Stanley Feld M.D.,FACP,MACE

The healthcare system is dysfunctional. All the stakeholders are to blame. President Obama’s healthcare reform act is going increase this dysfunction because the healthcare reform act does not solve the basic problems in the healthcare system.

For many physicians, the realities of our health care system have led to an inevitable conclusion. In order to survive, physicians must abandon the very ideals that drove them to become physicians.

The problems that will not be solved but will be intensified under Obamacare are the complexity of billing codes, the threat of malpractice, the frustration of not having the time to relate to patients effectively and the burden of the administrative bureaucracy (paper work). Patients have been conditioned to be suspicious of physicians’ skills and motives. Physicians have become suspicious of their patients.

Ryan Flesher, MD an emergency room physician directed and produced a documentary, “The Vanishing Oath” with Nancy Pand. The dysfunction of the healthcare system is described from an emergency physician’s perspective.

It is the story of a physician’s disillusionment with his life’s dream and profession. It is the story of his discovery that many physicians feel the same way. It is a story of emotional exhaustion.

“Dr. Flesher’s story is about himself, and also other physicians caught in the whirlwind of the healthcare system, their day-to-day exhaustion, and unhappiness woven in a tightening bureaucratic vice.”

He describes becoming increasingly unhappy in a system that seemed to unravel and become "critically wounded.” Doctors are bailing out of their chosen profession because they are not able to have enough time for their patients or themselves.

“Flesher hated being a physician in a manner that he says the system demands. “It was just pretty frustrating," he says. "Since I was young, I focused on becoming a doctor." Over time, as he grew more unhappy, " I began asking myself, ‘what’s wrong with me, why am I so unhappy?”

It was therapeutic for him to make this film. It was sad for him to see physicians weep with despair over their profession. Physicians were frustrated that they could not understand their patients’ illness beyond what their charts tell them. The time allotted to each patient has been truncated.

Medical care is an art as well as a science. Most physicians believe in order to be therapeutically effective there is more art than science in the patient physician relationship.

President Obama’s healthcare bill and Dr. Berwick’s philosophy assumes that medical care can be commoditized. They are wrong. They are going to destroy the physician workforce. The result will be many unintended consequences with a restriction of access to care and rationing of care.

These unintended consequences are already occurring in the dysfunctional healthcare system. President Obama’s healthcare reform act does nothing to correct the dysfunction which will only intensify.

"We’re just jammed, ambulances everywhere, beds full, I’m carrying 16 or 17 patients of my own, pretty sick," Flesher says in the documentary. "Before I go three steps, I’m confronted with the billing agent for the ER who says we can’t get paid because my charts — eight of nine — required review assistance components. Two, I’m confronted by the service rep for the hospital (who says) my patient satisfactory scores are only 93% – we’ve got to be above 96."

"The CEO says we are getting backed up (in the emergency room), and we need to get patients through the ER quicker," he adds. "The Joint Commission rep says she caught me drinking (soda) three feet too close to the patient care area and she’s going to cite me for—whatever. I didn’t even see a patient yet and my mind is already clouded."

It reminds me of the funny bit done in the 1960s.

“My name is Jose Jiménez. Jose said, “How would you like to be the monkey that presses the button and puts the scientist into space?”

The healthcare system is sick and getting sicker. The losers will be patients, physicians, and taxpayers. The winners will be the government bureaucrats and the healthcare insurance industry.

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

Stanley Feld M.D.,FACP,MACE

Last week I received several emails from readers expressing their frustration with President Obama. The readers suggested I present these points of view. I have chosen three which could be considered informative.

The first is Steve Wynn’s his view of the reasons President Obama’s economic stimulus has not worked and why the healthcare reform will not work. Mr. Wynn believes President Obama has placed the United States in great danger.

Steve Wynn is a casino resort/real-estate developer who has been credited with spearheading the dramatic resurgence and expansion of the Las Vegas Strip. In 2009, Steve Wynn was the 468th richest man in the world.

The interview is riveting and a must watch.

http://www.infowars.com/steve-wynn-takes-on-washington/

Next was a note from Norm Green to his friends. Norman N. Green has been a very successful business man in both Canada and the U.S. He is a shopping mall developer from Calgary, Alberta.

Norm Green owns and operates approximately 5 million square feet of commercial real estate in the U.S. and Canada.

He was a co-owner of a National Hockey League franchise, the Calgary Flames, Minnesota North Stars, later the Dallas Stars.

He is a member of the executive committee of the board for the Edwin L. Cox School of Business at Southern Methodist University and has been active in philanthropic and community service activities for over 30 years.

Norm Green sent this email to friends to his friends who frequently asked him to explain the differences between healthcare in Canada and the United States. The article appeared in Investor’s Business Daily.

