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Stakeholder Mistrust

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Government Is The Problem Not The Solution

Stanley Feld M.D.,FACP,MACE

 

The government has been attempting to take over the healthcare system since 1935 at the time of the Roosevelt administration.

The government took over the healthcare system 30 years later during the Lyndon Johnson administration. LBJ passed Medicare and Medicaid. It turned out that financial projections were faulty and the business model was defective.

Medicare and Medicaid provided medical care for the elderly and the poor at an affordable price at that time. Everyone loved it. At the time it was also affordable for the government.

I do not think anyone contemplated the healthcare inflation that occurred as a result of the government’s business model.

Inflationary pressure increased rapidly.

Finally, President Reagan said the government could not afford the increasing prices any more. He said enough is enough. He decreased provider (hospital, doctors, pharmaceutical company, and insurance company) reimbursement for Medicare and Medicaid services.

The reduction in reimbursement for services resulted in price shifting increases in reimbursement in the private sector.

Both the private sector and the public sector experienced increased inflationary pressure as a result of this maneuver.

It was clear by 1984 that Medicare and Medicaid were unsustainable long term.  

America did not have a free market healthcare system before Obamacare. It was a hybrid system.

The country already had 90 million Americans in a single-payer system. Ninety million Americans get coverage from Medicare, Medicaid, and the Veterans Health Administration systems.

The problem is these government controlled single-payer systems did not work efficiently. They were financially unsustainable.

Obamacare expands the single party payer system to eventually cover all Americans. Obamacare simply adds on to an existing unsustainable healthcare.   Raising taxes is not going to make it more sustainable.

The expanded bureaucracy will only make the system more inefficient and more prone to fraud and abuse.

President Obama is already modifying the law without congressional approval. He is trying to hide elements of this unsustainability from the American public.

The federal government’s Obamacare enrollment system www.Healthcare.gov alone has already cost taxpayers about $2.1 billion dollars according to a Bloomberg government analysis of contracts related to the project.”

The website is still not working perfectly at the backend after spending $2.1 billion dollars.

Americans will experience more of the www.healthcare.gov dysfunction after the mid term elections.  

Navigator companies hired to help people enroll cost $48 a session. These companies are increasing their prices for the 2015 enrollees.

 

These same companies have had their fraud and abuse exposed. Nevertheless they have been rehired at the increased price by the Obama administration.

President Obama announced to Democrats last spring that Obamacare would not be an issue at the time of the midterms.

This week the administration also announced that the cost of healthcare insurance through the health insurance exchanges is decreasing next year.

It was also announced that there is an increase in the choice of insurance carriers in most states resulting in competitive premium pricing and lower premiums.

President Obama announced that Obamacare is working. He said Obamacare is a non issue in the 2014 mid term elections.

Nothing could be further from the truth.

If our elected officials cannot see President Obama’s trick play how can the public expect to understand the deception?

This is another of the manipulations of Obamacare designed to hide its impending failure from the public.  

The Obama administration set up a reinsurance company funded by taxpayers that eliminates any insurance risk the healthcare insurance companies might incur in insuring enrollees.

Healthcare insurance companies are signing up and competing for market share to gain profit from this no risk insurance. They can easily afford to lower the premiums because the government will cover their supposed loses.

None of this has anything to do with patient care or the quality of patient care.

It has little to do with providing low cost insurance. The cost of insurance keeps increasing. The government pays the difference between the cost of insurance and what patients who receive subsidies pay for their premiums.

Obamacare misses the main problems in the healthcare system. Obamacare creates more dysfunction in the healthcare system.

 Obamacare will result in greater unfunded future liabilities.

White House spin pretends otherwise, but the unfunded liabilities may exceed $100 trillion.”

 The Congressional Budget Office said,

 “Looking indefinitely into the future, the unfunded liability, with optimistic assumptions, is $43 trillion—almost three times the size of today's economy.”

Based on more plausible assumptions, such as those reflected in the "alternative" scenario for Medicare produced by the Congressional Budget Office in June 2012, the long-term shortfall is more than $100 trillion.

It is the responsibility of our elected officials control America’s expenditures.

Unfortunately, for American’s, this is not how a government controlled system works.

Voters must decide how long they are going to tolerate this abuse of power.

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



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Obamacare: Its Failure Increases

Stanley Feld M.D.,FACP,MACE

 

C-Span has provided the public with important lessons on how our government is really run by televising various congressional committee meetings.

The traditional mainstream media provides us with little of the important information that comes out of these committee meetings.

C-Span’s coverage has revealed how inefficient, political and bureaucratic our government is.

Americans should elect representatives to be our spokesmen. Our representatives should do what is right for us and not for the vested interests of various special interest groups.

The latest information about Obamacare has not been reported in the media but came out in committee.

The Obama administration had announced publicly to a subcommittee in April 2014 that its "risk corridor" plan would be revenue neutral.

In English, it means that there would be no extra taxpayer dollars available to cover the losses of the healthcare insurance companies. Those healthcare insurance companies insure enrollees through the government’s healthcare insurance exchanges.

