Quality medical care measures

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“President Obama’s Cure Is Worse Than The Disease” An Additional Comment

February 7, 2010

inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Quality medical care measures, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

Matthew Modleski has been following Repairing the Healthcare System for several years. He is a former jet fighter pilot. Now he is a strategic planning consultant.

His firm is Stovall Grainger Modleski Inc. His comments over the years have always impressed me. He has a grasp on the big picture. Most people concentrate on the short term solutions.

I am publishing, in full, his last comment to me. I feel it is an extension to the point made in my last blog. President Obama’s healthcare reform bill is non-strategic. His healthcare reform bill adds on to a non-strategic healthcare system rather than converting the system to a strategic healthcare system. .

It has non enforceable mandates with penalties rather than encouraging self responsibility by patients and physicians. The regulations are restrictions on healthcare delivery. It lacks a Six Sigma strategy( continuous quality improvement modality).

You cannot put patches on a broken system especially when those patches restrict the freedom to choose, think and be innovative and be successful. The result of these restrictions will inevitably result in costly unintended consequences

The government’s job should be to make the rules and then get out of the way. If the rule book needs slight modifications because it forgot something then add a new rule.

A rule change example would be the NFL rule book. The rules committee forgot to include the rule that you cannot hit the quarterback after he throws the ball. The rule was added for quarterbacks’ unprotected safety.

Dr. Feld

Another nice blog, I would add:

1. There is a lack of accountability for one’s health and the consequences of poor choices in maintaining it. We are all going to die. The three questions that currently go unanswered is “when” (we’ll never know until the day), how much money are we going to spend between now and then, and who’s money will it be (mine or someone else’s)?

Someone should have the courage to say, “if you can’t/won’t modify poor behavior you are going to die earlier”. All the data collected in healthcare over the years supports that reality.

2. The current healthcare delivery system is non-strategic and therefore makes a lot of mistakes and lacks both efficiency AND Quality. If we kill between 4000 and 8000 people per month due to mistakes and errors (most Americans have NO IDEA), we have to get a better, more strategic delivery system in place and we have to measure results.

In order to make the measurements meaningful, we must compare apples to apples. Only then, with meaningful information on provider quality, based on the results they achieve per dollar spent (over a period of time), can consumers make meaningful choices in terms of the value they get for what they spend.

Without information, we are blind in our purchasing power. I know you don’t want to address a disparity in the quality of care delivered across the spectrum of providers (they’re your peers), but it is significant. I do agree with meaningful information and financial as well as healthcare consequences for their purchases in healthcare, that consumers can drive meaningful change.

Who’s going to provide that information, and when will providers begin to align into a more focused delivery system that permits excellent results at a lower cost? The answer is when the reimbursement system rewards results over time versus an activity not linked to results.

3. In my former business, no one wanted to be last in terms of “how good we were at our job”. There were huge egos on the line and everyone in that business graduated at the top of their class and had a high level of skill at what we did. We were driven by a professional work ethic and sound principles.

In our business we ranked each member of our team on their performance and published the results on the wall for everyone to see EVERY DAY. The results of that clear measurement was that if you were last on the list or near the bottom, you sought out someone at the top of that list and asked “how do you get the results you get because I want to be better”?

My old business was the Jet Fighter Business and if we were bad at our job, we could die quickly. The same is true in medicine, except 4000-8000 patients die each year, not providers.

Let’s put a comprehensive plan together Dr. Feld, it could be the blue print for meaningful healthcare reform in our country!

Cheers,

Matt

Matt

I am game.

1.Quality has to be judged correctly and not artificially as it is done by the healthcare industry and the government.

The consumer has to put pressure on the physicians and hospitals, not the healthcare insurance industry or the government.

2 The fighter pilot example is a single point example. There are many elements to evaluating quality medical care. The definition of quality medical care is much more than the measurement of life or death.

3.Physicians must be inspired and motivated to improve quality once quality is defined appropriately. A jet pilot is certainly motivated by the nature of the job. Physicians can learn to do a better job once the definition of a better job is clearly defined in a non punitive environment.

Again. I am game. Let us do it.