The article compares the Canadian healthcare system’s outcomes to our healthcare system’s outcomes.

His comment in the last sentence says it all. It is worthwhile to study each outcome.

“A recent "Investor’s Business Daily" article provided very interesting statistics from a survey by the United Nations International Health Organization.”
Percentage of men and women who survived a cancer five years after diagnosis:
U.S.             65%
England        46%
Canada         42%

Percentage of patients diagnosed with diabetes who received treatment within six months:
U.S.             93%
England        15%
Canada         43%

Percentage of seniors needing hip replacement who received it within six months:
U.S.             90%
England        15%
Canada         43%

Percentage referred to a medical specialist who see one within one month:
U.S.             77%
England        40%
Canada         43%

Number of MRI scanners (a prime diagnostic tool) per million people:
U.S.             71
England        14
Canada         18

Percentage of seniors (65+), with low income, who say they are in "excellent health":
U.S.             12%
England        2%
Canada         6%

I don’t know about you, but I don’t want "Universal Healthcare" comparable to England or Canada. Moreover, it was Sen. Harry Reid who said, "Elderly Americans must learn to accept the inconveniences of old age."

SHIP HIM TO CANADA OR ENGLAND!

Sen Harry Reid is "elderly" himself but be sure to remember his health insurance is different from yours as Congress has their own high-end coverage!  He will never have to learn to accept "inconveniences"!!!

Norman Green
dallas texas

Craig H. Weinstein, MD, MPH
Sports & Orthopaedic Specialists

Gilbert,AZ  85296

It is obvious that frustration over President Obama’s administration is mounting. As President Obama makes policy mistakes, people are worried about the ability of the economy to recover. Every week the unintended consequences of his mistakes increase. More and more people, Republicans, Independent, Libertarians, and Democrats are speaking out against President Obama and his puppets in the congress.

Maybe President Obama will start listening to the will of the majority soon and make a sharp right turn toward the center. His legacy will depend on it.

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

Stanley Feld M.D.,FACP,MACE

President Obama has used many trick plays on congress and the American people to get his agenda passed. Now he is trying one on the judicial branch of government. I have pointed out the trick plays used during the healthcare debate.

President Obama has also used trick plays with the off shore drilling crisis, the banking crisis, the financial reform act, and passage of the stimulus package.

The details of all these tricks are interesting. They demonstrate President Obama’s cleverness. More importantly they demonstrate his disregard for the will of the people and his disrespect for congress.

President Obama’s goal is to increase government control over the economy, our freedoms and the American way of life.

President Obama’s latest trick play demonstrates that he believes the end justifies the means.

Initially, fourteen states, and now twenty one states, have filed suit against the healthcare reform law.

“In April 2010, State attorneys general wasted no time filing legal challenges to President Obama’s healthcare reform law, swinging into action with legal filings in Florida and Virginia within minutes of the White House signing ceremony on Tuesday.”

States claim the law is unconstitutional. The major constitutional violations are the mandate for citizens to buy healthcare insurance and the federal government infringement on States rights.

“This lawsuit should put the federal government on notice that Florida will not permit the constitutional rights of our citizens and the sovereignty of our state to be ignored or disregarded,”

The issue is federal infringement on free choice and the infringement on the duties of the states as defined in the constitution.

“The multi-state lawsuit maintains that new law infringes the liberty of individual state residents to choose for them whether to have health insurance. It also says the states themselves are victims of a federal power grab by leaders in Washington.”

President Obama and his attorney general Eric Holder immediately claimed the States were wasting taxpayers’ money. The lawsuit would be dismissed. The state did not have standing in the lawsuit.

The traditional media supported President Obama. The media did not provide much coverage of the facts in the case. The public was starved for the facts. Much of the public perceived the healthcare law as an attack on freedoms.

On July 1, 2010, the Department of Justice argued in court for dismissal of Virginia’s lawsuit challenging the health care reform act.

“ Deputy U.S. Assistant Attorney General  Ian Gershengorn argued that Virginia lacks standing to challenge the “minimum coverage” provision because it applies to individuals and not to the state. Gershengorn also defended the mandate, calling it a necessary step to control skyrocketing health care costs and ensure that uninsured individuals pay for the health care they receive.”

A deputy to Virginia Attorney General Ken Cuccinelli argued that the federal law collides with a new state statute that protects individuals from being required to purchase health insurance.

“U.S. District Judge Henry Hudson presided over a two-hour hearing in a packed Richmond courtroom, peppering lawyers on both sides with pointed questions about the constitutionality of the federal health care law and Virginia’s efforts to combat it. Hudson said he will issue a ruling on the federal government’s dismissal motion within 30 days.”

President Obama and his administration sensing, Judge Henry Hudson would rule against the government, changed their argument on July 16^th. They now said this provision is not a mandate it is a tax.

