals with the day’s murders, tragedies and traffic accidents in exhausting details. Important stories are covered and dismissed with meaningless sound bites.

Americans are interested in learning the story beneath the sound bites. This is the reason traditional newspapers are failing. Its old business model doesn’t work any more.   

Americans want affordable high quality healthcare available to everyone. Most Americans are charitable and hard working. They want to help the unfortunate.  They are sick of entitlements and their wasteful costs. They do not want a system that discourages hard work and responsibility.

President Obama is expanding healthcare entitlements while totally disregarding the fiscal responsibility of the federal and state governments. 

He continues to use fuzzy math to blur the resulting increases in deficits.  

The entrepreneurial spirit in Americans is the spirit that has made America great. President Obama’s policies are going to destroy this spirit.   

This week a reader wrote:

“Hi Dr. Feld

I’m using my soon to be published book to organize America.  Do you think your son Brad would be interested in setting up a website that helps “defund” the political parties by coalescing average Americans who are tired of the lies to send a dollar to candidates who are not from the establishment of either party?

Until we can get people organized using the internet to change the people in DC, we lose.  It’s all about the money.  1% of America, giving 1 dollar each can send a new face to Congress.  We can do it! we must do it!”

I sent the message to Brad.  On the surface Brad’s reply is straightforward. No is no! To me it has deeper meaning.   

“I'm not really interested in engaging in this. I'm drifting further away from politics every day as I don't think you can easily fix the macro through surgical strikes.”

I have often been asked why, as a retired endocrinologist, I display so much passion for repairing the healthcare system.

During my thirty years in practice I lived through the destruction of our healthcare system. Our government has had its heart in the right place but always seemed to do things to the disadvantage of the two principle stakeholders, patients and physicians. These two stakeholders are the most disorganized and least politically powerful of all the stakeholders involved in the healthcare system.

President Obama either doesn’t have a clue to the problems in the healthcare system or doesn’t care what patients or physicians think. He is either naïve or married to untested theoretical concepts. President Obama is going to destroy our healthcare system and replace it with a bureaucratic system that will make medical care mediocre for all. The federal government cannot afford the cost of his “new healthcare system.”

There is also a big ideological issue. President Obama believes the government needs to do everything for the people. The opposite argument is Americans need to do everything for themselves. The government’s job should be to level the playing field among stakeholders.

Patients and physicians want independence and personal responsibility. President Obama is not listening to the people. 

Kris Kristofferson is one of the great popular poets of our time. His song “To Beat The Devil” has been the inspiration for my blog. My goal is to educate the public beyond the typical sound bite. 

If you waste your time a-talking to the people who don’t listen
To the things that you are saying who do you think’s going to hear? 
And if you should die explaining how the things that they complain about
Are things they could be changing, who d’you think’s goin’ to care? 

There were other lonely singers in a world turned deaf and blind who
Were crucified for what they tried to show,
And their voices have been scattered by the swirling winds of time,

‘Cause the truth remains that no-one wants to know!

When no-one stood behind me but my shadow on the floor and lonesome was more
Than a state of mind. You see, the devil haunts a hungry man; if you
Don’t want to join him you’ve got to beat him. I ain’t sayin’ I beat the
Devil, but I drank his beer for nothing, and then I stole his song!

 

And you still can hear me singing to the people who don’t listen
To the things that I am saying, praying someone’s going to hear;
And I guess I’ll die explaining how the things that they complain about
Are things they could be changing, hoping someone’s goin’ to care.

I was born a lonely singer and I’m bound to die the same
But I’ve got to feed the hunger in my soul;
 

  

 

The reader of my blog I quoted is yearning to use the new media to educate and organize the public to say no to the politicians who seem to do everything they can to screw up things the public is complaining about and has no interest in hearing their complaints or eliminating them.

 

On the other hand Brad is saying surgical strikes to the political process does not change things in our society. Innovations by entrepreneurs change things. This is the deeper meaning of Brad's comment.

We are going through an electronic revolution. Jeff Bezo with Amazon.com and the Kindle revolutionized the book publishing business. Google revolutionized the information business. Steve Jobs did the same for the communications and information business with the IPhone and the IPad. Netflix is revolutionizing the movie and television business. Think about the power of Twitter and Facebook. Social networking is in its infancy. It continually gets bad press because of its threat to the traditional media and political power.

These innovations are revolutionary. They will empower citizens to be a deterrent to politicians’ power. They will not be able to limit our freedom of choice. 

Petty political arguments about decreasing the budget by $3 billion vs. $38 billion dollars are silly. Americans are not stupid. This debate is not newsworthy.  Our deficit is over $1 trillion dollars a year. Government spending has not stimulated our economy. It has not increased our standard of living. Both political parties are lost in translation.

“President Obama believes that prosperity begins inside someone's head in Washington and then flows out to the country”

Most Americans disagree.

We need leadership that believes in innovation and entrepreneurship. Leaders should understand that prosperity is born inside the head of several hundred million citizens. 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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The Federal Government and Accountable Care Organizations (ACOs)

  

Stanley Feld M.D.,FACP,MACE

In 2009 President Obama stated that Accountable Care Organizations (ACOs) were going to be pilot programs in real world settings. The goal was to see if they effective in reducing costs and increasing “quality of care.” The results of the pilot programs have not been published.

