Stanley Feld M.D.,FACP,MACE

I thought America was a free country. Last week, Judge Rosemary Collyer ruled that seniors have a legal obligation to accept government health benefits (Medicare Part A) or they will lose their Social Security benefits. What happened to freedom of choice?

What does Medicare Part A have to do with Social Security? Americans pay a separate payroll taxes for each. If Americans choose not to accept Medicare Part A, why should they lose their Social Security benefits?

Americans should have the freedom to choose to accept or reject an entitlement for which they paid. Americans who rejected Medicare Part A would not get their Medicare Part A prepayment back. .

Americans pay a separate tax for the Social Security retirement benefits. Why should the government be able to eliminate the Social Security benefit when someone gives up his Medicare benefit?

It looks like another one of President Obama trick plays. This judgment would help him in the implementation of his healthcare reform act. Obamacare’s goal is eliminate to Americans’ freedom of choice.

President Obama’s lawyers have not only tricked the American people by eliminating their freedom to choice, they tricked the judge who does not understand the long term consequences of her judgment. Two years ago, she made the opposite judgment.

Judge Collyer’s judgment has not been widely covered in the traditional media. Its significance has not been discussed. It is a significant victory for President Obama’s healthcare reform act. I presume Judge Collyer’s judgment has gotten limited coverage because President Obama did not want seniors and others to realize the significance of the judgment.

President Clinton promulgated the so-called POMS rules. The POMS is a primary source of information used by Social Security employees to process claims for Social Security benefits.

The rules stated that seniors who withdraw from Medicare Part A must forfeit their Social Security benefits.

Few people are aware of President Clinton’s POMS rules. Three years ago, a group of senior citizens sued the government about this rule. The seniors wanted to be allowed to opt out of Medicare Part A without losing their Social Security benefits.

Their logic was impeccable.

1. They paid their Medicare taxes separately from their Social Security taxes all their working lives.

2. Both Social Security and Medicare are separate benefits.

3. They are not asking for their Medicare payments to be returned.

4. They want to buy private insurance with their own money.

5. They do not want to lose their Social Security benefits. Social Security is a separate benefit.

Two years ago, Judge Collyer supported the seniors’ position and rejected President Obama’s argument. His argument was;

1. Plaintiffs were fortunate to receive Medicare Part A coverage.

2. Plaintiffs suffered no harm from Medicare Part A coverage and therefore lacked standing in the case.

3. President Clinton’s POMS are part of a government handbook.

4. The POMS never went through a formal rule-making process.

She also refused the Administration’s request to dismiss the suit, noting, "neither the statute nor the regulation specifies that Plaintiffs must withdraw from Social Security and repay retirement benefits in order to withdraw from Medicare."

Last week something caused the Washington D.C. judge to revisit and reverse her decision. Her logic is very shaky.

She said:

1. The Medicare statute provides that only individuals who are "entitled" to Social Security are "entitled" to Medicare Part A.

2. Therefore it follows,” the only way to avoid entitlement to Medicare Part A at age 65 is to forego the source of that entitlement, i.e., Social Security Retirement benefits."

This is not syllogistic reasoning. It is not logical. In order to obtain Medicare you have to be eligible for Social Security. This concept is reasonable.

If one does not accept Medicare one cannot receive Social Security benefits is disconnected and arbitrary. If this judgment stands it will set the precedent forcing Americans to have a duty to accept all entitlements the government rules necessary or suffer a penalty. Americans will have lost an important freedom.

“Plaintiffs attorney, Kent Masterson Brown, warns: "Anyone concerned with what will happen when the bureaucrats start writing the thousands of pages of rules that will govern" ObamaCare need only look at this ruling. "Nothing will be optional."

This judgment will help President Obama in the Supreme Court fight for his mandate requiring Americans to purchase healthcare insurance. It will be a deterrent for business to create innovative and cheaper forms of healthcare insurance. It will eliminate healthcare insurers from the marketplace. It will lead the way to the “Public Option.”

There will be no need for a “Public Option.” Americans will have no other option than to accept government healthcare coverage.

President Obama’s next step would be to require all physicians to accept the government rules. The government will dictate to physicians who they can see and how they can treat them.

If physicians do not accept the mandate, they will lose their license to practice medicine.

President Obama’s goal is not about saving money or providing choices. His goal is to force all Americans into the same healthcare coverage program. A program the government controls completely.

I hope, for freedoms sake, President Obama does not get away with this trick play.

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

Stanley Feld M.D.,FACP,MACE

The larger the bureaucracy the more inefficient a system becomes. Several things can happen in the decision making process.

