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Quality medical care measures


One Could Go Nuts

Stanley Feld M.D.,FACP,MACE

Measuring quality care in the healthcare system is out of control. My conclusion is that these measurements of hospitals and providers by Obamacare to determine medical care quality is distraction to quality medical care.

The method used is so complex that its measurements are inaccurate and the system is destined to fail.

The measurements are a distraction and costly. They end up diverting resources away from the hospitals’ and providers’ primary mission to provide quality healthcare at an affordable price.

In March 2016, the Healthcare Association of New York State (HANYS) published a report called Measure Madness. The report identified 2,100 required measurements of “quality care” imposed by the federal government and in turn the healthcare insurance industry on hospitals and physicians. The goal is to rate the quality of care given by hospitals and physicians.

The measurement agency claims that the rating system is set up to help consumers make better healthcare choices.

Below is a graph of the various measurements:

Measurement madness final. jpg

Researchers at Weill Cornell Medical College in New York City teamed up with the Medical Group Management Association to put a price on time spent per physician to enter the data into the electronic health record to keep track of newly introduced measures and create protocols to track and report them.

Each year US physician practices in four common specialties spend, on average, 785 hours per physician and more than $15.4 billion dealing with the reporting of quality measures.”

 This report only covers 4 common specialties,and not all specialties and all hospital costs. There is no telling what it costs other hospitals and providers
HANYS report stated “

The volume of measures that exist, promulgated by lack of alignment and poor coordination, has created an environment of measure madness, “Consuming precious resources that could be directed toward meaningful efforts to continuously enhance quality and patient safety.”

The “measurement madness” may be doing more harm than good, according to the report. It’s the latest in a growing number of reports urging consolidation and standardization among the various groups that require reporting of healthcare quality and safety data. 

The Electronic Medical Record is a great idea in theory. I have discussed functional Electronic Medical Records in detail previously. A reader can go to the search engine on this blog to review my criticism of the defects in the Electronic Medical Records sold to hospitals and doctors.

A major defect in EMR is hardly ever discussed. There is a massive amount of copy and pasting to complete the “documentation. The record does reflect anything about the patient’s illness or real progress. It does not provide a true reflection of the patient’s quality of care, natural history of his disease or disease improvement. It does not compare efficiency of medical care outcomes with the financial results of care.
The HANYS report listed the number of reports required for a computer program to evaluate the quality of medical care delivered. It is reflected in the crazy cartoon at the top of this blog.

Number of Reports Per Measurement

Accountable care organizations: 33

The Delivery-System Reform Incentive Payment (or DSRIP) : more than 100

Private Health Plans: 546

National Quality Forum: 635

CMS: 850

Each report has at least one sub report. One has only to recall all the agencies Obamacare has set up.



This bureaucratic scheme can never work efficiently.

HANYS urges stakeholders to do the work to fix the system.

The call for action was for providers of healthcare to jointly commit to the minimum number of measures needed to evaluate healthcare quality, align them with national, standardized, evidence-based data, and focus on efforts that target the most vital aspects of care.

Last week CMS was forced to delay publishing its hospital quality ratings until July 2016 because of the perceived defects in the Obamacare’s measurements.

Congress received tremendous pressure from hospitals because of the confusion the measurements have created.

CMS also plans to host calls with providers to clear up questions about current methodology and get feedback on refining the program”.

Obamacare has been promoting the ratings for hospitals, nursing homes, dialysis facilities and other providers as a way for consumers to compare and select providers.

If one measures the wrong things one will get the wrong answer.

Only 87 hospital of more than 3,600 U.S. hospitals got the highest five-star rating, according to the American Hospital Association.

Just over half of the hospitals fell within the three-star range.

A total of 142 got one star. In January, the AHA challenged the CMS, stating that the program “oversimplifies the complexity of delivering high-quality care.”

Hospitals reviewed the ratings earlier this year.
Sixty U.S. senators heard the hospitals’ message. They sent a letter to CMS earlier this month urging the delay of the program. The senators warned of confusing methods, compromised outcomes for hospitals in disadvantaged communities and the potential to mislead consumers.

The American Hospital Association (AHA) has not been able to come up with the same conclusions as CMS, using the same data sets and methods.

“The delay is a necessary step as hospitals and health systems work with CMS to improve the ratings for patients,” the AHA said in a statement.

On May 12 a conference call is scheduled to educate hospitals on how to analyze and interpret the data. In general, even the government has been confused about how best to interpret the data.

Ben Harder and Avery Comarow of U.S. News & World Report said in a recent article, “Different methodologies can produce different results even when the same raw data sets are used, said cent article.

“No approach to identifying outstanding medical centers is ideal—not ours or the government’s or anyone else’s,” the column stated.”

 A case in point: none of CMS’ five-star facilities made it onto U.S. News’ annual Honor Roll. Ben Harder said, It is likely because the CMS does not yet adjust for socio-economic factors.

 Again the Obama administration is making another costly complicated mistake that is making hospitals and providers go nuts and distract from their main mission of providing quality care at an affordable price.

If anyone thinks complete control of the healthcare system by the federal government via a single party payer system can do better than this government mishmash they should think again.

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

All Rights Reserved © 2006 – 2015 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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More ICD-10 Codes

Stanley Feld M.D., FACP, MACE

Everything the Obama administration’s healthcare administrators do, to increase their control over the healthcare system backfires.