Last week despite the lack of proof of concept HHS and CMS announced new proposed regulations for ACOs.

The new delivery and payment model the agency estimates could serve up to 5 million Medicare beneficiaries through participating providers, and also potentially save the Medicare program as much as $960 million over three years. 

How were these estimates derived? It could be another accounting  trick by President Obama’s administration.

The idea of coordinating care and developing systems of care is a great idea theoretically. From a practical standpoint, execution is very difficult.

I tried to execute something similar in 1996 with the American Association of Clinical Endocrinologists; a national Independent Practice Association. AACECare received little cooperation or interest from Clinical Endocrinologists. 

The problem is coordinated medical care is dependent on physicians cooperating and not competing with each other.  It also depends on  hospital systems developing an equitable partnership with physicians.

The equitable partnerships between hospital systems and physicians are difficult to achieve if past results are any indication of future results.

 An important element to the success of ACOs is patients’ use or abuse of the ACO. There are no incentives provided for patients to manage their chronic diseases and avoid complication of those diseases. 

Some of the problems with Dr. Don Berwick’s rules and regulations for ACO’s are:

1.Patient compliance is not considered in the system. Positive outcomes and savings are mostly dependent on patient behaviors and compliance with treatment.

2. ACOs are dependent on hospital systems developing a network of physicians who cooperate to coordinate care.

3. Cooperation between physician and hospital systems depends on mutual trust. The hospital systems will receive and distribute the money received from the government. This is an area ripe for conflict and mistrust.

4. Dr. Berwick does not calculate the role of patients in risk management of their chronic disease.  Patients are the drivers of their medical outcomes.

5. One Medicare and Medicaid check would go to the hospital system to be distributed to physicians. The administration of the ACOs would determine the distribution. This will result in great conflict. The trust issue must be resolved from the onset.

6. Physicians are uncomfortable working for organizations who determine the value of their intellectual property or surgical skills. 

 ACOs’ will have to develop systems to dictate care consistent with government determined evidence based medicine. The government will reward organizations that are successful. It will penalize organizations with poor outcomes. The hope is to increase quality of care and decrease the cost of care.

 The execution will be difficult. In reality ACOs are HMOs on steroids.

The proposed payment formula is difficult to follow. It must be understood in order to appreciate the defects in the system. 

1. Hospital systems will own and control physicians’ intellectual property.

2. Hospital systems’ political decision process will determine pay and distribution. 

3. The federal government will determine what it will to pay the ACOs. This is a major defect given the federal government past behavior in judging the value of physicians intellectual property and surgical skills. As a reason of budget pressure the federal government will be forced to decrease reimbursement.

4. It will be the ACO’s responsibility to come in under budget. If the ACOs come in under budget the excess will be shared 50/50 between the government and the ACOs.

5. Each ACO will have an individual budget based on patient demographics and risk weighting. Risk weight is an imperfect science.

6. ACOs must define the processes it uses to coordinate care. CMS rules outline a range of strategies for ACOs to accomplish this. The processes included must be;

             a. Predictive modeling.

             b. Use of case managers in primary-care offices.

             c. Use of a specific transition-of-care program that includes clear guidance and instructions for patients, their families and their caregivers;

             d. Remote monitoring.

             e. Telehealth.

If any of these processes are lacking or defective in the government’s judgment the ACO will not be eligible to save in any savings.

The payment system is equally frightening under the proposed regulations:

1.ACOs would provide an organization with a separate tax identification number. 

2. Payments would go directly to the ACO’s administration. The ACOs administration would decide on the distribution of those payments to its member providers.

3. The ACO rules would allow ACOs to receive shared savings if they meet both the quality performance standards established by the HHS secretary and their target spending goals.

4.The target spending goals would be set for each ACO by HHS.

5.HHS can also limit or adjust the total amount of shared savings paid to an ACO.

 6. There will be no administrative or judicial review process for determining ACO's eligibility for shared savings. There is no review process for “termination of an ACO” for failing to meet quality performance standards.

7. ACOs can participate under either :

                  a. A model that shares both savings and losses from the beginning of a three-year period or

                  b. shares only savings in the first two years and shares both savings and losses in the last year.

8. ACOs will be required to demonstrate a partnership with Medicare fee-for-service beneficiaries by having a beneficiary represented in the ACO's governing body.

In order for ACOs to share in savings, ACOs would have to meet quality standards in five key areas determined by the government:   

Patient/caregiver care experiences

Care coordination

Patient safety

Preventive health

At-risk population/frail elderly health.

None of these measures are clearly defined. It will become a bureaucratic mess.  The results will compromise medical care. It will promote adversary relationships among and between stakeholders. It will promote dependence on the government’s bureaucratic discretion among stakeholders.

ACOs are much to complicated to work. The further along Dr. Berwick gets in constructing the infrastructure the harder it will be to dismantle it.

I believe this is the reason President Obama’s Justice Department is stalling the appeals process of the challenges to the constitutionality of President Obama’s Healthcare Reform Act.