1. The decision making process can become opaque rather than transparent.

2. Decisions are made by a committee by consensus.

3. Consensus committee decisions might not sharply define the original goals.

4. Blame for errors gets dissipated.

5. Decisions are only as good as the information that is gathered.

6. Changing a wrong decision can be difficult and costly.

President Obama’s healthcare reform law is creating 256 new agencies to gather information and recommend decisions for other agencies to write regulations.

The following decision is being made by an agency in Washington state. It is not only the wrong decision, but is a decision that will set back the care of Type 2 Diabetes Mellitus 15 or 20 years. It is a decision being made using the wrong information.

Ironically, the chairperson of the agency (the Health Technology
Assessment Group) is being promoted to head President Obama’s Patient-Centered Outcomes Research Institute as a reward for her good work in the state.

The Health Technology Assessment group’s actions are one of many warning signs for future tragedies of government controlled healthcare.

The subsidized, mandated and overregulated insurance model is imploding in Massachusetts yet the Secretary of Health and Welfare in Massachusetts last week announced it was a success.

In 2006, the state of Washington created the Health Technology Assessment group. The group scrutinizes the cost-effectiveness of various surgeries and treatments. Last week the panel presented its conclusions on lack of value of home glucose monitoring (HGM) for diabetic children under 18.

The board is targeting a fundamental standard of diabetes care. Home glucose monitoring has been well established as a cornerstone of diabetes care for three decades. The agency is wasting its time scrutinizing home glucose monitoring’s cost effectiveness. It has made a decision to eliminate the state’s insurance coverage on the basis of the wrong information. HMG is cost effective because its use decreases long term complications of diabetes.

The issue of cost effectiveness of a test deserves far more scrutiny. “ObamaCare” and the economic stimulus package have devoted billions of dollars to comparative effectiveness research.

President Obama has so often said; "The idea is to pit Treatment X against Treatment Y and find out "what works and what doesn’t." In theory, it sounds great. The Health Technology Assessment in Washington State is an example of how comparative effectiveness will work in the real world, as the political system tries to find ways to restrict or limit treatment to control entitlement spending with little regard for long term outcomes.

I have many ideas on how to control entitlement spending. Eliminating HMG is not one of them.

What is revealing is last November, Ms. Hole-Curry and others debated whether patients were the institute’s "primary constituents."

I believe these bureaucrats believe the budget deficit is their prime constituent. The Health Technology Assessment board is looking to decrease costs short term. Remember the oil filter advertisement, “Pay now or pay more later.”

In 1993, the Diabetes Control and Complication Trial (DCCT) showed that normalizing the blood sugar decreased the incidence of complications of diabetes. The complications of diabetes account for 80% of the cost of diabetes care. It takes 10 to 20 years to develop diabetes complications after the onset of the disease. Complications can be reduced at least 50% with glucose control.

The American Association of Clinical Endocrinologists’(AACE) system of intensive diabetes self- management teaches patients how to control their blood sugars. The system teaches patients how to adjust medications based on HGM readings.

Home glucose monitoring is a major tool used by patients to control their blood sugars.

It is ridiculous for an agency to discuss the efficacy of home glucose monitoring. By discontinuing payment for home glucose monitoring the group shows a disregard for medical science and its ability to prevent the complication of this devastating disease.

The 11-member Health Technology Assessment does not include an endocrinologist or any other physician with relevant clinical experience whose expertise is in diabetes.

“More to the point, as shown by the arbitrary Washington state method, political comparative effectiveness is not about informing choices. It is really about taking away options.”

Washington’s Health Technology Assessment makes the decisions about state-subsidized health care for 750,000 people including Medicaid beneficiaries, public employees, and prisoners.

The Health Technology Assessment program targets therapies that it thinks may be wasteful or unnecessary, and then in nearly all cases it proceeds to ban or restrict state payment for those treatments.

Since 2006, the Assessment program has eliminated coverage for or imposed restrictive conditions on drug-coated cardiac stents, knee replacements for osteoarthritis, ultrasounds for pregnant women, infusion pumps for chronic pain medication, lumbar fusion back surgery and hip resurfacing arthroplasty to name a few.

The Health Technology Assessment program is the prototype for ObamaCare’s many comparative effectiveness programs. No one is discussing the healthcare insurance industry abuse, bureaucratic waste, or decreasing access to care.