The federal government has the “power to lay and collect taxes.” This is being said, President Obama asked the judge to dismiss the case. President Obama is trying to avoid a negative judgment.

“And that (taxes) power, President Obama says, is even more sweeping than the federal power to regulate interstate commerce.(impose an individual mandate)”

President Obama and the administration now defend the insurance mandate as a tax.

In September 2009 during an interview with George Stephanopoulos on the ABC News President Obama vehemently denied the mandate was a tax.

“For us to say that you’ve got to take a responsibility to get health insurance is absolutely not a tax increase,”

“When Mr. Stephanopoulos said the penalty appeared to fit the dictionary definition of a tax, Mr. Obama replied, “I absolutely reject that notion.”

Please watch this video in full. President Obama says what he has to in order to increase government power over the people and circumvent the constitution. He has not minded contradicting his pledges to the American people.

President Obama has used another trick play changing the mandate to a tax at the last minute.

“J. Kenneth Blackwell, former Treasurer of Ohio and a professor at Liberty University School of Law and Kenneth A.Klukowski, special counsel at the Family Research Council and senior legal analyst at the American Civil Rights Union and coauthors of "The Blueprint: Obama’s Plan to Subvert the Constitution and Build an Imperial Presidency" (Lyons, 2010) wrote an recent article in the Wall Street Journal. They defined the differences between a tax and mandate.”

“They concluded that with either definition the healthcare reform act is unconstitutional.”

“A tax is when the government takes money from individuals, puts it in the Treasury, and plans to spend it.”

“With the health-insurance mandate, the government is not taking money from private individuals; rather, it is commanding
them to give their money to another private entity, not to the Treasury.”

“If individuals don’t obey the mandate, they pay a penalty to the Treasury. But penalties aren’t taxes. The mandate is legally separate from the penalty.”

It does not matter what words President Obama uses. A mandate is a mandate and not a tax. Even if it is accepted as a tax, the tax is unconstitutional.

“Even if the Justice Department were to get the mandate considered a tax, it would be an unconstitutional one.”

“Unlike the states, the federal government has limited jurisdiction. Under the 10th Amendment, the federal government has only those powers enumerated by the Constitution, and all other powers are reserved to the people or the states.”

“Every federal action must be authorized by a constitutional provision. If there is no such provision, then the action is unconstitutional. No provision of the Constitution authorizes the federal government to command people to buy insurance.”

President Obama has disrespected the congress. He is now disrespecting the intelligence of the judicial branch of government.

I do not think he will get away with it.

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

Stanley Feld M.D.,FACP,MACE

Obamacare is already proving it is going to fail. By President Obama’s own admission, it will not achieve universal coverage. It will not provide affordable coverage because the healthcare insurance industry is already raising the price on private insurance and the fees it charges the government to administer service for Medicare and Medicaid.

Seniors will notice that their Medicare premiums for Part F has increased starting August 1^st. Seniors can also expect premiums for Medicare Part D, Ordinary Medicare and Medicare Advantage to increase on January 1^st 2011.

Why would premiums increase? Physician reimbursement has decreased.

There will be an increase in the fee the government pays administrative service providers (healthcare insurance industry) to subsidize Medicare and Medicaid. The reason for these increases will be non- transparent.

To many the name Newt Gingrich is a dirty word. Nonetheless, he is perceptive. In his recent book “Real Change: A Fight for America’s future”, he explains why the current third party payment system for healthcare is inefficient, ineffective and leads to fraud. I will amplify his model in order to point out the dysfunction in the healthcare system and its solution.

He explains why a “buyer-seller model” in healthcare is more efficient than a" “buyer-seller-receiver bureaucratic model”, whether it is a public or private system.

In the third party payer system (buyer-seller-receiver system), the buyer (insurance company, employer or government) receives no direct value for its payment. Its goal is to pay as little as possible. The seller (physicians or hospitals) knows the buyer suspects the seller of greed, and incompetence. The relationship is adversarial.

The receivers (patients) have little concern of cost. They have first dollar coverage. They have no incentive to save money. They have been conditioned to believe the medical care is an entitled service. Patients want more service with more convenience. They have no accountability for their habits. They have no incentive to lose weight or exercise consistently. Obesity leads to chronic disease and its complications. Patients have no incentive to care for their chronic disease.

President Obama’s healthcare reform plan does not provide these incentives. Yet the key to repairing the healthcare system is patients being the keeper of their health and the manager of their disease.

On the other hand, in a buyer-seller system, the buyer (patients) can be given incentive and educated to be a wise buyer of a service (medical care). The buyer (patients) has freedom of choice. Patients decide whether a service is worth the price. They decide whether they want to avoid the cost by taking care of their health.