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

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Healthcare Is A Team Sport

April 26, 2009

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

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Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Davon Jacobson, MD • April 27, 2009

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

It looks like hospitals are marginalizing physicians. Cardiology practices are now mostly hospital owned. Hospitals are buying medical practices regularly. EMRs are being selected by hospitals, not physicians. The ownership of the EMR establishes the branding of the practice and creates defacto referral systems among specialities that share the EMR. We physicians are letting this happen. My colleagues tell me I’ll just have to get used to the EMR cause that’s the way it’s going. It so frustrates me to see hospitals choose winners and losers in referral patterns. It will become nearly impossible to form new medical groups when all groups essentially have become parts of multispeciality groups. Competing single specilaity groups, which is the basis for the quality drive in medicine today, will disappear, and the satisfaction of hospital administrators will determine if a group is viewed favorably. Of course, that means that groups that refer most to the hospital will be the most rewarded. Surgicenters will be hit, hospital outpatient care will cost more, less patients will be served, doctors will be less efficient, and patients will have to wait.
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You Can’t Change The Practice Of Medicine With Demand-Side Reforms. Let Us Put An End To Pay For Performance (P4P) Initiatives: Part 1

January 25, 2009

inChronic Disese Management, Consumer Driven Health Care, Medicare, Medicine: Healthcare System, Pay for Performance (P4P), Quality medical care measures, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

I
have pointed out the folly of P4P initiatives as a methodology for improving the
quality of medical care. Quality
medical care has not been adequately defined. One definition could be to
maintain health at the lowest cost. Physicians have classically been trained to
fix things that are broken. The paradigm shift has been to prevent things from
becoming broken.

Prevention
is a two way street. It is the patient who needs to prevent disease from
occurring. It is the physician who must teach the patient how to prevent disease
and its complications.

Punitive
measures will not encourage behavior change. The economist, John Goodman,
stated: “You
can't change the practice of medicine with demand-side reforms.” I have
said repeatedly it can only be changed with innovative and incentive driven
education for both patients and physicians. This will lead to behavior change
and a true increase in quality of care.

Quality medical care should not be judged on what tests are done for a
particular chronic disease in a given year. It should be judged on the basis of
maintenance of health of a patient with chronic disease. It should be evaluated
as a dual responsibility of both the patient and physician. If there is going to
be an increase reimbursement for performance, performance has to be judged
correctly and both physician and patient should be rewarded.

Quality medical care should be judged on the maintenance of health and
avoidance of the complications of chronic disease. The treatment of the
complications of chronic disease utilizes 80% of the healthcare dollar. If
complications of chronic disease are avoided the costs to the healthcare system
costs would be decreased to manageable levels and Americans would be healthier.

Several readers have challenged me on the use of the term “socialized
medicine”. One reader said “our healthcare system is socialized already. The
government through Medicare and Medicaid controls 40% of the expenditures for
healthcare.” This is true.

The term “ socialized
medicine” has been demonized. I believe most physicians’ and patients’
objection to “socialized medicine” is rooted in experiences they have had. It
has restricted access to care and freedom of choice, and it has dictated
permissible care of physicians. It has also produced an added layer of
inefficient bureaucracy.

Medicare
premiums for patients are becoming expensive. The premium is determined by
means testing. It can be as high as $14,000 per year. The government subsidizes
that amount with an additional $6,600. Medicare advantage costs the government
over $9,000 extra. Yet there is a decrease in access to care as the costs of
the system are spinning out of control.

The government has its heart in the right place in wanting to provide
universal care. Americans should have access to healthcare coverage. A few
changes in the tax rules can solve many problems. The self-employed should be
able to purchase healthcare insurance with the same pre tax dollars as
businesses. They should have the same negotiated price structure large companies
have. The self-employed should have the same guaranteed insurability as those
working in a large company without a premium penalty.

The healthcare system’s costs rise each year. The Medicare premiums rise each
year and patient’s out of pocket expenses rise each year. Medicare is going to
bankrupt the country. It will only be accelerated by putting everyone on
Medicare.

In order to reign in expenses someone came up with the idea of pay for
performance. It is a reasonable concept if a system could be devised that could
evaluate performance accurately and encourage improvement.

In order to test validity of any concept the government subsidizes
initiatives at a great expense. These initiatives are costly because of the
bureaucratic evaluation of the requests for proposals and the measurement
mechanism.