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

 

 

 

 

 

  

 

 

 

 

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Electronic Medical Records (EMRs) And President Obama’s Economic Stimulus Package

 Stanley Feld M.D.,FACP,MACE

President Obama’s has created an incentive program to encourage physicians to adopt functional Electronic Medical Records.  The program’s $27 billion dollars (funded by President Obama’s Economic Stimulus package) will turn out to be a colossal failure and a waste of money.

Twenty seven billion dollars would provide $44,000 for 640,000 physicians. After the bureaucratic infrastructure is built the federal government will be lucky if one third of the money remains for bonuses to physicians.

Only 21,000 of 650,000 (3%) of physicians have applied to date.

 Complex bureaucracies and complicated regulations never save money. These bureaucracies create bigger government, inconsistent policies, more complicated regulations and inefficiencies.

The best and cheapest way to create a universally accepted and functional EMR is for the federal government to put the software in the cloud and charge physicians by the click for the use of the Ideal Medical Record.

Upgrades in software to the Ideal Medical Record will be swift , inexpensive and instantly adopted.

The federal government has done it before with an electronic billing system in the 1980’s. The incentive to physicians was to be paid in one week as opposed to the one to two months wait for payment using a paper claim.

Last week the proposed rules for defining “meaningful use” of EMRs starting in 2013 were published.

As soon as Stage 2 of President Obama’s EMR bonus program were published organized medicine complained that the rules were unrealistic and onerous.

Organized medicine is correct.  This usually happens when the bureaucracy piles one set of rules on top of another. The Stage 2 rules will discourage physicians from participating even at the threat of an undisclosed penalty.

 "Meaningful Use Workgroup Rules Regarding Meaningful Use Stage 2," from the Office of the National Coordinator for Health Information Technology requires the following in order to be eligible for the federal bonus;

Higher thresholds (in % of eligible patients, visits or orders)

  • Use computerized physician order entry (CPOE) (from 30% to 60%:
  • CPOE will expand from drug orders to lab and radiology orders)
  • Use e prescribing (from 40% to 50%)
  • Record demographics (from 50% to 80%)
  • Record vital signs (from 50% to 80%)
  • Record smoking status (from 50%to 80%)
  • Use medication reconciliation (from 50% to 80%)

Elective to mandatory requirements

  • Implement drug formulary checks
  • Record existence of advance directives
  • Incorporate lab results as structured data
  • Generate patient lists for specific conditions
  • Send patient reminders
  • Provide summaries of care record
  • Submit immunization data
  • Submit syndromic surveillance data

New measures

  • Use electronic physician notes
  • Offer clinical encounter information for download
  • Offer health record information for download
  • Ensure patient use of online portal
  • Ensure patient use of secure messaging
  • Record patient preferences for communication medium
  • Provide lists of care team members
  • Record longitudinal care plans

 

Physicians can receive bonuses from Medicare of $44,000 and Medicaid of up to 63,750 for installing and using an eligible EMR system.  These payments (bonus) if you qualify are taxable as ordinary income.

There are several practical problems;

1. Most physicians and physician practices cannot afford the time it takes to find an eligible EMR they can trust.

2. An EMR that might be eligible for federal bonus could cost $70,000 per physician.

3. Physicians cannot visualize the potential payback.

4. Physicians cannot visualize the added value toward improving quality care when quality care has not been adequately defined.

5.Physicians cannot get loans from banks to finance the costs.

6.Most physicians are uncertain about the future of their practices.

Thousands of physicians (3%) are trying to meet stage 1 requirements, which went into effect January 2011.

Eligible EMRs in Stage 1 must be able to meet 15 core measures of functionality and the physician's choice of five out of 10 elective measures.

In order to meet Stage 2 requirements physicians have to spend more money to upgrade their information system to be eligible.

"Unrealistic stage 2 requirements will overly burden physicians and hamper adoption — especially for those physicians in small or solo practice."

Karen Bell, MD, chair of Certification Commission for Health Information Technology said she “does not believe any vendor's system can meet stage 2 requirements yet.”

Developing EMR technology is expensive, and vendors don't want to build complete systems when the standards probably will change in the future.

A Family Practice Group of 4 physicians in Georgia recently spent $75,000 per physician upgrading the practice's EMR in order to meet meaningful use stage 1 requirements. Five years ago they spent $200,000 to launch their original EMR.

Fulfilling stage 2 requirements will probably cost at least another $75,000 per physician to continue qualifying for federal bonuses.

This Family Practice is chasing its own tail. It is working at the whim of a bureaucracy whose job it is to write regulations and not think of the consequences to practicing physicians.

Wouldn’t it be easier for the federal government to install its approved software in the cloud, upgrade it as necessary and charge physicians by the click?

Wasting $27 on bureaucratic regulations is a complicated mistake that is destined to fail.

$27 billion dollars could be better spent on direct patient care and the implementation of my ideal Electronic Medical Record   

 

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

 

 

 

 

 

 

  • electronic medical records

    Interesting post! thanks for sharing this update about “Electronic Medical Records (EMRs) And President Obama’s Economic Stimulus Package” I am well informed.
    -mel-

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