Chet Burrell, head of Maryland insurer CareFirst told Valarie Jarrett this plan would result in premium increases of 20% or more later this year as Obamacare policies come up for renewal. 

He warned it would be "an unwelcome surprise" to the Democratic Party and Democrats running for reelection in November.

The Obama administration was very concerned about a 20% premium increase for enrollees in Obamacare. After a while, Ms. Jarrett assured Mr. Burrell the insurance industry would get 80% of the subsidy (bailout) they sought.

The 80% was granted by executive order without congressional approval. A few weeks later the healthcare insurance industry bailout was changed to almost 100% of the request with little notice from anyone.

The government guarantee affects all of the enrollees in Obamacare. It also permits the increase in private insurance plans.

There are 50 million people on Medicare, 65 million people on Medicaid, 9 million in the VA system, 7.3 million in Obamacare and an additional 149 million for employer-provided healthcare insurance.

It turns out that Obamacare is just another government subsidy program with the government throwing more money at the health care insurance industry while the healthcare insurance industry raises the premiums.

President Obama, by executive order, has created an unlimited Obamacare reinsurance program covering the healthcare insurance industry’s supposed losses.

According to some, the total subsidy to the healthcare insurance industry is $1.3 trillion dollars.

It’s no surprise that many more healthcare insurance companies are planning to participate in President Obama’s health insurance exchanges.

If a healthcare insurance company sells insurance without risk it is a great deal. Taxpayers are assuming the risk for the insurance companies. Some insurance companies are decreasing their rate to capture a larger market share. They will  cash in on the Obamacare subsidy.

This subsidy is a mistake. It adds little value in improving the nation’s health. President Obama does not seem to care about how much money he is wasting.

It is all about politics. 

The subsidy adds much political value to Obamacare because it postpones the 20% premium increase at this midterm election.

Bob Laszewski, a policy wonk and former insurance executive said,

 “The administration has succeeded in temporarily suppressing incipient Obamacare price hikes, contributing to an illusion of Obamacare sustainability.”

However, the healthcare insurance industry is finding it necessary to increase premiums an additional twenty percent despite the tremendous subsidies. This is the result of the enrollees who acquired insurance but did not pay the premiums and used the services and the terrible demographic distribution of enrollees who paid their premium.  Eighty-five percent of the people who paid premiums were high risk patients with pre-existing illnesses. 

The rules of Obamacare have turned out to be totally improvised. The Obama administration changes the contents of the law in order to keep it afloat without the approval of congress.

The plot thickens. A challenge is in the courts right now on whether the government health insurance exchanges are allowed to provide subsidies to enrollees.

The law specifically states that tax credits are only available through the state health insurance exchanges and not the federal health exchange.

Funny things are going on in the courts. One panel said yes, the subsidies may be provided by the federal health insurance exchanges. The D.C. panel of three judges said no.

Attorney General Holder appealed to the D.C. court of appeals. He wanted the judgment determined by the entire panel of 9 judges not a subpanel of 3 judges.  The 3 judges’ decision was overruled by the 9 judge panel.

I still do not understand how tax credits are given to people who do not earn enough to apply a tax credit to their income tax. Why do they receive a subsidy? They pay no federal income tax.

I hope Americans wake up soon to the fact that Obamacare is deeply flawed and cannot work. The only thing that will overturn it will be an overwhelming taxpayer protest.

This midterm election cycle is a good place for voters to start. A Republican majority of the senate might be able to stop Obamacare in its tracks.   

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



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A Bogus Attack For A Political End

Stanley Feld M.D., FACP, MACE

The New York Times continues to be a mouthpiece for the Obama administration. I suspect the editorial board thinks the only thing that will save the healthcare system in America is a government controlled single payer system.

This is President Obama’s goal even if he has to destroy the medical care system.

On September 20th, 2014 the front page top right hand column article in the Sunday New York Times was  After Surgery, Surprise $117,000 Medical Bill From Doctor He Didn’t Know appeared.

In the past the New York Times reserved this spot for the most important story of the day.

This story was the most important news story on Sunday September 200h 2014. The Times thought it was more important than a story about the economy, ISIS, the mid-term elections, Israel, Hamas or Iran’s nuclear ambitions. 

The story intended to inflame the New York Times’ readers so they would be angry at the medical profession.

The problem is that the story is peppered with misinformation and disinformation.

The New York Times writer used a typical Saul Alinsky tactic. Her goal was to prevent the opponents of the story from responding intelligently. 

Public opinion will be on her side because the New York Times is supposed to be a credible source.

Saul Alinsky’s rules instruct one to lie if necessary. The next step is to frighten consumers into thinking the system under attack cannot work.

Before his three-hour neck surgery for herniated disks in December, Peter Drier, 37, signed a pile of consent forms.”

Peter Drier did not read or modify the consent forms. He should have made the   hospital and his doctor liable for any unauthorized expenses, providers, or events.

Peter Drier is a bank technology manager. Banks have their own small fine print intended to keep consumers liable and uniformed.