The list of government initiatives is long. The pilot studies are 3 to 5
years. There have been many cost overruns so that several outsourced study
vendors are dropping out of the management of the initiatives. Most initiatives
have been unsuccessful in proving cost savings.

The reason for lack of proof of cost saving to the healthcare system is
because of errors in design. The wrong questions are being asked and the imposed
bureaucracy is punitive to the healthcare entities. Below are initiatives that
are presently funded for pay for performance.

MEDICARE "PAY FOR PERFORMANCE (P4P)" INITIATIVES

“Medicare has various initiatives to encourage improved quality of care in
all health care settings where Medicare beneficiaries receive their health care
services, including physicians’ offices and ambulatory care facilities,
hospitals, nursing homes, home health care agencies and dialysis
facilities.”

HOSPITALS

1. Hospital Quality Initiative (MMA section 501(b))

2. Premier Hospital Quality Incentive Demonstration

PHYSICIANS OR INTEGRATED HEALTH SYSTEMS

1. Physician Group Practice Demonstration (BIPA 2000)

2. Medicare Care Management Performance Demonstration (MMA section
649)

3. Medicare Health Care Quality Demonstration (MMA section 646)

DISEASE MANAGEMENT/CHRONIC CARE IMPROVEMENT

Chronic Care Improvement Program (MMA section 721)

ESRD Disease Management Demonstration (MMA section 623)

Disease Management Demonstration for Severely Chronically Ill Medicare
Beneficiaries (BIPA 2000)

Disease Management Demonstration for Chronically Ill Dual Eligible
Beneficiaries

Care Management For High Cost Beneficiaries

So far the chronic disease management initiative have not been proven to save
money.

The pilot initiatives are not directed by physician in private practice.
Physicians are the stakeholders that will make these initiatives work. Nine
sites selected are either healthcare insurance companies or disease management
groups. Disease management groups can be successful facilitators of physician
care only if they are extensions of physicians care rather than physician
substitutes.

Help desks of the healthcare insurance companies do not work because they are
not an extension of the physicians care. Free standing chronic disease
management clinics do not work because they are not extensions of physicians
care. Many hospitals have tried to set up Diabetes Education Centers only to
have them close because physicians do not refer patients to the centers. The
center is not reimbursed adequately by the government or private insurers to be
profitable. The fees charged in hospitals are at least twice as much as the fees
the physicians charges. Once the physician knows the charges he is even more
hesitant to send the patients to the centers.

The following are the groups selected for the pilot phase: Humana in South
and Central Florida, XLHealth in Tennessee, Aetna in Illinois, LifeMasters in
Oklahoma, McKesson in Mississippi, CIGNA in Georgia, Health Dialog in
Pennsylvania, American Healthways in Washington, DC and Maryland, and Visiting
Nurse Service of NY and United Healthcare in Queens and Brooklyn, New York.

I believe we should give up on trying to produce a pay for performance system
that will reduce medical costs. The health policy wonks should concentrate on
something that will work.

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

Call CareNet • April 20, 2009

I have always gone to Call a Nurse for all of my health concerns. Whenever I have a question I call Call a Nurse and they are always very polite and knowledgeable.
Rhinoplasty Beverly Hills • May 28, 2010

This is quite a comprehensive and interesting posting on the approach to put an end to the system of Pay for Performance Initiatives. This approach may turn out to be effective in the end.
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Most Doctors Aren’t Using Electronic Medical Records! : Part 1

July 27, 2008

inEMR, Medicine: Healthcare System, Quality medical care measures

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Stanley Feld M.D.,FACP,MACE

Why do physicians seem resistant to the use of Electronic Medical Records (EMRs)? The answer is there are at least three barriers to adoption of EMRs that healthcare policy wonks seem to ignore that must be cured.

The New York Times reported on a survey published in the New England Journal of Medicine that less than 9% of physician in small physician office practices use EMRs? The major barrier is these small physician practices cannot afford to buy them and do not know which EMR to buy.

There are different sized medical practice groups in the United States. However, more than 50% of physicians practice in groups of one to three physicians. The survey points out that the smaller the group the less likely they are to have an EMR.

“Dr. Paul Feldan, one of three doctors in a New Jersey practice, said switching to electronic records did not make economic sense.”