The Obama administration has not admitted that the new coding system (ICD-10) has not worked out as well as it should have.

The fact that CMS has to add 5,500 codes in 2017 suggests that somehow the new system is being gamed.

The increase in codes from16,000 codes (in ICD-9) to 68,000 codes (in ICD-10) is a way to force providers to more fully document their diagnosis and treatment.

It is described as a way to improve patient care. I suspect it will be used as a weapon to decrease reimbursement.

The best way to improve patient care and decrease healthcare cost is to let the patients be responsible for their health and healthcare dollars.

A way needs to be developed to measure medical out as it relates to medical costs. These outcomes must be provided to patients.

The more codes there are the more the coding system can be gamed and abused by hospitals, physicians and other providers.

At this point the government is paying many other providers. These providers can also game the system. The increase in codes can result in a further increase in costs to the healthcare system.

Never the less the Obama administration seems to spin everything that backfires on it into a positive. The people are not accepting the spin anymore.

One example of the spin is the information paper CMS published about ICM-10.

One section is entitled;

How will my practice benefit from ICD-10?

ICD-10 provides an enhanced platform for physician practice. As of October 1, 2015, the ICD-10 coding classification became the new baseline for clinical data, clinical documentation, claims processing, and public health reporting.

The statement means physicians have to provide more documentation in order for the government and the healthcare insurance industry to have more control over physicians’ practices.

From proper observation and documentation to improved clinical documentation, progress notes, operative reports, and histories, the benefits of ICD-10 begin with enhanced clinical documentation enabling physicians to better capture patient visit details and lead to better care coordination and health outcomes.

It does not enable physicians to better capture patient visit details and lead to better care coordination and health outcome.

It enables government and the healthcare insurance industry to capture patient visit details. It does not necessarily lead to better care coordination and health outcomes.

Ultimately, better data paves the way for enhanced quality and greater effectiveness of patient care and safety. The benefits of ICD-10 will impact everything from patient care to each practice’s bottom line.

Better data might not lead to enhanced quality care or lead to better care coordination and health outcome. It can lead to more paperwork and more false data.

It also could conclude that the best physicians are the best documenters. It will not tell us which physicians have the best clinical judgment.

Reasons to prepare for ICD-10 can be broken down into four categories:


  • Informs better clinical decisions as better data is documented, collected, and evaluated
  • Provides new insights into patients and clinical care due to greater specificity, laterality, and more detailed documentation of patient diseases
  • Enables patient segmentation to improve care for higher acuity patients
  • Improves design of protocols and clinical pathways for various health conditions
  • Improves tracking of illnesses and severity
  • Improves public health reporting and helps to track and evaluate the risk of adverse public health events
  • Drives greater opportunity for research, clinical trials, and epidemiological studies.
  • A lot of this is just word salad.


  • Enhances the definition of patient conditions, providing improved matching of professional resources and care teams and increasing communications between providers
  • Affords more targeted capital investment to meet practice needs through better specificity of patient conditions
  • Supports practice transition to risk-sharing models with more precise data for patients and populations.


  • Provides clear objective data for credentialing and privileges.
  • Captures more specific and objective data to support professional Maintenance of Certification reporting across specialties.
  • Improves specificity of measures for quality and efficiency reporting
  • Aids in the prevention and detection of healthcare fraud and abuse
  • Provides more specific data to support physician advocacy of health and public health policy

This section clearly defines the intention of the expanded ICD-10. It is an attempt to define physicians’ quality of care by computer and award or penalize physicians based on a potentially faulty definition of quality care. It could lead to quality care being defined by documentation, not by clinical judgment.


  • Allows better documentation of patient complexity and level of care, supporting reimbursement for care provided
  • Provides objective data for peer comparison and utilization benchmarking
  • May reduce audit risk exposure by encouraging the use of diagnosis codes with a greater degree of specificity as supported by the clinical documentation

Physicians can interpret this category as a threat to their reimbursement and their clinical judgment.

Physicians might conclude that they should do what the government tells them to do or they will lose their livelihood.

The government’s healthcare policy wonks. They are not practicing physicians. They do not understand physicians’ potential reactions. They do not consider the unintended consequences of this policy.

Once physicians understand the goal is let the government control physicians’ medical judgment there is no telling what will happen to the quality of medical care.

Quality medical care is not a science or a social science that can be managed by computer. It is a learned process by physicians integrating scientific knowledge an art of personal relationships.

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

All Rights Reserved © 2006 – 2015 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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How Should Healthcare Quality Be Measured?

Stanley Feld M.D., FACP,MACE

 The U.S. Preventive Services Task Force’s (USPSTF) grading system for measuring the quality of healthcare is an wrong. It results in a way to limit physicians’ judgment and treats medical care as a commodity. It enables a computer program to judge if physicians have followed an algorithm to treat patients.

 “The U.S. Preventive Services Task Force (USPSTF).[57][citation needed has developed grading systems for assessing the quality of evidence for making judgments about treatments. 

  • Level I: Evidence obtained from at least one properly designed randomized controlled trial.
  • Level II-1: Evidence obtained from well-designed controlled trials without randomization.
  • Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
  • Level II-3: Evidence obtained from multiple time series designs with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
  • Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.”