Peter Drier should have modified the consent forms before he signed them. He can refuse to authorize treatment or payment to any provider or procedure performed in the hospital that was outside of his insurance network.

In Network providers have to agree to accept the negotiated fee. If they need an additional provider it must be a provider that will accept the negotiated fee of his insurance company.

A bank technology manager who had researched his insurance coverage, Mr. Drier was prepared when the bills started arriving: $56,000 from Lenox Hill Hospital in Manhattan, $4,300 from the anesthesiologist and even $133,000 from his orthopedist, who he knew would accept a fraction of that fee.

Every consumer should find out if their providers are in their insurance network .  

All of those prices are ridiculous retail prices. The real question is how much did his insurance company pay and how much is he liable for.

Peter Drier did not do a very good job in researching his insurance company’s coverage. A third party payer would never approve a $56,000 payment to the hospital for the proposed procedure.

Hospitals bill very high retail prices. They will negotiate a price that is 50-90

5 lower than the retail fee.

 

The author, ELISABETH ROSENTHAL, has a list of recent articles criticizing the healthcare system about exorbitant retail pricing. 

  • COLONOSCOPY: Colonoscopies Explain Why U.S. Leads the World in Health Expenditures
  • PREGNANCY: American Way Of Birth, Costliest In The World
  • JOINT REPLACEMENT: In Need Of A New Hip, But Priced Out of the US Market
  • HOSPITAL PRICES SOAR: A Stitch Tops $5000

All of these articles criticize the retail price providers charge. They do not tell the reader what the providers receive as reimbursement by the government or the healthcare insurance company.

Consumers are the victims of the constant effort to try to reduce healthcare costs and stick consumers with the bill.

Obamacare has driven the healthcare insurance industry to raise premiums and decrease coverage in order to cover their supposed actuarial risk.

The decreased reimbursement by the healthcare insurance industry has driven providers to increase their fees for service. The hope is to occasionally catch a consumer who is uninsured and liable for the fee.

The uninsured consumer cannot afford the fee and therefore will not pay the fee. The provider then has to sue the consumer to collect whatever they can. The cost of the suit is not profitable for the provider. He usually writes off a loss.

President Obama and the government control advocates will use the resulting chaos in the marketplace to prove that a free market for healthcare system does not work. Therefore the country needs a government controlled single party payer system.

The problem with these horror articles is they frighten consumers. They do not address the reason that the healthcare industry costs $2.7 trillion dollars a year.  

The chaos in the marketplace is the result of the government (Obamacare) involvement into the free market system.

I am also not sure if the $2.7 trillion dollars is from retail charges or negotiated payments. The answer to the question is totally opaque.

The reasons for the increasing costs are many.

Americans are becoming less healthy because they are not being responsible for their health. It is hard to maintain weight when almost every restaurants main dish is higher than their daily caloric allotment. 

470 cal 9 24 2014

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The result is an obesity epidemic. Over 50% of Americans are Obese.

Obese individuals have a 40% increased incidence of chronic disease.

Eighty percent of the healthcare dollars spent are spent on treating chronic diseases and the complications of those chronic diseases.  

Controlling a chronic diseases can decrease the complication rate of those diseases by at least 50%.  

If we ran the numbers we could reduce the healthcare costs below one trillion dollars a year.

Everyone complains about the grotesque profits the healthcare insurance companies make. Everyone understands the profits result from the inflated bureaucracies and double payments made to segments of the bureaucracy.

If one insurance company wanted to be competitive it would lower its premiums and overhead. All the other insurance companies would do the same to stay competitive.

One has only to look at the cell phone industry. Not only has the cost of the cell phones been lowered but monthly charges are continually decreasing.

One should also look at what ITunes did to the music industry.

Look at what Dr. Keith Smith’s surgical center model is doing to the local hospitals’ costs for surgery in Oklahoma City. They are falling precipitously.

The government should stop feeding the public disinformation leading to confusion of the facts..

President Obama's goal is to destroy the medical system so that consumers will believe the only thing that will work is a government controlled single party system.

Single payer systems throughout the world have proven to be unsustainable.

The healthcare system is dysfunctional. Medical care has been distorted at the consumers’ expense and for the profit of the profit of the healthcare industry.

America has to become innovative and build a healthcare system to the advantage of the consumer.

The solution 

 Is about consumers becoming aware.

 Is about leadership.

 Is about innovation.

 Is about consumers being responsible for their health and their healthcare dollars.    

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



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Obamacare Application Data Is Wrong For 2 Million Applicants Receiving Subsidies

Stanley Feld M.D.,FACP,MACE

The second really big deal is the fact that over two million people lied on their application for Obamacare through the federal health insurance web site www.healthcare.gov.

We do not know how many of the 1.2 million who received insurance through state exchanges lied. 

Unfortunately, the Obama administration throws so many numbers out of context at the American public that it is impossible to follow the true facts and subsequent disastrous consequences.

Let us look at the numbers slowly. President Obama was claimed that 8 million people signed up for Obamacare by March 31,2014.