President Obama has already hired Ms. Hole-Curr, head of the Health Technology Assessment program to head his comparative effectiveness program

President Obama’s healthcare reform act will create de facto criteria for procedures through his comparative effectiveness program. The result will be to dictate all the choices about how doctors are allowed to treat patients.

This is not “evidence based medicine.” Anyone can believe prove anything if they evaluate the wrong information. If the government’s imperative is to save money, new and effective tests and treatments will be rationed to the detriment of patient care.

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

Stanley Feld M.D.,FACP,MACE

Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee announced on March 8,2011 that “The Senate will never vote to confirm Dr. Donald Berwick as CMS administrator.” Dr. Don Berwick is currently serving through a temporary one year appointment made by President Obama while congress was in recess last summer.

Mr. Bacus did not call for confirmation hearings before the recess because of fears that Dr. Berwick’s views would be too controversial for him to be confirmed. He and President Obama feared the Senate and the American people would reject Dr. Berwick’s nomination.

Last week 42 Republican Senators sent a letter to President Barack Obama requesting that he withdraw Berwick from consideration. The Republican Senators said they would not vote for Dr. Berwick under any circumstances.

Senator Bacus said the “Republicans won”. He said alternative nominees to the post are "up to the president."

President Obama has announced, after receiving the Republican Senators letter, his support of Dr. Berwick’s nomination. President Obama declared Dr. Berwick is the most qualified candidate to lead CMS. Dr. Don Berwick told reporters that he “was grateful for the White House support.”

The 42 no votes would block confirmation because 60 votes are needed. Dr. Berwick was asked if he has met with any of those Republican senators to address their concerns about him. He said he would “meet with anyone in Congress who wants better healthcare.”

His answer implies Senate Republicans do not want better healthcare. It also implies that Republican Senators have no interest in meeting with him and that he knows the answers and they do not.

Republican Senators have expressed many concerns. One concern stems from Dr. Berwick’s praise of the British single-payer system which is failing and the sense President Obama’s healthcare reform act is heading toward a single party payer system.

The concerns are deeper than these. There has been little coverage of the Republican Senators’ letter to President Obama in the traditional media.

The Republican Senators wrote; “Withdrawing Dr. Berwick’s nomination would be a positive first step in rebuilding the trust of the American people.”

The letter says; “CMS is in charge of both Medicare and Medicaid, and will oversee most of the implementation of the recently-enacted health law.”

The Republican Senators letter lists the reasons for their request in a civil way.

1.“Don Berwick is a contentious choice to head an agency with a budget larger than the Defense Department’s and implement the vast majority of the $2.6 trillion health law.

2. “ The White House’s handling of this nomination – failing to respond to repeated requests for information and circumventing the Senate through a recess appointment – has made Dr. Berwick’s confirmation next to impossible,”

3.  “In the spirit of cooperation, the President should withdraw his nomination and choose a different candidate who has the support and confidence of the American people.”

4. “Both Congress and more than 100 million Americans that will be affected by this partisan health care reform plan need to know who is minding the store at CMS.

5. There are just too many questions about what Dr. Berwick and CMS are doing or will do with the unprecedented power they have been given to reshape our health care system,”

6.  “The President should start with a clean slate and send the Senate a nominee who is willing to answer our questions and seek our bipartisan support as he or she leads CMS in implementing the new health care law.”

7. “ The occupant of this important position, which affects the health care of so many Americans on a daily basis, requires an individual with the appropriate experience and management ability. Our seniors and those who rely on Medicaid deserve no less.”

The letter questions Dr. Berwick’s experience and management ability to handle large organizations. There has not been evidence presented to the congress verifying that Dr. Berwick has experience in running large organizations with multiple competing vested interests.

The healthcare system is dysfunctional. Only a consumer driven healthcare system with consumers in charge of their healthcare dollars will repair the healthcare system. Consumers must have access to appropriate information and appropriate incentives to make wise health decisions. This is the only way to control the costs of the healthcare system. A complex bureaucracy will not do this.

Mistrust of President Obama is rampant among Americans. President Obama must regain the trust of the American people and stop his trick plays.

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

Stanley Feld M.D.,FACP,MACE

Last year’s “Doctor Fix” was passed the last week congress was in session in 2010. This was after the medical profession was held in suspense for 9 months.

The “Doctor Fix” was supposedly the result of President Obama making a deal with the AMA for the AMA’s support. He was going to pass a real “Doctor Fix” in 2011 by repairing the defective sustainable growth rate formula (SGR). Nothing has been done about this by President Obama in 2011. The cumulative physician reimbursement reduction of 25% was suspended until January 2012.