The grading system is wrong. I will lead to shabby medical care. If quality of care should be measured, it should be measured by using Evidence-Based Behavioral Practice evaluations

 “Evidence-based behavioral practice (EBBP) "entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected.”

Empirically supported treatments (ESTs) in some clinical settings are defined as "clearly specified psychological treatments shown to be efficacious in controlled research with a delineated population" [3]

Only when physicians’ clinical judgment and observations are included in the assessment of their quality of medical care should evaluation of that quality of care be measured.

The narrow criteria of the USPSTF will not define quality. It will only serve to restrict access to care and penalize physicians for using clinical judgment and consumers’ from receiving medical care.

Suddenly, it becomes easy to see how difficult it is to assess the quality medical care.

There is little question that an occasional physician practices terrible medicine. This is obvious to the medical community. The mechanism for improving a bad physicians quality of care is in place but not well executed.

Few, especially healthcare policy wonks, seem to understand the difficulty of assessment of medical care.

It should be easy for policy wonks to understand the limitations and criticisms of evidence based medicine.

Yet the Obama administration regards evidence-based medicine as measured presently as the gold standard of clinical practice,

Limitations and Criticisms of Evidence-Based Medicine (EBM)

  • EBM produces quantitative research, especially from randomized controlled trials (RCTs). Accordingly, results may not be relevant for all treatment situations.[67]

This is obvious to most physicians.

  • The theoretical ideal of EBM (that every narrow clinical question, of which hundreds of thousands can exist, would be answered by meta-analysis and systematic reviews of multiple RCTs) faces the limitation that research (especially the RCTs themselves) is expensive; thus, in reality, for the foreseeable future, there will always be much more demand for EBM than supply, and the best humanity can do is to triage the application of scarce resources.

The reasons for EMS shortcoming are listed below. The list is not complete.

  • Because RCTs are expensive, the priority assigned to research topics is inevitably influenced by the sponsors' interests.
  • There is a lag between when the RCT is conducted and when its results are published.[68]
  • There is a lag between when results are published and when these are properly applied.[69]
  • Certain population segments have been historically under-researched (racial minorities and people with co-morbid diseases), and thus the RCT restricts generalizing.[70]
  • Not all evidence from an RCT is made accessible. Treatment effectiveness reported from RCTs may be different than that achieved in routine clinical practice.[64]
  • Published studies may not be representative of all studies completed on a given topic (published and unpublished) or may be unreliable due to the different study conditions and variables.[71]
  • Research tends to focus on populations, but individual persons can vary substantially from population norms, meaning that extrapolation of lessons learned may founder.
  •  Thus EBM applies to groups of people, but this should not preclude clinicians from using their personal experience in deciding how to treat each patient. One author advises that "the knowledge gained from clinical research does not directly answer the primary clinical question of what is best for the patient at hand" and suggests that evidence-based medicine should not discount the value of clinical experience.[56] Another author stated that "the practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."[72]
  • Hypocognition (the absence of a simple, consolidated mental framework that new information can be placed into) can hinder the application of EBM.[73]
  • Valid enthusiasm for science should not cross the line into scientism, losing critical perspective.
  •  Although clinical experience and expert opinion are insufficient by themselves, neither are they valueless, as EBM fervor that approaches scientism sometimes tends to paint them.

This last point is repetition of a very important shortcoming.

  • An informed clinician can weigh confounding variables in a clinical case and decide that following a population-based guideline to the letter feels inadequate for the situation. Thus clinical backlash against "cookbook medicine" is not always misguided, and "guidelines are not gospel."[74]
  •  Conceptual models, by having fewer variables than always-multivariate reality, face limits of predictive accuracy, just as even the best supercomputer simulations cannot predict the weather with 100% accuracy, whether because of the butterfly effect or otherwise.
  •  Thus, just as clinical judgment alone cannot give epistemological completeness, neither can RCTs and systematic reviews alone.”

The answer to the reader’s last comment and question, “I believe a carrot and stick approach may be necessary with more carrot and less stick.  Your thoughts?” is

I believe that government must learn how to evaluate quality medical care accurately, if they want to base healthcare payments on the quality of medical care. Presently, the government is far from achieving that goal.

It could also be that measuring quality medical care is not President Obama’s goal.

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

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The Growth Of Concierge Medicine

 Stanley Feld M.D.,FACP,MACE

In the accelerated chaos Obamacare has created for both patients and physicians an increasing number are trying to find ways to maintain their freedom of choice. Patients are recognizing that Obamacare is causing a commoditizing of healthcare and the destruction of the Patient/Physician relationship.

Patients and physicians yearn to have a good Patient/Physician relationship.

Physicians love the practice of medicine but they hate the burden being imposed on them.,

  1. Increased government regulations and requirements,
  2. Increased paper work to prove every clinical decision they make on the patient’s behalf.
  3. The restrictions on their use of clinical judgment.
  4. The increased overhead to comply with regulations of both the government and the private insurance plans.
  5. The decreasing reimbursement.
  6. The lack of malpractice reform.
  7. The pressure on primary care physicians to see 30-50 patients a day to cover overhead resulting from decreased reimbursement.
  8. The inability to spend more time with patients because of this patient volume pressure.
  9. The inability to get to know their patient better because of time constraints.