President Obama and the healthcare insurance industry were terrified about adverse selection by the people signing up. Both worked hard to get young people with no preexisting illnesses to sign up so the insurance premiums would not increase next year.

Basketball, baseball and football stars were recruited to advertise Obamacare’s benefits on TV and encourage enrollment.

The population, in the uninsured individual insurance market, was only 14 million out of a population of 350 million people. Three hundred and thirty six million received waivers from Obamacare for one reason or another.

What will happen when 336 million must participate in Obamacare? The percentage of participants in the population will be tiny if the individual market is a guide.

Seven million of the fourteen million lost their healthcare insurance because of Obamacare’s requirements. Eight million signed up for healthcare insurance under Obamacare. This represents an increase of only one million and not and increase of eight million.

Of the 8 million, 85% or 6.8 million people applied and received government subsides. These subsidies were supposed to be tax credits.

The www.healthcare.gov did not have a functional back end to the website to check if these people were lying about their income, job status, and even citizenship.

 If people intentionally misstated information, they were warned they could be charged with perjury. I assume President Obama will waive that charge.

Only citizens and legal immigrants are eligible under the law for subsidized coverage.

 The government signed up about 5.4 million people, while state-run websites signed up another 2.6 million.

Only 1.2 million of those were not eligible for subsidies.

Are these 1.2 million the part of the 7 million who lost their insurance because of Obamacare? Are the 8 million the people who did not have insurance before Obamacare?

Both are important questions that we have not gotten answers to.

My guess is the people who signed up were people who could not get insurance because of preexisting conditions or people who could not afford insurance in the individual market.

In either case the will be adverse selection and increased healthcare utilization. Insurance premiums will increase for everyone in the health insurance exchanges. 

 Some 80% of all those who have enrolled in plans nationwide, according to federal statistics released today, have chosen a silver plan, meaning deductibles of $2,000 for singles and $4,000 for families, or gold or platinum plans, which have no deductibles. “

“Only 18% have opted for bronze plans, which offer lower premiums, balanced by deductibles of $4,500 for singles/$9,000 for families.”

Many consumers can hardly afford the bronze plans with subsidies much less the high deductibles. Those consumers will be forced drop out of Obamacare.

“The Associated Press reports that of the 5.4 million people who signed up for health insurance through the federal marketplace 2 million submitted information that does not match up with federal data.”

The discrepancies could affect their subsidy adversely. Applications were accepted on boy scouts’ honor. The subsidies were determined on the basis of the information on the application. These people will owe the government the difference plus a penalty. They are also liable for perjury.

The back end of www.Healthcare.gov is still incomplete.

“Serco, a foreign contractor already under investigation, was awarded a $1.2 billion contract to process Obamacare’s paper applications, and the AP reports they will be tasked with resolving these application issues. “

Despite having had three years and more than $600 million to work with the federal governmentand its chosen contractor could not build a functional website. It cost an additional $200 million dollars and four months to get the front end to work.

The $600 million to build www.healthcare.gov was more than it cost Apple to develop the iPhone. Apple is an American company with American jobs. 

It should be recalled that another foreign contractor (CGI of Canada) got the first contract. Michelle Obama’s Princeton classmate happened to be an executive,

 

Serco is a foreign company riddled with a history of transgressions. The most recent transgression was that Obamacare contractors were literally being paid to do nothing.”

The White House has attempted to dispel concern about the website being dysfunctional.

However, the report of over 2 million falsified applications has reignited the questions of government incompetence and misleading information about the dysfunctional website as the enrollment period approached.

As Americans for Prosperity reported in the Washington Times early last month, “the website was originally intended to function automatically, calculating premium subsidies, making government payments, and tracking enrollment information that would affect future costs.”

“ But the interim system currently in place (that resulted in the newly revealed data discrepancies) is “pretty much a spreadsheet and some informed estimates,” according to Politico.

Compounding www.healthcare.gov  problems are a Roll Call report that almost 3 million Medicaid enrollees have not yet had their applications processed.

These issues are all separate issues from Obamacare’s cancelled healthcare plans, physicians opting out or retiring, and the scandal with the Veterans’ Affairs health care system.

In reality all the issues are one with the Obama administration making it clear that a government run bureaucratic healthcare system is a nightmare that will destroy the healthcare system in America.

8 20 2014 Obamacare-Delays

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

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A CMS Mistake!!

Stanley Feld M.D.,FACP,MACE

For years practicing physicians knew that hospital outpatient clinics charges were 30-60 percent higher that physicians’ free standing clinics.

CMS didn’t know it or didn’t want to know it.

CMS administers Medicare and Medicaid. CMS was restricting payment for outpatient procedures and tests done in freestanding practicing physicians’ offices while paying higher fees for the exact same outpatient hospital procedures and tests.

As rules and regulations and the complexity of the business of practicing medicine in private freestanding outpatient clinics increased physicians sold their practices to hospital systems.

The government and the healthcare industry encouraged these sales by increasing the complexity of running a private practice.

The probable logic was they would only have to deal with one entity (the Hospital System) rather than 600 individual doctors or clinics using that hospital system.