The sellers (physicians, hospitals, or pharmacies) can choose to sell at the offered price or refuse to sell. The seller has a free choice. The seller’s freedom is not shackled by government regulations. The price is determined by previously negotiated prices. Prices are transparent.

Patients must be made aware of the negotiated prices by the government.

The buyer-seller-receiver bureaucratic model with the government being the buyer in a single party payer will lead to;

1. Fraud, abuse and administrative waste.

2. Lack of individual freedom of patients to choose their medical care.

3. Bureaucratic control of healthcare which undermines personal responsibility for health and medical care.

Fraud, abuse, and administrative waste.

There are many examples of fraud. The easiest examples to comprehend are the occasional physician or physician’s clinic billing for services not performed.

There are examples of hospital systems overbilling Medicare and Medicaid for non-rendered services. These actions seem to have political overtones. It is usually private hospital corporations or management companies and not faith based non-profit hospital systems that are accused of this level of fraud.

Medicare and Medicaid outsource the administrative services to the healthcare insurance industry. There are many examples of the fraud and abuse by the healthcare insurance industry.

The public perceives the largest cost is physician abuse. Physicians are the weakest stakeholder. However, if the government looked closely enough it would find the largest area of fraud and abuse comes from the healthcare insurance industry.

A popular notion in congress is that 40 cents of every healthcare dollar goes for administrative costs to the healthcare insurance industry. I believe this is a low estimate. Some economists have demonstrated that administrative services expenses are 60 cents of every healthcare dollar.

Congress has chosen not to change the accounting rules used by the healthcare insurance industry. These defective accounting regulations lead to the largest area of fraud and abuse. An estimate is $250 billion dollars a year.

The Government Accounting Office estimates that 10% of Medicare and Medicaid spending is lost to fraud and abuse. Ten percent of Medicare and Medicaid cost is $80 billion dollars a year. Over the next decade, the cost would amount to $800 billion dollars if both programs were not expanded. With the entitlements being expanded it could be 2 to 3 trillion dollars over the decade.

I believe if we created a buyer seller system, the fraud and abuse would decrease to less than 1% of healthcare expenditures. Every patient would be a police officer for his own healthcare dollar.

Lack of individual freedom to choose.

Bureaucracy can only function by creating rules and regulations to control the receiver and the seller. This leads to an increase in the number of regulatory agencies. The result is many unenforceable and conflicting rules and regulations. The rules and regulations usually lead to unintended consequences and greater budget deficits.

The receivers’ (patients’) medical needs might be unfulfilled by these rules and regulations.

Americans love the free market and their ability to make choices. We love to be consumers and admire incentives, bargains, and choices. One only has to look at consumer products such as electric products and automobiles. Consumerism drives our economy not centralized bureaucratic control. Healthcare should be driven by consumers and not by the system, which President Obama and Dr. Donald Berwick advocate.

Bureaucratic control of healthcare will undermine personal responsibility for health and health maintenance.

The buyer (the government bureaucracy) pays for the receiver (patient) to receive care from the (physician). The patient is forced into a passive position. The government defines what care the patient can receive. The physician must provide the care the government dictates.

Patients are conditioned to believe that someone besides themselves is responsible for their health and healthcare.

The government should provide the appropriate information and education for the patients to make wise hea
lth decisions. These wise decisions must be encourage by giving patient control and ownership of their own healthcare dollars.

This can be accomplished through the ideal medical savings account.

Patients should make healthcare and medical care decisions for themselves.

Patients must play an active role in the management of their health and disease.

I believe the bureaucratic single party payer system will not Repair the Healthcare System.

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

Stanley Feld M.D.,FACP,MACE

This week Senate Republicans demanded to hear from Dr. Don Berwick, the physician President Barack Obama appointed during the July 4^th Senate recess to run the Medicare and Medicaid programs.

Dr. Berwick took office last week.

“Republicans on the Finance Committee, which has jurisdiction over the post, say that not holding a hearing with Berwick would “result in circumventing the open public review that should take place for a nomination of such importance” and “casts a shadow over his legitimacy and authority to serve as administrator during a critical time for CMS.”

President Obama did an end around on Finance Committee Chairman Max Baucus (D-Mont.). Senator Baucus said he was troubled that Dr. Berwick did not have a confirmation hearing.

“Senate confirmation of presidential appointees is an essential process prescribed by the Constitution that serves as a check on executive power and protects Montanans and all Americans by ensuring that crucial questions are asked of the nominee – and answered,”

After Dr. Berwick was installed in office, Senator Baucus said, “fully expects" new Medicare chief Donald Berwick to testify before the panel "in the near future."

Does President Obama have enough respect for the Senate or the American people to honor Senator Baucus’ request?