Physicians face a 29.5% Medicare Pay Cut in January 2012. Four and one half percent was added to last year’s cumulative physicians reimbursement reduction. The reduction was calculated into the CBO’s cost score for President Obama’s Healthcare Reform Act.

Last week an official with the Centers for Medicare and Medicaid Services unveiled the 29.5% rate reduction for 2012 in a recent letter to the Medicare Payment Advisory Commission. This will become another distraction for physicians and the media as President Obama stalls for time.

“Leaders of the American Medical Association and other medical societies have warned that such a huge pay cut would force physicians to turn away not only seniors but also military families whose TRICARE coverage is based on Medicare rates.”

President Obama is stalling for the development and implementation of Accountable Care Organizations. His goal is to deal with big hospital systems, clinics, and not 600,000 individual physicians.

President Obama is ignoring the fact that Accountable Care Organizations (ACOs) are difficult to organize and impossible to execute efficiently and effectively. ACOs will fail for the reasons I have outlined previously.

It will end up costing the federal government more rather than less than the present system does. Hospital systems are excited because they think they will own the physicians and make a killing on Accountable Care Organizations. They think they will own physicians intellectual property. They cannot be more mistaken. They can expect a lot of fighting and grief.

At the same time, President Obama is dispiriting the physician workforce with his duplicity. He is increasing physician mistrust for government control over medicine.

President Obama’s proposed budget for fiscal 2012 calls for delaying the next cut from January 1, 2012, until January 1, 2014, freezing rates in the meantime.

Why doesn’t he fix the SGR? It is a screwy way to do business.

The healthcare system needs to be repaired. President Obama is going about it the wrong way.

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

Stanley Feld M.D.,FACP,MACE

The truth about President Obama’s healthcare reform act is becoming obvious. The problem is the traditional media is not covering the true implications of President Obama’s healthcare reform act. The traditional media simply prints the administrations press releases. While the media covers some of the problems, it does not connect the dots to produce the true picture.

There are so many problems with President Obama’s healthcare reform act that the only way to fix it is to repeal it and start over again.

President Obama used tricky tactics to get the bill passed. They are now catching up with him. This week several problems became obvious. A significant problem as putting all the decision making power in the hands of the Department of Health and Human Services(HHS).

Kathleen Sibelius admitted to the House Energy and Commerce Health Subcommittee that the books were cooked in the passage of the healthcare reform act. Kathleen Sibelius and CMS made fools of themselves at an Energy and Commerce Health Subcommittee committee hearing admitting that President Obama cooked the books by double counting.

It was also clear that HHS did not have a handle on the potential unintended consequences of the healthcare reform act.

 Representative Marsha Blackburn (R-TN), asked Kathleen Sibelius to estimate the amount of money lost to Medicare and Medicaid fraud in those programs. She said, “We don’t know.” The Democratic congress and President Obama has put vast power in Kathleen Sibelius’ hands.”

She is in control of 18-25% of America’s gross domestic product, yet she did not know the answer to this basic question.

Do you think anything else could be overlooked?

Representatives of CMS admitted they did not know the extent or cost of Medicare and Medicaid fraud. Neither any of the CMS representatives nor Kathleen Sibelius knew the real estimate of the costs of healthcare reform.

It is becoming clear that President Obama’s “seminal accomplishment”, his healthcare reform act, will make medical care unaffordable, balloon the federal and state deficits even further, raise taxes and provide less care. The law will include healthcare insurance with less coverage and provide a decrease of access to care. The quality of care will not improve.

Last month, Judge Vinson’s opinion effectively put an injunction on the law. He expected the Justice Department to appeal immediately. President Obama and HHS ignored the judgment and continued to implement the law. The Justice Department has not filed an appeal after 30 days. Judge Vinson was annoyed at the administrations delaying tactics, and its attempt to ignore his ruling.

He is trying to force President Obama’s administration to file an appeal within one week.

The House passed a bill repealing the provision in “Obamacare” requiring everyone who pays more than $600 for a product or service to provide the vendor with a 1099 form. The purpose was to collect more taxes to pay for President Obama’s healthcare reform act.

The provision created a tremendous paperwork burden for small businesses for relatively small payments. The IRS estimated it would increase revenue by $17 billion dollars. Seventeen billion dollars is a long way from covering the $1.5 trillion dollar budget deficit this year. The cost to small business owners would be great enough to bankrupt some of them.

The provision would have increased the number of 1099 forms filed each year by something like two thousand percent. In the end, 70 percent of the House voted in favor of repeal, including 238 Republicans and 76 Democrats.