The government’s excuse for cutting out freestanding individual practices and clinics was efficiency and patient safety.

The hospitals were overjoyed to be able to buy physician practices.

“As the Affordable Care Act attempts to steer people away from pricey hospital inpatient admissions, hospitals have begun buying up doctors’ offices in hopes of increasing their revenue and market share.”

The hospital systems’ then discovered they were losing money by buying physicians’ free standing practices.

 In essence they were trying to buy physicians’ intellectual property and surgical skills because the traditional brick and mortar hospital building was becoming less profitable. Many surgical procedures were being done as outpatient procedures.

Physicians were less productive as hospital employees than they were when they owned their own practices. They were guarantied a salary.

Hospitals did not bother to calculate the money they made from doing the entire outpatient testing and procedures when presenting the loss to the government.

Hospital systems have been selective, first buying Primary Care Physicians’ freestanding office practices. Next they started trying to buy oncology practices.

The number of oncology practices owned by hospitals increased by 24 percent from 2011 to 2012. By turning what used to be independent medical offices into so-called hospital outpatient centers, hospitals are creating networks that, critics say, give them the power to set prices and ultimately raise costs for private insurers and government programs such as Medicare.”

To further encourage physician owned clinics to migrate to hospital system owned practices the government and the healthcare insurance industry provided separate revenue codes to allow hospital systems to collect more for the same tests and procedures done in physicians’ free standing offices.

Finally,

“The Medicare Payment Advisory Commission, which advises Congress, are sounding the alarm. In May, MedPAC Executive Director Mark Miller testified before a House panel that these price differences “need immediate attention.”

 Medicare should align rates “to limit the incentive to shift cases to higher cost settings,”

The hospital systems’ excuse for the higher charges is it has higher operating costs than freestanding clinics such as running an emergency room.

Hospital systems receive higher reimbursement than private freestanding clinics doing the same procedure or delivering the same treatment.

The hospital system’s retail price is much higher than what it receives from CMS and the healthcare insurance industry. The discount price is somewhere around 50%

Even with the discount the hospital systems’ prices are 30-50% higher than the freestanding clinics’ prices.

The glossary of charges and discounts should be available to all consumers of healthcare. None of the prices are transparent. Patients’ have to fight hard to get the prices.

The focus or reports of prices has been on the outrageous prices for cancer drugs.

“A treatment of Herceptin, a breast cancer drug from Genentech, cost private insurers $2,740 when used in an independent clinic and $5,350 in a hospital outpatient setting, according to an analysis of 2012 claims by PricewaterhouseCoopers’ Health Research Institute.”

“The price of Avastin, another Genentech cancer drug, increased from $6,620 to $14,100, the Health Research Institute says.”

Echocardiograms in a hospital facility are reimbursed at twice the price as the reimbursement in a private physician owned facility. 

Dr. Keith Smith with the Oklahoma Surgical Center charges less than some patients’ deductible for some surgical procedures without accepting Medicare or private insurance.

If Medicare paid the lower office rate for 66 outpatient services even when they’re performed in hospital-owned facilities, the government would save $1 billion a year and lower Medicare patients’ bills by $200 million, MedPAC Executive Director Mark Miller said before the House panel. Medicare insured 49 million Americans at a cost of $573 billion in 2012.

This is an analysis of only 66 outpatient procedures. There are hundreds of outpatient procedures. Imagine the savings if all the procedures were captured.

Hospital outpatient visits for echocardiograms jumped 33 percent from 2010 to 2012, MedPAC found, while visits to independent offices declined. Echocardiograms cost more than double in hospital-owned locations.”

As hospital system merge the price will go up even further. The hospital systems are now negotiating from a position of strength. Hospital systems are making the money as private physicians’ reimbursement shrinks.

The government and the healthcare insurance industry are finding their scheme to destroy private practice was a big mistake.

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

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Physicians Are Getting Ready To Fight Back

 

 

Stanley Feld M.D.,FACP, MACE

Practicing physicians’ frustrations with the healthcare systems are mounting. It is clear that patients are not first. The secondary stakeholders such as the healthcare insurance industry, pharmaceutical companies, hospital systems and the government come before patients in the healthcare system. Money is first for these stakeholders.

The government tries to control its cost as it outsources most of its administrative services to the healthcare insurance industry.

The healthcare insurance industry, pharmaceutical companies and hospital systems try to maximize their profits by trying to get around many of the government’s complex regulations.

The result of maximizing profit is abusing patients’ ability to get medical care and physicians’ attempts to deliver medical care.

Traditional healthcare insurance is not the only way of paying for patient care. It is the most expensive way. Traditional healthcare insurance is most prone to political and moral corruption.

Moral and political corruption leads to increased insurance processing costs which lead to higher premiums and higher deductibles. This leads to less health insurance coverage.

Recently, I wrote about physicians being pawns in the healthcare system. They are the easiest to attack because they are the least organized.

Physicians are the easiest to abuse by the secondary stakeholders because they believe patients come first. Physicians are too busy taking care of their patients to figure out how to respond.