Why all the fuss?

There are two reasons:

1. “Dr. Berwick’s ideas on the design and purpose of the U.S. system of medicine aren’t merely about "change." They would be revolutionary.”

2. “One may agree with these views or not, but for the president to tell the American people they have to simply accept this through anything as flaccid as a recess appointment is beyond outrageous. It isn’t acceptable.”

Problem solving has three components;

a. Goals

b. Philosophy

c. Mechanisms.

All three must be kept in mind when evaluating decisions. There is no question that the mechanical aspects of healthcare and medical care must be changed in order to have a more cost effective, affordable system. I have discussed all of the areas of waste and abuse in the healthcare system previously. Many of these areas are not addressed in President Obama’s healthcare legislation.

Increasing the bureaucracy without developing a system of individual responsibility, individual choice, and individual accountability has not worked historically.

Yet Dr. Berwick’s many public statements reflect a new system that denies these freedoms and subjugates the individual’s freedom of choice to collective government decisions.

I am amazed at how few people are aware of the Dr. Berwick issue. I am again publishing his statements as Daniel Henniger did in order to bring more attention to the issue.

Excerpts are from past speeches and articles by Dr. Berwick:

"I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do."

"You cap your health care budget, and you make the political and economic choices you need to make to keep affordability within reach."

"Please don’t put your faith in market forces. It’s a popular idea: that Adam Smith’s invisible hand would do a better job of designing care than leaders with plans can."

"Indeed, the Holy Grail of universal coverage in the United States may remain out of reach unless, through rational collective action overriding some individual self-interest, we can reduce per capita costs."

"It may therefore be necessary to set a legislative target for the growth of spending at 1.5 percentage points below currently projected increases and to grant the federal government the authority to reduce updates in Medicare fees if the target is exceeded."

"About 8% of GDP is plenty for ‘best known’ care."

"A progressive policy regime will control and rationalize financing—control supply."

"The unaided human mind, and the acts of the individual, cannot assure excellence. Health care is a system, and its performance is a systemic property."

"Health care is a common good—single payer, speaking and buying for the common good."

"And it’s important also to make health a human right because the main health determinants are not health care but sanitation, nutrition, housing, social justice, employment, and the like."

"Hence, those working in health care delivery may be faced with situations in which it seems that the best course is to manipulate the flawed system for the benefit of a specific patient or segment of the population, rather than to work to improve the delivery of care for all. Such manipulation produces more flaws, and the downward spiral continues."

"For-profit, entrepreneurial providers of medical imaging, renal dialysis, and outpatient surgery, for example, may find their business opportunities constrained."

"One over-demanded service is prevention: annual physicals, screening tests, and other measures that supposedly help catch diseases early."

"I would place a commitment to excellence—standardization to the best-known method—above clinician autonomy as a rule for care."

"Health care has taken a century to learn how badly we need the best of Frederick Taylor [the father of scientific management]. If we can’t standardize appropriate parts of our processes to absolute reliability, we cannot approach perfection."

"Young doctors and nurses should emerge from training understanding the values of standardization and the risks of too great an emphasis on individual autonomy."

"Political leaders in the Labour Government have become more enamored of the use of market forces and choice as an engine for change, rather than planned, centrally coordinated technical support."

"The U.K has people in charge of its health care—people with the clear duty and much of the authority to take on the challenge of changing the system as a whole. The U.S. does not."

Is this what the American people want? If so, that is America’s choice. Americans must be given that choice with a televised transparent confirmation hearing.

Barack Obama cannot deny Americans the understanding of Dr. Berwick’s positions. Thankfully, Senator Baucus has spoken out.

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

Stanley Feld M.D.,FACP,MACE

President Obama has used one trick after another to get his healthcare reform bill passed. He has also used many tricks to put control of the healthcare system in the hands of the executive branch of government. The Secretary of Health and Human Service has the power to make healthcare policy without congressional oversight.

The Secretary of Health and Human Services can delegate her powers to whomever she chooses. I was astonished that neither congress nor the Republicans made a fuss about President Obama usurping congressional power.

President Obama is moving further away from respecting the will of the people. It is clear that the majority of Americans oppose most aspects of President Obama’s healthcare plan. They do not like the implications of government control over the entire healthcare system, the specter of a public option, a single party payer,or rationing of healthcare.

Americans despise the implication of the loss of freedom to choose. They feel deceived by President Obama’s statements that if you like your physician or your healthcare plan you may keep it. In reality, this was a false promise.

President Obama nominated Dr. Donald Berwick to be Director of Center of Medicare and Medicaid Services (CMS). Dr. Berwick dedicated his life to healthcare policy. His ideas are “progressive” ideas. I disagree with many of his ideas. I also believe the congress and the American public should have been exposed to these ideas through the usual Senate confirmation process.