      10. Their inability for physicians to have empathy for patients after they see the tenth patient   because of burnout.

       11. Their inability to develop a viable patient/physician relationship.

       12. Spending at least three hours weekly dealing with insurance plans preauthorization.

       13. Their clerical staff and nursing staff spending at least fifteen hours weekly obtaining preauthorization from the insurance company or government before providing patient care.

        14.Their ability to keep up and comply with all the bureaucratic requlations and requirements.

An AMA survey of 2,400 primary care physicians believe private insurers and government insurers have excessive requirements for preauthorization for tests, procedures, and medications.  

  • More than one out of three have a rejection rate of 20 percent for first-time preauthorization on tests and procedures,
  • More than half of physicians have a 20 percent rejection rate on prescriptions.
  • About one half of physicians have difficulty obtaining preauthorization from insurance plans.
  • About two out of three wait several days for permission.
  • About the same proportion report difficulty in determining which tests, procedures and medications require preauthorization.

These are just a few of the reasons the enjoyment has been taken of the practice of medicine. Many physicians have said I am finished dealing with all these rules and regulations, the government and the private insurance industry.

Many Primary Care Physicians are converting their medical practices to Concierge Medical Practices.

Proponents say concierge care is a revolt against the modern health care system where diminishing Medicare and insurance payments have forced doctors to herd dozens of sick patients through their offices in five-minute increments every day.”

What is concierge medicine?

Concierge medicine is a relationship between a patient and a primary care physician in which the patient pays an annual fee or retainer. This may or may not be in addition to other charges depending on the business model being used and the retainer charged.

The up front retainer allows physicians to decrease full time staff to a minimum. It decreases the complexity of practicing medicine. Physicians do not deal with insurance companies or the government. They only deal with their patients. This permits physicians to decrease the number of patients they see a day and increase time spent with and relating to patients.

Doctors who charge an annual fee to patients in exchange for customized care including house calls are drawing the ire of some health insurance companies.”

Concierge medicine is a way of taking first dollar coverage away from the healthcare insurance industry and putting control of care in patients’ hands. It prevents the insurance companies from feeling they own physicians and patients.

If the Patient/Physician relationship is not important too many large healthcare companies. Physician are simply one provider among many such as nurse practitioners, physicians assistants, social workers and pharmacists.

All these healthcare companies are interested in is maximizing their profits from this 2.7 trillion dollar business.

Concierge medicine would not be growing by leaps and bonds if this companies concentrated on the welfare of consumers.

Both physicians and patients are feed up with the development of central control of the healthcare system.

All of us remember President Obama’s lie, “If you like your doctor you can keep your doctor with Obamacare.”

Obamacare was passed because of this lie.

The concierge retainer fees can vary from $500 to $38,000 dollars per year. Concierge medicine will create a two tier Healthcare System. I disagree with a two tier system!

It is occurring because we have a dysfunctional healthcare system. Obamacare is making the healthcare system more dysfunctional.

The healthcare system is not servicing either patients or physicians well. Each is searching for an alternative before Obamacare and the entire healthcare system collapses under it own weight.  

Patients yearn for a positive Patient/Physician relationship. As more physicians are adopting the concierge business model patients are signing up to the surprise of the government and the healthcare insurance industry.

These stakeholders have underestimated the value of the Patient/Physician relationship.

Maybe the trend will wake up the government and the healthcare insurance industry and fix the things that are broken.

Obamacare is not doing it! It is making things worse.

Maybe these two stakeholders will realize that they do not own the physicians or patients. Any attempt to own them is futile. It is not in the American culture being to be enslaved.

The answer is not fancy information systems that do not work perfectly. It is not by creating expert panels to tell physicians what they can do. It is not these panels telling patients the care they can have. Our healthcare system is dysfunctional. The system does not evaluate the quality of care effectively.

All one has to do is look at the VA system’s problems. The VA system’s problems are a disgrace. It should also be a warning about the future of Obamacare.

Obamacare and its bureaucracies are going to create another VA system for all Americans.

The answer is to teach consumers what is good treatment and what is not good treatment. It is to help consumers evaluate their physicians. Price transparency is a good beginning in order to get the stakeholders to start competing.

Tort reform is another good start.

Government could help by teaching consumers to ask the right questions.

It should start realizing that we have to have a consumer driven patient centric system where patients are responsible for their health and healthcare dollars.

The problems in the healthcare system can be solved with a consumer driven healthcare system using my ideal medical saving account.

The public health problems are a different issue. There are three diseases we can prevent. They are obesity, alcoholism and drug addiction. The government must deal with these diseases on an educational and social level.

The government has not done a very good job with any of these three diseases. The prevention of these diseases is a public health problem.

It should not be mixed up with individual medical care. Obamacare does with the causes of these diseases or the environmental cures.

Obamacare is another unsustainable entitlement program. The government should not be creating another unsustainable entitlement program.

It should be creating a program that promotes individual responsibility for health, healthcare, and healthcare dollars.  

Hopefully the growth of concierge medicine will be a wake up call to a misguided Obama administration wanting top down control of the healthcare system.

They must realize that the Patient/Physician relationship is sacred to cost effective medical care.

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

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Patients’ Responsibility And Hospital Readmissions

Stanley Feld M.D.,FACE,MACE

has rules to penaliz
e hospital systems if a patient was readmitted to the
hospital before 30 days of initial admission.