A reader sent me an article that appeared in the Dallas Morning News illustrating a tiny fraction of the abuse physicians take and the lack of respect they encounter when their orders interfere with the healthcare industry’s profit.

The article is about the need for prior authorization to reduce drug costs in an insured patient. As you read this, think of the increase in the insurance company’s administrative waste, and the disrespect for the physician’s time and judgment.

Millions of prior authorization letters are sent every day for drugs, hospitalizations, and treatment plans. They are the result of actions that do not fit into a healthcare insurance company’s computer algorithm.

Insurance company workers know little about medical care these prior authorizations are challenging. These workers know little about medical judgment or medical care.

The healthcare insurance industry believes it is an effective way to prod physicians away from more expensive treatments and toward less expensive alternatives.

It makes it harder to prescribe costlier medications. In reality, it is a wasteful administrative nightmare.

The letter in my hand concerned one of my patients, Mr. V., who suffers from stubborn hypertension. His chart is a veritable tome, documenting the years of effort it took to find the combination of four different blood-pressure medications that controls his hypertension without upsetting his diabetes, kidney disease and valvular heart disease or making his life miserable from side effects. We’ve been on stable ground for a few years now, a state neither of us takes for granted.

But Mr. V. had changed insurance companies, and now one of his medications required a prior authorization. The last thing I wanted was for him to be turned away at his pharmacy and have his blood pressure spiral out of control, so I called right away to sort things out.

Twenty minutes of phone tree later, I discovered that the problem was that I had exceeded a pill limit for one of his medications. Mr. V. needed to take 90 of those pills each month for the high dosage that his blood pressure required. I patiently explained this to the customer care representative.

Equally patiently, she told me that 45 pills a month was the maximum allowed for this particular medication.

Three more phone trees and three more customer care representatives later, my patience was flagging. Apparently a request for 90 pills was flummoxing the system. Representative No. 4 went down her checklist. “Would taking 45 pills per month instead of 90 pills adversely affect Mr. V.’s health?” she asked.

At first I thought she was joking. “Well,” I replied, “it would probably make his blood pressure shoot up in the second half of the month.”

She paused, then asked her next question with the encouraging uplift of suggestion. “Has Mr. V. ever tried 45 pills per month instead of 90 pills?”

Then I realized that she was not joking. “Are you out of your mind?” I hollered into the phone. “It’s taken years — years! — to find the right combination of meds to control his blood pressure without killing his kidneys or making him dizzy or nauseated or depressed or ruining his libido or running his potassium off the charts or breaking his bank account. Do you really think I’m going to randomly jiggle the dosages just for the hell of it?”

“A simple yes or no will suffice, doctor.”

This interaction demonstrates a lack of respect for the physician and his judgment, and a lack of understanding of the patient’s illness. I have said over and over again that you cannot commoditize patients’ illnesses or physicians’ skills.

If the insurance company’s computer system has a beef with physicians’ judgment it should get a second opinion by a neutral expert physician in the field of hypertension to review the chart and the patient’s illness. 

The writer says,

 I bit my tongue for the remainder of my conversation with the insurance company, holding back long enough to obtain the prior authorization that would allow Mr. V. the 90 pills he needed each month. I tried not to break the phone when I finally slammed down the receiver.”

These interactions are not good for physicians’ health or morale.

They increase physicians’ cynicism.

 “I’m all for controlling medical costs and trying to apply rational rules to our use of expensive medications and procedures. But in the current system, everything seems to be in service of the corporate side of medicine, not the patient. The clinical rationale and the actual patient — not to mention the doctors and nurses involved in the care — are at best secondary concerns.

In the end, we were able to keep Mr. V.’s blood pressure under control. My blood pressure, however, was a different story.”

These interactions go on daily and waste physicians’ time and energy. Physicians have no ability or representatives to fight back. However, they are ready to fight back. All they need is someone to come up with a plan.

A good start is changing the paradigm of healthcare insurance so that it is a consumer driven healthcare system with consumers being in charge of their healthcare dollars and their health. 

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

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Physicians’ Problems With The Healthcare System

Stanley Feld M.D.,FACP,MACE

I must start this article with a disclaimer. I am a retired Clinical Endocrinologist that practiced Clinical Endocrinology for 30 years. I became involved in medical politics because I wanted to help make Clinical Endocrinology a household word. We succeeded at the American Association of Clinical Endocrinologists to make Endocrinology a household word.

 At that time I saw that the medical profession was slowly being destroyed. I wanted to make whatever contribution I could to save the medical profession in order to preserve the care patients were given and help promote the progress in medical research.

Today I see the delivery of medical care diminishing and the infrastructure of medical care being destroyed by the Obama administration’s ideology coupled by government bureaucrats as well entrepreneurs that see profit in business opportunities that do not add value to medical care.

I do not have a horse in this arena anymore. The only vested interest I have in the healthcare system is that an effective medical care will exist when I need it.

How do we create systems of care that promote high performance? I do not believe it is by a series of top-down highly specific mandates. I believe it is by creating general guidelines for physicians and providing tools to help physicians advance medical therapy using advanced technology.