The Senate did not schedule the confirmation hearings because the nomination paperwork had not been completed.

During the July 4^th recess, President Obama simply appointed Dr. Berwick as Director of CMS. I believe President Obama made this recess appointment to avoid a Senate debate on his choice.

“Circumventing Senate confirmation to appoint the new Medicare chief is part of the same political willfulness that inflicted ObamaCare on the country despite the objections of most voters.”

Democrat Max Baucus, the Senate Finance Chairman, issued a statement critical of this end-around. Finally, an important Democratic Senator has reacted to President Obama’s usurping congressional power.

“Mr. Baucus hadn’t scheduled hearings because the nomination paperwork wasn’t even finished 11 weeks after Dr. Berwick was named.”

The obvious question is was the administration stalling to make the appointment without proper debate and vetting during the July 4^th recess?

President Obama claims that the Republicans were impeding the appointment "for political purposes."

It is obvious that President Obama wanted to avoid restarting the healthcare debate in an election season.

Dr. Berwick’s opinions agree with President Obama’s philosophy on healthcare reform. The direct appointment avoids reigniting the philosophical disagreements with Republicans.

Dr. Berwick’s philosophy is expressed in his 1996 book “New Rules” and in position papers of the Institute of Healthcare Improvement.

A primary function of health regulation is to “constrain decentralized, individual decision making and to weigh public welfare against the choices of private consumers.”

This sounds like socialized medicine to me. It sounds like a restriction of freedom of physicians to use clinical judgment and consumers freedom of choice.

He believes that "protocols, guidelines, and algorithms for care," with the common underlying notion that someone knows or can discover the ‘best way’ to carry out a task to reach a decision, and that improvement in medical care can come from standardizing processes and behaviors and demanding conformity.

It sounds like government control of the practice of medicine and patient choice. Sometimes there is not a single way to treat patients. Rationing should be determined by freedom of the individual to choose and not a central authority.

“In a now-notorious interview last year Dr. Berwick said, "The decision is not whether or not we will ration care—the decision is whether we will ration with our eyes open."

Since the federal government is running out of money, the bureaucracy will determine what is the best treatment at the cheapest price.

“Dr. Berwick personal view is the "public welfare" should have the power to trump the mere "choices of private consumers."

Dr. Berwick is also a believer in the value of the defective Dartmouth Atlas conclusions.

“Dr. Donald Berwick, nominated by President Obama to run Medicare, called it the most important research of its kind in the last quarter-century.”

Dr. Donald Berwick deserves a proper vetting because of the power he will wield. President Obama has pulled another t
rick play on the American public. He should not be permitted to get away with it.

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

Stanley Feld M.D.,FACP,MACE

Government spending for Medicare in its present form is unsustainable. Medicare premiums for many seniors are not cheap. Medicare premiums are determined by means testing. The determination includes all income sources such as capital gains, interest income, annuities and pension distributions. Some seniors are paying more than $15,000 a year in after tax dollars for full Medicare coverage. .

President Obama’s goal is universal affordable insurance coverage with increased quality of medical care.

His philosophy is to have the federal government have complete control of the healthcare system.

The weakest stakeholders in the healthcare system are patients and physicians. President Obama cannot control the healthcare insurance industry. He is dependent on the healthcare insurance industry for administrative services. The healthcare insurance industry, plaintiff attorneys and Big Pharma control too much lobby money.

A system of government control of physicians and patients is destined to fail because President Obama is restricting freedom of choice. He is not fixing the problems that caused the dysfunction in the healthcare system. The Massachusetts healthcare reform system has been the perfect example of uncontrolled costs and failure to provide universal coverage and higher quality of care.

One mechanism President Obama is using to achieve his goals in the framework of his philosophy is the proof provided by “medical claims data”.

Medical claims data is worthless in my view. The conclusions from medical claims data have been used against physicians even though it does not provide an accurate view of the quality of medical care. The data does not include risk assessment of patients’ illness or the effect of the physician patient relationship and disease.

Medical claims data does not measure the role of patients’ responsibility for their medical care.

Medical claims data does accurately evaluate the value a physicians’ quality of care.

Healthcare experts concede that even though medical claims data does not provide an accurate picture of the truth it is the best data we have. These experts should try to develop a system that measures the truth before defective policy destined to fail is developed.

I have never understood this logic. It is used as evidence in social science, political science and clinical science. It is extremely easy to reach false conclusions and make the wrong decisions.

Even though the conclusions drawn from medical claims data are mostly inaccurate they are accepted by President Obama and his healthcare team to formulate healthcare policy. Why? The conclusions of the data verify his philosophy.