President Obama said he supported the repeal. His trick is he did not suggest a source for potential revenue replacement. Senate Democrats are balking repeal. They complain there is no revenue replacement. Repeal will increase the healthcare reform act’s deficit even further.

Harry Reid and the Democratic Senate do not want to pass the law. Mr. Reid is demanding a provision to fund the $17 billion dollar loss.

The weeds are getting higher each day for President Obama and his healthcare reform act. The truth of the high costs are coming out.

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

Stanley Feld M.D.,FACP,MACE

Once again, President Obama is being disingenuous. He told the nation’s governors he was willing to amend his healthcare reform act. He said he would give states the ability to opt out of its most controversial requirement the mandate for citizens to buy insurance in 2014.

Last week he started his speech by spinning his charm at the National Governors Association meeting by saying:

“I am aware that I have not convinced everybody here to be a member of the Affordable Care Act fan club,"

He said he understood that the majority of the public were not members of the Affordable Care Act fan club either.

He did promise “to give states the power to determine their own health-care solutions.” His qualifications to state power are the deal breaker.

President Obama’s qualifications to state power change in his healthcare reform act as it relates to Medicaid are:

1. The Administration retains the power to decide which states deserve a waiver.
2. The state would still need to cover the same number of uninsured.
3. Its coverage would still need to include the same comprehensive benefits.
4. It must be as "affordable" as determined by the Administration.
5. States could opt out of some consumer or employer mandates. This is a minor concession.
6. In reality, his conditions leaves no room for the states to innovate.
7. Innovations such as;
   1. Straight tax deduction or credit to purchase individual coverage.
   2. Alternative insurance designs such as;

              i. The high-deductible ideal medical savings accounts,

              ii. Plans that can be bought across state lines.

1. Even if the change was approved, it could be difficult for states to meet the federal requirements for the waivers.

Mr. Obama also asked the governors to come up with a bipartisan group to find ways to reduce Medicaid costs. There is no way to reduce Medicaid costs under the structure of President Obama’s healthcare reform act. The structure is defective.

President Obama must have stayed up all night trying to figure out ways to fake out the State Governors. President Obama is trying to reposition himself to the political center issues in the wake of the drubbing his party took in the November midterm elections. This proposal will not do it.

He has once again used smoke and mirrors.

This is not a shift. The mandate in particular is under fierce attack in the courts, where federal judges have issued conflicting opinions on its constitutionality. The mandate is also a rallying cry for conservatives and Tea Party supporters, who regard it as a prime example of overreaching by the federal government.

President Obama will not allow states to cut Medicaid rolls to ease their fiscal distress.

President Obama said. “I am not open to refighting the battles of the last two years,” he said, “or undoing the progress that we’ve made.”

Gov. Rick Perry of Texas, chairman of the Republican Governors Association said. “Pretty much all he did was to reset the clock on what many of us consider a ticking time bomb that is absolutely going to crush our state budgets. The states need more than that.”

Indiana’s Mitch Daniels and 20 other Governors recently wrote to President Obama requesting a genuine relaxation of the waiver standards. He has also asked for states to have the ability to be innovative and control each individual Medicaid program.

"Healthy Indiana" the Medicaid reform Governor Daniels initiated in Indiana is run because of special federal permission. The program has been a huge success. Federal support for the program is about to disappear.

The Health and Human Services(HHS) department does not like the Healthy Indiana program because it features health savings-like accounts. Healthy Indiana decreases federal control over the Medicaid system in Indiana. The program puts the healthcare dollars under patients’ control.

‘The reality is that the liberals who wrote this bill really do think they have a monopoly on good ideas, and they do not include markets. Democrats are more than happy to give the states more freedom, as long as the states use it to impose comparable government control.’

That may be why we hear that White House health staffers Stephanie Cutter and Nancy-Ann DeParle have been privately telling liberal interest groups that this is a way to increase centralization—for instance with a state-based "public option" or even single payer.

President Obama’s “flexibility” is a shame. He is telling the states you can do anything you want. However, you must do what we want you to do. We will determine what we will approve.

The list is defined arbitrarily by unelected bureaucrats and a non- congressional approved head of CMS (Don Berwick) who refuses to answer any congressional questions directly.

I believe President Obama wants the healthcare reform act to fail. He wants the federal government to get complete control over the entire healthcare system.

He is stalling for time with his most recent tactic. It is essential to him to get all new 256 agencies up and running. Then it will be difficult to close down new agencies.

I hope the state governors are not faked out by his charade.

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