It boils down to policy makers’ view of physicians.

Are physicians knights to be empowered in their service of patients?

Are physicians knaves not to be trusted?  

Are physicians pawns in a healthcare system to be manipulated by the powers that be?

At present, healthcare policy makers view physicians as knaves and pawns. This view has to change in order to have a functional healthcare system because people behave has you project them to behave.

If the policy makers approached physicians more as knights, physicians would once more behave as knights and not as bitter misanthropes. The result would result in a desire to provide the best possible care for their patients.

The environment is conducive to the destruction of the healthcare system. Barriers that inhibit effective medical care and increase the cost of medical care can easily be overcome if the Obama administration wanted to fix them.

The public and future administrations have to understand the barriers to effective medical care in order for the healthcare system to arrive at a future state that is not on the way to self-destruction.

America’s healthcare system needs a new vision of physicians and patients. The change in vision would result in a new business plan built around a new system of care.

The healthcare systems needs input from physicians and patients. They are the two most important stakeholders in the healthcare system. Without physicians or patients there would not be a need for a healthcare system.

The promotion of a vibrant patient/physician relationship is the keystone to a viable future state of the healthcare system.

I will first list the barriers and then explain them and their solutions in my next blog. Some of the barriers have been covered in previous blogs.  

The barriers to effective and efficient medical care are causing physicians to adjusted in a distorted and destructive way. These barriers are not increasing the quality of medical care they are serving to decrease the quality of medical care.

            Lack Of Malpractice Reform

            Problems Trying to Increase Reimbursement

  • Stripped of Negotiating Clout
  • Turned Into Captives of the Insurance Industry
  • Pressured to Sell Healthcare as a Commodity
  • Pushed to Abandon Clinical Judgment
  • Under Hospitals' Thumb
  • Shunted Aside by Policymakers
  • Shunted Aside by Entrepreneurial Management companies
  • No One Is Advocating for Physicians

The VA Healthcare System is the perfect example of a top down Platonic approach to a healthcare system.  Government bureaucracies have proven over and over again that it does not work.

The American healthcare system needs a bottom up system that is based on empowering physicians to act professionally in the best interest of patients.

The bureaucrats for a top down system should enable a higher level expectation of care from physicians and provide education about the higher level of expectations for patients.

The driver of the healthcare system must be the consumer. The government and physicians must emphasize the consumers’ responsibility in their health, healthcare and medical care.

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

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Creating Confusion And Blame

Stanley Feld M.D.,FACP,MACE

President Obama is in the midst of a leadership crisis on many fronts. A large number of voters have no idea of the details of each crisis or scandal.

They figure they elected a President who will not only take care of a crisis when it develops but he will look after America’s best interests.

There are other voters who have become news junkies. They are interested in each crisis. The source of their information is the traditional media.  The traditional media provides filtered sound bites that lead them to erroneous conclusions.

People are mistrusting the administration and the traditional media because they are realizing that are being fed disinformation. They realize they are being manipulated. It is becoming clear that the administration is not defending the constitution and the people’s freedoms.

The defects in Obamacare are affecting people directly. All of a sudden seniors cannot find a physician who will take Medicare.

If they sign up with a concierge physician they receive no reimbursement from the government for Medicare premiums they have paid.

People with employer sponsored healthcare insurance are having difficulty finding a physician unless they pay a fee to a concierge physician.

Their portion of the healthcare insurance premium has increased with a threat of higher premiums next year. A 15-50% increase is expected. Their copays and deductibles have also increased.

The employer sponsored healthcare insurance plans are going to be available to only full time employees.

Last month there was an increase in employment of 288,000. However there was a decrease in 708,000 fulltime jobs and an increase in 1,115,00 part time jobs because of Obamacare and its mandate to provide healthcare coverage for people who work more than 35 hours a week or face a penalty.

 Writing in the Wall Street Journal, Mortimer Zuckerman — real estate developer and editor in chief of U.S. News & World Report — says yes. Some data seem convincing. In June, part-time jobs (defined as less than 35 hours a week) increased by 1,115,000, reports the Bureau of Labor Statistics (BLS); full-time jobs fell by 708,000.”

Just think of all those Americans working part time, no doubt glad to have the work but also contending with lower pay, diminished benefits and little job security,” wrote Zuckerman.”

The New York Times and Paul Krugman keep telling us Obamacare is a success. They ignore the facts.

 A few weeks ago a study showed that 85% of the people who signed up for Obamacare on the individual market received subsidies from the government.

It turns out many people lied on their enrollment applications and they will not receive the subsidy. The Obama administration took their enrollee's word because it did not have the infrastructure to check the applications. These people cannot afford the premium now much less after the subsidy is removed and back payment to the government is made.

This will reduce the 8 million claimed valid enrollees to below 5 million enrollees.

The execution and implementation of Obamacare is a great setup for fraud and abuse. It is described in the following You Tube.

I do not think President Obama is going to demand back payment. This is not the first time President Obama has changed the law without consulting congress.  