“In selling the health care overhaul to Congress, the Obama administration cited a once obscure research group Dartmouth Atlas of Health Care at Dartmouth College to claim that it could not only cut billions in wasteful health care spending but make people healthier by doing so.”

Peter Orszag, the president’s budget director has used the Dartmouth Group data to proclaim that perhaps $700 billion a year of wasteful spending — “does nothing to improve patient health but subjects you and me to tests and procedures that aren’t necessary and are potentially harmful,”

“Mr. Orszag even displayed maps produced by Dartmouth researchers that appeared to show where the waste in the system could be found. Beige meant hospitals and regions that offered good, efficient care; chocolate meant bad and inefficient”.

It is difficult to understand what makes Peter Orszag a medical care expert. The Dartmouth medical claims data is quoted without considering that maybe the $700 billion dollars a year is spent on defensive medicine that President Obama refuses to consider.

The Dartmouth Atlas of Health Care has been widely interpreted as showing the country’s best and worst care. How this conclusion is reached is confusing to me. The Dartmouth researchers themselves acknowledged their medical claims data measure the varying costs of care in the government’s Medicare program and does not include the entire healthcare system. The Dartmouth group has also proclaimed that the data does not measure the quality of care.

Quality medical care has not be defined adequately to date.

“For all anyone knows, patients could be dying in far greater numbers in hospitals in the lower cost regions than hospitals in the higher cost regions, and Dartmouth’s maps would not pick up that difference. As any shopper knows, cheaper does not always mean better.”

Yet President Obama is leaning heavily on the Dartmouth group’s “data to fulfill his goals in the framework of his philosophy.

“President Obama said it would ask the Institute of Medicine, a nongovernment advisory group, to consider ways of putting the Dartmouth findings into action by setting payment rates that would punish inefficient hospitals and reward efficient ones”.

What are other potential defects are in The Dartmouth Atlas of Healthcare data?

1. The principal argument behind Dartmouth’s research is that doctors in the Upper Midwest offer consistently better and cheaper care than their counterparts in the South and in big cities, and if Southern and urban doctors would be less greedy and act more like ones in Minnesota, the country would be both healthier and wealthier.
2. But the real difference in costs between, say, Houston and Bismarck, N.D., may result less from how doctors work than from how patients live. Houstonians may simply be sicker and poorer than their Bismarck counterparts. Also, nurses in Houston tend to be paid more than those in North Dakota because the cost of living is higher in Houston. Neither patients’ health nor differences in prices are fully considered by the Dartmouth Atlas.
3. The Dartmouth Group hospital rankings do not take into account care that prolongs or improves lives. “If one hospital spends a lot on five patients and manages to keep four of them alive, while another spends less on each but all five die, the hospital that saved p
   atients could rank lower because Dartmouth compares only costs before death.”
4. David Cutler, a professor of economics at Harvard, likens it to failing to account for inflation when looking at gross domestic product. “Nobody in their right mind would talk about G.D.P. growth without adjusting for prices,” he said.
5. One example of extrapolation of the data was when Dr. Fisher, in testimony before Congress last year, summarized his and others’ work by asking, “Why are access and quality worse in high-spending regions?”

Many studies have shown no link, either way, between spending and quality. Quality is not being measured by the Dartmouth group by its own admission.

1. “There is little evidence to support the widely held view, shaped by the Dartmouth researchers, that the nation’s best hospitals tend to be among the least expensive.”

“In interviews, Dr. Fisher and Mr. Skinner acknowledged that there was no proven link between greater spending and worse health outcomes.

“ And Dr. Fisher acknowledged the apparent inconsistency between his statements in interviews with The New York Times and those made elsewhere, saying that he was sometimes less careful in discussing his team’s research than he should be.”

“In any case, the more-is-worse message has resonated with insurers, whose foundations now help to finance the Dartmouth Atlas.”

The take away point is patients, physicians and hospitals will suffer from the advertised implications of the Dartmouth Atlas’ data. President Obama is using this data to achieve his philosophical goal. The goal is total government control of the healthcare system.

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

Stanley Feld M.D.,FACP,MACE

More and more physicians are beginning to realize the effect President Obama’s healthcare reform law is going to have on their practices and on their physician patient relationships. They do not like it.

Recently, Daniel Palestrant, MD Founder & CEO of Sermo, Inc. wrote an excellent summary of what is causing physicians to be galvanized in their opposition to the healthcare reform law.

Sermo has 115,000 practicing physicians in its online community. Sermo is revolutionizing the way physicians communicate across the United States. It’s where practicing US physicians—spanning 68 specialties and all 50 states—communicate on difficult cases and exchange observations and views about drugs, devices and clinical cases, clinical issues and healthcare reform.

Sermo has been named to Fast Company Magazine’s list of the world’s most innovative companies. Sermo, through its surveys’ on healthcare reform, is rapidly replacing the AMA as the voice of the practicing physicians.