Prior to October 1,2012 Medicare revised hospitals' readmissions penalties
. On October 1 Medicare started fining hospitals
that have too many patients readmitted within 30 days of discharge due to
complications of their disease.

The formula for determining these penalties is
extremely complicated
. The formula is almost impossible to understand.   

Hospitals whose admission rates are above the
national average will be penalized. The data analytics are supposed to risk
weight patients to see if the hospital should be penalized.

Patients with multiple co-morbidities have a higher
chance of readmission.

The penalties are part of a broader
push under President Barack Obama's
health care law to improve quality while
also trying to save taxpayers money.”

The gigantic perverse incentive is for hospitals to
avoid the initial admission of sick patients with multiple morbidities. Those are
the patients that have a better chance of being readmitted within 30 days.

It is also impossible to evaluate quality of medical
care using claims data. False  conclusions will not be a true reflection on who
is at fault and should be blamed and penalized for the readmission.

 It could be
that patients did not adhere to the discharge instructions.  

two-thirds of the hospitals serving Medicare patients, or some 2,200
facilities, will be hit with penalties averaging around $125,000 per facility
this coming year, according to government estimates.”

The formula for penalty
assessment  is extremely complicated. The
Centers for Medicare & Medicaid Services has discovered errors in its
initial calculations in August 2012.  

one in five Medicare patients return to the hospital within a month of
discharge, costing the government an extra $17.5 billion in 2010.”

A total of 2,217 hospitals are being
punished in the first year of the program, which began Oct. 1. Of those, 307
will be docked the maximum amount: 1 percent of their regular Medicare

Only acute myocardial infarction,
congestive heart failure and pneumonia will be evaluated the first year.


Overall, Medicare has estimated it will recoup about $280 million
from hospitals where it determined too many heart attack, heart failure or
pneumonia patients returned within 30 days

Dartmouth Atlas of Health Care and the Robert Wood Johnson Foundation latest
report "The Revolving Door Syndrome on
hospital readmissions points out highly variable rates.

Ninety two (92) academic
medical centers and 37 hospitals saw readmission rates for their patients
actually increase. 

                                               Double click to see legend

David Goodman, MD, co-principal investigator
for the Dartmouth Atlas Project said
. "Despite
awareness of the problem, progress and improvement has been slow."

report divided readmissions into two types, those affecting patients whose
first admission was for a surgical procedure and those affecting patients whose
first admission was for a medical condition such as congestive heart failure,
pneumonia, or heart attack.

The surgical 30-day readmission
rate dropped from 12.7% in 2008 to 12.4% in 2010, while the medical 30-day
readmission rate went from 16.2% to 15.9%.

The report shows wide
among academic medical

“The highest readmission rates in 2010 were the
Cleveland Clinic, with 21.6%
, and the Hospital of the University of
Pennsylvania, with 21.4% among AMI, congestive heart failure and pneumonia.

The hospital with the lowest rate was NYU Langone Medical Center, with
14.4%. “ 

The University of
Medicine and Dentistry in New Jersey (UMDNJ) had the highest surgical
readmission rate with 20.7%, and the Stony Brook University Medical Center on
Long Island, with 20.6%.

If this data is correct
academic institutions will not be in the mood to be penalized for taking care
of sick patients.

Other studies have shown
that there is only a 50-60% adherence rate by patients to prescribed treatment.
This lack of adherence can be a significant driver to readmission rates. There
is no data evaluating patients’ role and responsibilities in re-admission

What are patients’
responsibility for their care? If patients do not receive enough education to
avoid hospitalization they should demand the education.

If patients are not
interested in self-management of their disease they should tell their

If the patient is too sick
to learn to self-manage a family member should be involved.

Patients have responsibility
for their self management to avoid readmission is high!

Yet the government is quick
to blame hospitals and physicians for high re-admission rates without examining
all the facts.

Another factor not
evaluated in determining readmission rates is the pressure on the hospitals to discharge
patients quickly.

doctors feel they are caught in a squeeze play
," the report says.
"Hospital administrators carefully monitor length of stay—they are eager
to send people home because the longer a patient stays, the less money they
make. Thus providers said that the prevailing pressure is to discharge
patients as early as possible" even if it's too soon.”

is the slippery slope the healthcare system is on. The data management is
faulty. The government is not evaluating all the complex variables resulting in
hospital readmissions. This defect leads to faulty decisions. Those decisions
lead to more complicated unintended consequences.

should be driving the healthcare system not the government. The government
should make the rules to level the playing field for all stakeholders.

government should defend the interests of patients.

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

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Paul Ryan on Medicare


 Stanley Feld M.D.,FACP,MACE

 Paul Ryan and the Republican House passed the 2012 budget that has been ignored by Harry Reid and the Senate.  Harry Reid gets his orders from President Obama. He chose not to consider the Republican House budget. Instead Democrat chose to demonize Paul Ryan.

 President Obama seems to be ignoring America’s debt and deficit spending crisis. The Senate has not produced a budget in over 900 days. President Obama has presented numbers to the CBO that would result in decreasing the budget deficit. The numbers presented to the CBO are phony. The Healthcare Reform Act will result in a huge increase in our deficit. It will result in higher taxes.