The law states that people can qualify for tax credits. A tax credit is defined as a deduction off the income tax due. People making under $40,000 do not pay income tax. Some receive a check from the government.

How was a tax credit changed to a subsidy?

The law specifically states that the state health exchanges and not the federal health insurance exchanges can provide the tax credits. Thirty-six states have not set up state health exchanges. 

 Those thirty-six states predicted that the exchanges would be a failure and a tax burden to its citizens.

 Many of the remaining states that set up health insurance exchanges are failing.

The federal government set up health insurance exchanges in those thirty-six states instead. The federal health insurance exchanges have not been a  success despite the statements by the New York Times and Paul Krugman to the contrary.   

President Obama’s pledge to bail out the healthcare insurance industry if the industry does not make as much money as they expected to make because of the demographic profile of the people who sign up is another sign of failure. It points out how dependent the Obama administration is on the participation of the healthcare insurance industry.

Where is President Obama going to get the money to pay for all the pledges? The CBO now predicts Obamacare create a 1 trillion dollar deficit rather than an excess over the next decade. This is after collecting increased taxes for 6 years before full implementation of Obamacare.  

There are many other defects in Obamacare. It is a failure.

The Obama administration with the help of the traditional media is trying to distract the public from the facts by withholding facts and feeding the media confusing facts, disinformation and lies about Obamacare’s success.

The administration blames Obamacare’s difficulties on the Republicans using non-facts.

The Obama administration can get away with this for only so long. The middle class is realizing the economic burden Obamacare has created for the middle class and the economy.

The middle class is realizing this because the facts are affecting them directly.

With the atmosphere of mistrust, and distrust created by the economy, the decrease in the value of the dollar, the lies and withholding of information about Bengasi, Fast and Furious, the IRS, the Ukraine, Syria, Iraqi, Afghanistan, Iran debacles, and the VA scandals it is going to take a lot for the people to regain its trust in President Obama.

Alinsky’s methods of lies, obfuscation of the truth and blame are running out of steam.

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

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More Bad News For Obamacare And Taxpayers

Stanley Feld M.D.,FACP,MACE

The Obama administration and the traditional mainstream media are working very hard to keep the bad news about Obamacare away from the general public.

The Colorado exchange (Connect for Health Colorado) expects nearly 24% of the enrollees to drop health exchange coverage in fiscal 2015.

This is a direct contradiction to the Obama administration’s projection of the growth of health insurance exchanges.

“In April 2014 after open enrollement closed, the staff of Connect for Colorado projected 13 percent of people enrolled will drop or not pay for policies in fiscal 2015, but now they are expecting about 24 percent to drop their policies, according to the latest model.”

“And in fiscal 2016, the revised figures show dropped policies going from the 16 percent projected in April to nearly 22 percent.”

The Colorado Health Insurance Exchange’s chief financial officer Cammie Blais said the staff is using the higher drop rate in more recent models because that is how national figures are tracking.

President Obama and the Obama administration are aware of these figures. As usual they are keeping it from the public.

Why is happening nationally? There are multiple reasons.

Eighty five percent of the people who have enrolled have qualified for subsidies on the basis of the information they gave on the enrollment form.

The federal government was not set up to verify the information given on the enrollment form at the time of enrollment.

President Obama told everyone he would take his or her word for the information’s accuracy. This was a tremendous defect in the Obamacare system.

Many enrollees are going to lose part or the total subsidy provided by Obamacare. For some, the original subsidy was not enough to reduce the burden of insurance. In many cases the burden included high deductibles and copays that were unaffordable.

Many of the remaining fifteen percent of the enrollees had preexisting illnesses and could not buy insurance on the open market and/or were making over $50,000 a year.

Their premiums plus deductibles and copays are so high that enrollees making over $50,000 a year realize they cannot afford the insurance and have to drop out of next year’s exchange.

As a result of this adverse selection healthcare insurance industry’s premiums are going to skyrocket in 2015 as they have skyrocketed in 2014.

If the government starts convincing the majority of the public that the free market solution of the health insurance exchanges doesn’t work, the only choice will be a single party payer system for the entire population.

The VA system is an example of a single party payer system run by the government. It is a bureaucratic mess that is inevitable with a government run single party payer system.

A large bureaucratic single party payer systems relying on rules and regulations will end up with as non-transparent bureaucracy built for the benefit of the bureaucrats and not the people.

I think the public understands this. I think the Obama government is out of touch with the people.

President Obama ought to reexamine his premises.

The Obamacare system being built is destined to fail. It is not a consumer driven free market system. It does not follow that a single party payer system will work.

In reality none of the government controlled single party payer systems throughout the world work. They are just free. However, these systems are unsustainable.

The 8 million enrollees that President Obama ran his Obamacare victory lap on continues to dwindle at an accelerated rate.

If the DC appeals court rules against the federal government ability to provide subsidies, the number of enrollees will decrease even further.

The law states that only State health insurance exchanges can provide subsidies.

Obamacare is getting further and further away from being functional.

The Obama administration and the traditional media are working very hard to keep this information from the general public.

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

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