I have described the ideal electronic medical record. I have also emphasized that the patient should own the record. Its distribution should be exclusively in the hands of the patient. Technology exists to create a fabulous electronic medical record. The data generated could increase the quality of medical care and decrease medical errors. The result could be an enormous decrease in the costs to the healthcare system.

So why is the medical community slow to adopt the EMR? The government sponsored survey points to two contradictory conclusions.

The New England Journal of Medicine published survey found that doctors who use electronic health records say overwhelmingly that such records have helped improve the quality and timeliness of care.

Dr. Peter Masucci, a pediatrician in Massachusetts, said shifting to computerized records helped improve his patient care.

The meaning of the concept of quality medical care should be obvious but is complex. The judgment of quality medical care by a computer program is frequently wrong. This, in my opinion, is the major problem with the present Pay for Performance fad. It is an attempt at a judgment of quality that results in a punitive action against the doctor rather than being an educational experience for him or her.

Physicians in private practice have been slow to adopt EMR’s for at least three reasons.

1. They do not have the financial resources to spend $25,000 to $80,000 per physicians to purchase an EMR. The range of cost for an EMR implies differences in quality and capability of the various EMRs on the market. Many physicians have made investments in EMRs only to find them to be deficient in many areas. The initial investment does not include a yearly maintenance service contracts or updates. Many EMRs lack adequate software support. Physicians do not have the skill or want to devote the time to figure out the best deal.

2. A second reason is the lack of financial incentives to purchase an EMR. The EMR might help the healthcare insurance and government accumulate data about physician practices and patients care. It might save money for these stakeholders but there are no assurances that the saving will be passed on to either physicians or patients. The promise of the EMR is it should increase productivity and decrease practice overhead. Physicians should be able to decrease the number of full time employees. In most cases this does not happen.

3. Patient privacy is the third barrier. In reality, at this moment patient privacy is non existent with paper records. If patients want to buy healthcare insurance complete medical histories are required by the healthcare insurance company. An EMR would make it easier for the healthcare insurance industry to evaluate a patient record and restrict a patient’s access to healthcare insurance. The element of mistrust by physicians and patients toward government and the healthcare insurance industry is difficult to erase.

The point of patient mistrust was expressed in late June when a House of Representatives committee introduced new healthcare privacy legislation that does not adequately protect patient privacy. The American Civil Liberties Union was the first to protest.

“Leaders of the Energy & Commerce Committee introduced H.R. 6357 this week, and the health subcommittee approved it on June 26. The full committee, as well as two other House committees, now will consider the bill.”

“The legislation lacks provisions to enable patients to review their own files and make corrections, decide who has access to personal health information, or simply opt out, according to ACLU.”

Caroline Fredrickson, director of ACLU’s legislative office in Washington, said in a statement. “If this legislation gets approved, Americans’ medical secrets will be extremely vulnerable to being lost, stolen or sold to the highest bidder.”

I have stated previously that mistrust of the secondary stakeholders by the primary stakeholders in the healthcare system, physicians and patients, must be understood by healthcare policy makers. The issue of mistrust has to be resolved if any progress is to occur in accelerating physician adoption of the EMR.

Both the government and the healthcare insurance industry seem to encourage this mistrust unintentionally by introducing punitive measures to solve the healthcare systems’ problems. These measures simply heighten the primary stakeholders’ cynicism and mistrust.

What Does Chronic Disease Management Mean? Part 2

July 9, 2007

inChronic Disese Management, Medicine: Healthcare System, Patients Problems, Physician's Problems, Quality medical care measures

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Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Electronic Medical Records • April 2, 2009

Gaining favor with employer groups, health-care organizations and health payers, these programs are being increasingly questioned
Keranamu Gula • September 2, 2010

Interesting and valuable post. I believe those with diabetes will appreciate your post. Thanks.
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What Does Chronic Disease Management Mean? Part 1

July 5, 2007

inChronic Disese Management, Medicine: Healthcare System, Patients Problems, Physician's Problems, Quality medical care measures

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Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

Aiams1 • May 4, 2011

I’m curious as to what type of care and treatment patients with Cronic illness will receive if we have universal healthcare. Not those who can prevent symptoms etc but those who need continual aggressive treatments?
2012 moncler coats • November 21, 2011

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