The traditional media has been very effective in demonizing Paul Ryan’s budget proposal.. The TV ad implying that Paul Ryan is pushing grandma off the cliff is a total lie. The media should fact check before accepting an inaccurate advertisement .

If anything, President Obama’s Healthcare Reform Act will push grandma off the cliff.

Paul Ryan’s explanation of our debt crisis and deficit spending is clear. His budget proposal is also clear.



Paul Ryan questions the reasons President Obama and the Democratic Senate are ignoring the coming disaster.


The healthcare system is inundated with waste, fraud, abuse, a lack of competition and well-directed incentives for the healthcare system to function efficiently.

 President Obama’s healthcare reform law is awash with penalties, punishment and rationing as well as waste in the form of more bureaucracy, committees, studies and pilots. Medicare is unsustainable.


The healthcare insurance industry has figured out how to profit from the proposed ACO (Accountable Care Organizations). It means more bureaucracy resulting in higher fees to charge the government for providing administrative services. The result will be higher unsustainable costs for both the government and seniors.






Hospital systems know are not prepared for ACOs. ACO’s are too costly to set up. Most hospital systems information systems are not good enough to provide the data the government wants to evaluation the care given. Administrators managing hospital systems intuitively know that the government will make decisions that will be counter to hospital systems’ vested interests.



Physicians know that hospital systems are going to try to capture as much of their intellectual property as possible and restrict their freedom to make medical judgments. It will be very difficult to create physician hospital alignment under an ACO.


This is a must watch You Tube

Patients know ACO’s are going to restrict access to care, increase their out of pocket expenses, ration care and result in higher taxes and higher deductible. Partial implementation of President Obama’s healthcare act already has resulted in all of the above.

Hospital systems and physicians have not signed up for ACO’s. That resulted in Dr. Don Berwick and CMS revising their ACO final rules. Dr. Berwick is trying to entice hospital systems and physician groups to sign up and form ACO’s.

Dr. Berwick says he is for patients, hospital systems and physicians delivering better care to patients. I believe him. However, he is doing it the wrong way.

 The only thing the new rules accomplish is to make forming an ACO more affordable at the front end. Medicare ACO’s continue to be a government controlled system with penalties and punishments to providers. 

Patients’ treatments will be determined by a non-elected committee and not their physicians.  The committee might make the wrong decision by examining the wrong data.

The most recent example was the United States Preventive Services Task Force (USPSTF) on prostatic specific antigen (PSA).  

There was not one urologist on the committee. Another example was the USPSTF task force studying osteoporosis and the use of bone mineral density in men over 70. There was not one Clinical Endocrinologist on the committee.

All anyone has to do is go into any Wal-Mart on a Monday morning.  At least 50% of males over 70 years old look like they have lost several inches of height.  Each of these men has osteoporosis. They are at risk for hip fractures. Hip fractures at the least with decrease quality of life. At most, long hospitalization and death. Hip fractures can be prevented if treated properly.

Medicare will not pay for these men to have a bone density for the diagnosis of osteoporosis.  This leads me to the definition of quality medical care.

  The next step would be to study the number of hip fractures in men over 70 years old and the cost of treatment of these fractures. An evaluation of the quality  of life  after fracture must be evaluated to get an accurate assessment of the cost effectiveness of doing bone mineral density testing.

Medical care systems must be a patient centered and controlled. It must not be a government centered and controlled system. This is the only way to develop a cost efficient system. Dr. Berwick’s way will only increase the cost to the government. He will spend money the government does not have.

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






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Obamacare’s Magic Bullet (Accountable Care Organizations) Is Not On Target!

Stanley Feld M.D.,FACP,MACP


As we get closer to January 2012, the originally scheduled implementation date for Accountable Care Organizations (ACOs), the time has come to reexamine the showpiece of President Obama’s Patient Protection and Affordable Care Act (PPACA) of 2010. 

 The final rules for ACO’s are now scheduled for release on January 2012. The implementation was originally scheduled for January 2012. As the original rules are being studied and interpreted the program for ACOs implementation became more confusing. Dr. Don Berwick (CMS Director) has refused to discuss the final rules until they have been published in the Federal Register.

 “The ACO program is based on the hubristic assumption that the federal government can design the best organizational structure for the delivery of care, foster its development, and control its operation for the entire country.

 The federal government has big-footed health system reform. Although there is no one right way to organize care, the federal government (Dr. Don Berwick and President Obama) thinks it has found one—and exerts top-down, bureaucratic control through PPACA to implement it.”

 ACOs are supposed to be organizations that improve coordinated care. If an ACO decreases the cost of care the ACO will share the savings with the government with a formula for sharing to be determined by the government. The formula is complicated.

 ACOs will be required to accept responsibility for the cost and quality of care for defined patient populations. The government will define the population not the ACO or the patient. The goal is to prevent the ACOs ability to cherry pick a healthy population.

 ACOs will have to meet targets defined by their previous 3 years of Medicare Part A and Part B experience in order to share savings.

 Here is the first “Catch 22.”

 If an organization such as Mayo Clinic did a great job with its integrated system in the past three years it would have to do better in the next year to receive any savings. Let us say it is not possible to do better because they are so great. The only risk benefit reward for Mayo Clinic is a penalty.

If an organization did poorly in the last three years its upside potential is great if it performs well.

  Qualified ACOs can choose between 2 risk-benefit programs. The first involves upside potential from shared savings in the first 2 years, adding downside risk only in the third year of operation.

 In the second risk-benefit program, ACOs share a greater percentage of the savings with the government but are responsible for downside risk from the onset of the program.

 ACOs’ will be required to conduct quality improvement initiatives, care coordination, measure performance and develop infrastructure to meet government requirements to qualify to continue to be an ACO. The startup costs for a hospital system have been estimated to be $2 million to $12 million dollars.

  Hospitals and physician organizations have had adversarial relationships in the past that have to be overcome. In order for ACOs to have a chance to work, cooperative relationships must be developed between the hospital and physicians. Hospitals will control the money. They must distribute it fairly to physicians. Past behavior is a predictor of future behavior.  Hospitals have not had a successful record in the past of being fair to physicians.

 Systems of continuing quality improvement will have to be developed and implemented. Both physicians and hospitals have not had to deal with these systems in the past. In is not part of the medical care systems’ culture.  They will have to learn to adapt too quickly in Dr. Berwick’s timeline. 

 It will require a fundamental change in the U.S. healthcare system. It is not a bad thing to have systems of continual quality improvement. In my view the medical care system has to grow into it under steady but friendly pressure. The culture cannot be changed overnight. A consumer driven healthcare system can make it happen quickly. A government driven system will not be able to do it.  

 President Obama has stated over and over again that he is all ears for new ideas. Yet he does not listen to new ideas.

 It is an error to try to create a HMO on steroids. HMOs failed once and they will fail again. Many medical outcomes are unpredictable. Physicians and hospitals are not insurance companies. President Obama is trying to shift the risk to physicians and hospitals. Physicians and hospitals are aware of the difficulty. Many are terrified by the potential penalty.

 A recent report listed the 54 worse hospitals in the country as far as readmission rates after discharge in two out of three disease categories. President Obama has recognized some of these worst performing hospitals as having the best-integrated systems.

Among the hospital systems listed are the Cleveland Clinic, Beth Israel Deaconess Medical Center Boston, Barnes Jewish Hospital in St. Louis, MO, Northwestern Memorial in Chicago, University of Massachusetts Memorial Medical Center in Worcester, Henry Ford Hospital in Detroit, Johns Hopkins Bayview Medical Center in Baltimore and the University of Maryland Medical Center in Baltimore.

  President Obama is going to impose a penalty starting at 1% for Medicare DRG discharges and readmissions after Oct. 1, 2012, increasing to 2% after Oct. 1, 2013 and to 3% after Oct. 1, 2014.

President Obama must be reminded that it is difficult to get cooperation from organizations when they are threated by penalty. The development of complicated regulations that cannot be followed and then granting waivers to some and not others intensifies the mistrust and uncertainty felt by the medical community.

Creating new programs must provide adequate incentives not penalties. Penalties do not promote participation by providers.

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






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Pharmaceutical Companies Shafting Healthcare Insurance Companies

Stanley Feld M.D.,FACP,MACE


The pharmaceutical companies are marketing kings. The large increase in generic sales has affected their bottom line. When they are up against the wall marketing gets innovative.

EXECUTIVES of a small insurance company in Albany were mystified when, almost overnight, its payments for a certain class of antibiotics nearly doubled, threatening to add about a half-million dollars annually in costs.”

The drug benefits costs for this healthcare insurance company increased as it did for others because the drug company was innovative. It started giving out coupons to cover the patients’ co-pay. It did not cost the patient to pay for this new expensive medication. It cost the insurance company dearly because patients stopped using the generics since their co-pay was covered by the drug company. The effectiveness difference between the generic and the new antibiotic was questionable.

This is not the first time drug companies have given patients co-payment coupons. The coupons paid the branded drugs’ co-pay. This is another example of consumer driven power. Consumers will seek the best price and highest quality.

The use of such co-payment cards and coupons and other types of discounts has more than tripled since mid-2006, according to IMS Health, an information company that tracks the pharmaceutical industry.

Consumers are smart. They know when they are getting a good deal. Pfizer, the maker of Lipitor, introduced a new coupon card that reduces the co-pay for Lipitor to $4 a month. The co-pay for Lipitor is about $50 for a month’s supply. The coupon card saves consumers as much as $50 a month. The coupon gives Pfizer a chance to have Lipitor compete with generic Zocor at Wal-Mart and other chains.

The healthcare insurance industry pays much more for Lipitor than it does for generic Zocor. The clinical evidence for a difference in the medications is small. The marketing of the clinical evidence is a gimmick. The both work the same. Lipitor is twice as potent therefore, you need half the dose to achieve the same effect.

Drug companies say the coupon plans help some patients afford medicines that they otherwise could not. “

The health insurance companies say the coupons are a marketing gimmick. In reality they are. The healthcare insurance industry is just going to pass the cost to its bottom line to consumers by raising the price of insurance premiums.

The member is somewhat insulated from the cost of the prescription,” said Kevin Slavik, senior director of pharmacy at the Health Care Service Corporation, which runs Blue Cross and Blue Shield plans in Illinois and three other states. “In essence, it drives up the total cost of providing the prescription benefit.”

President Obama, where are you when the public needs you? The Food and Drug Administration has been ineffective.

The Food and Drug Administration, meanwhile, is studying the effect of the discounts on consumer perceptions, concerned that the coupons will make consumers believe that a drug is safer or better than it really is.”

The differences in costs are astounding.

  1. Once a day Minocycline is $700 per month. The price of a twice a day generic Minocycline $40 per month
  2. In New York City in a union representing public employees, 59 percent of claims were brand-name statins whose co-pay was coupon supported. The claims cost the union $17.3 million. The other 41 percent of claims were for generic statins. It cost the union only $179,000. The union has eliminated the co-pay on generic statins to encourage their use.
  3. Jazz Pharmaceuticals has quadrupled the price of its narcolepsy drug Xyrem, to about $30,000 a year, over the last five years. In order to cushion patients’ out of pocket cost, the company recently increased its co-pay assistance to as much as $1,200 a month.

“It seems the best strategy for a pharmaceutical company is to price their drug as high as they possibly can and offer that co-pay assistance broadly” to insulate consumers, said Joshua Schimmer,

Co-payment coupons are distributed by drug company sales representatives to physicians. Physicians are made to believe they are helping their patients. The coupons are also available directly to patients over the Internet. Patients present them at the drugstore when paying for their prescriptions and receive the discount.

Medicis, the company that sells Solodyn(Minocycline extended tablet), have told investors that the co-payment card is used by an “overwhelming majority” of patients, and is largely responsible for doubling use of the drug, to 26,000 prescriptions a week.

The use of once a day Minocycline vs. twice a day generic Minocycline results in a difference in cost of $2.6 billion dollars a year for this one drug.

There is something wrong. Physicians are not aware of the drug companies’ gimmicks. They think they are helping their patients. The pharmaceutical industry is indeed the king of marketing.

Pharmaceutical Companies Shafting Healthcare Insurance Companies. Healthcare Insurance Companies in turn will shaft patients by increasing their premiums.

President Obama’s healthcare reform act should be doing something about this if it wants to keep the cost of healthcare down. It is not doing anything about this problem.

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

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Getting Closer To The Ideal Electronic Medical Record

Stanley Feld M.D.,FACP,MACE

Over 70 % of physicians use smartphones. Physicians are not resistant to learning how to use an iPhone or one of the Android smartphones. The network speed is the irritation. Networks are confusing the public with 3G and 4 G network speed. They should just do it!

We are rapidly approaching the time when a smartphone will be an appliance. The best applications will survive. Medical applications will become fully functional.

Most individual physicians and group practices have had at least one electronic medical record (EMR). None has fulfilled its promises. None has been fully functional. The price paid for the EMR was high in the era of decreasing reimbursement.

Most practices need a fully functioning EMR. The practices are hesitant to endure the pain of conversion once more.

President Obama’s multi-billion dollar subsidy program is bogus. The amount of the subsidy is well below the cost of the EMR and its continuing service and upgrades. I believe the program will have little impact on adoption of EMRs.

If President Obama provided the ideal electronic medical record along with upgrades and service to physicians for a monthly fee, physicians could afford to sign up. They would not worry about an unaffordable capital expense. Physicians would be charged by the click just as MasterCard charges by the usage.

Instantaneously, the system proposed, would result in America’s physicians converting to a government certified fully functional EMR at minimal cost or risk.

Patients’ data could be kept on a hard drive in the physicians’ office to maintain patient privacy. Physicians would have to agree to release certain data to be used for educational purposes without compromising patients’ privacy.

Instead, President Obama’s new agencies are going to use inaccurate claims data to judge physicians’ care and impose penalties on physicians.

With the increasing development of cloud computing, President Obama could provide the software in the cloud with servicing and upgrading. It would cost the government less and the government would have created an income generating business.

Electronic medical records software producer ClearPractice has developed a SAAS (software-as-a-service application) for the Apple iPad to help doctors manage their workflow, from scheduling to prescribing to billing.

A fully functioning EMR can be developed with physicians using the functionality of an iPad and upcoming Android tablets.

I have not had the opportunity to study ClearPractice’s product. ClearPractice has the right idea. Its Nimble EMR cloud product is the first comprehensive EMR application designed to run on the iPad.

I think its distribution and storage model needs refining. It also should build iPad applications to interface seamlessly with an Android system Pad.

The software can be accessed from the cloud. Patient data files can be accessed from the physicians server using a Pogoplug. This would permit physicians to be in control of their patients’ data.

“In designing Nimble, ClearPractice tackled the slow implementation of EMR software, which costs physicians time and money and disrupts their workflow. "Traditional EMR systems slow down busy doctors."

A tablet can easily keep physicians connected to their patients’ data in their office, in the hospital and at night in their home.

ClearPractice claims its software-as-a-service application has scheduling, tracking in-patient rounds, prescribing, lab review/ordering and messaging applications. It also connects to the physicians’ billing system to automatically capture and submit charges for payment.

Nimble does not sound fully functional. The software must have the ability to connect financial outcomes with clinical outcomes to be appealing to physicians. Physicians must be able to use the data they generate to augment their value to the patient. They are hesitant to submit data to a third party that will use it to devalue their worth.

ClearPractice’s fee schedule is vague. Nonetheless, ClearPractice is on the right track. President Obama could save his subsidy money if he would start listening to physicians. He is going to ahead and will waste the money from the stimulus package. He will not make progress toward the goal of developing universal use of fully functioning electronic medical records.

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