Dr. Palestrant put together a list of the most important issues that seem to be causing practicing physicians to speak out:

1. Turns Out Legislators Want Physicians To Be Employees After All

“Very quietly, the State of Massachusetts has started the process of linking a physician’s eligibility for medical license to their participation in the state’s public access program.”

This critical development is necessary for President Obama’s healthcare reform. It eliminates physicians’ freedom. President Obama’s healthcare law is similar to the Massachusetts healthcare reform. Massachusetts healthcare reform did not attack the root causes of healthcare inflation.

This step is necessary to force physicians to participate in government programs against their will.

Physician Comment

“If any plan is tied to licensure just keep practicing without a license.

They can’t throw everyone in jail unless they make room by putting the druggies on the street.

The public would be on our side in a minute……IF we continue to practice. If we close our doors because we fear government reprisal, we lose the patients because they’ll never get the real message, and we lose to the government.

Hang together or we’ll surely hang separately, someone once said?”

Physician Comment

“Strike, for the love of Gad and the sake of all physicians in the country! The Massahatchet Massacre should not be allowed to succeed.”

Physician Comment

“I am not optimistic about my future here in Massachusetts. I am really considering my options for an exit out of this state. Main concern is where to go……is the grass greener and what practice model to involve myself with?”

Physician Comment

“If you can stand the heat, pack your guns and try Texas. Land of the free and home of the brave!

There’s no future for Docs in Massa-useless!”

“For the country it is the perhaps the clearest evidence yet what could be the unintended consequences of this reform effort and an alarming move towards socialism.”

2. Physicians WERE Right About the cost of Tort Reform

The timing around the recent Congressional Budget Office "revelation" that tort reform would in fact lead to "at least" $50 Billion in cost savings over 10 years, rather than originally estimated $5 Billion.

The CBO is still way off. I suggest President Obama and the CBO read the Massachusetts Medical Society survey on defensive medicine and malpractice reform. My calculated cost is closer to $700 billion per year. A popular number quoted by some is $300 billion per year.

Defensive medicine is the cause of excessive testing. Only tort reform will solve the problem.

“ Sermo physicians had listed tort-malpractice reform as a number one priority back in May, when the Physician’s Appeal was launched.”

President Obama should listen to his medical care providers (Physicians). 

3.Recognition that the AMA’s Support was "Purchased"

Physicians have finally realized that the AMA’s support of President Obama’s healthcare reform effort was less about physician advocacy and more about the AMA protecting its own financial interests. We all recognize the deals President Obama makes to “convince” organizations to support his efforts. 

“ The fact that the AMA receives the bulk of their $300MM in revenue, not from its physician members, but from insurance companies and hospitals, through a "special" arrangement with the government to provide CPT billing codes seems to be further eroding the claim that physicians in fact support the current reform efforts, not to mention the AMA’s legitimacy.”

Physician Comment

“I think things will continue to get worse until we take a stand. The problem is that currently so many physicians are in the dark and have no idea what is coming. I do not think they will be ready to take a stand until it is too late.”

Physician Comment

“Life seems hard now. I am resentful and feel contempt for the political processes that are occurring now. I feel trapped. Sermo has been good. Feedback has great. But still our profession has no powerful organization that stand for us and that is what we need.”

2. Market Forces Will Be Felt By Patients

Physicians are starting to take the necessary steps to maintain their own financial viability and autonomy. Patient access to healthcare resources will decrease as a result of these steps.

Most physicians have tried to serve their patients well. The healthcare system is dysfunctional. Both patients and physicians have been abused. When a person is sick they want the best care. The dysfunction and new government regulation will destroy medical care rather than improve medical care in America.

Physician Comment

“The majority of our brethren are clueless. They are being let like calves to slaughter.”

Physician Comment

“I can’t wait until the 40 million uninsured start showing up in the ER (Emergency Room) after ins
urance reform, when they can’t get in to see their PCP(Primary Care Physician). It’s going to get ugly.”

Ultimately, this strain will re-unite patients and physicians and start to squeeze out the countless interlocutors who created much of the inefficiencies in our healthcare system.  That being said, it will be a tough couple of years for patients, especially senior citizens and those with lower income, as their access to physicians is increasingly jeopardized.

Dr. Palestrant doesn’t think physicians are going to remain victims much longer. The comments on Sermo confirm his observation. Physicians are getting angry and depressed.

“Where organizations and associations have largely failed physicians, the doctor’s drive to stay in business so they can continue to treat their patients will force them to make some hard decision, and gradually allow market forces to accomplish what advocacy never could.”

Physicians want a reasonable income, a good patient physician relationship and freedom to practice without bureaucratic restraints. They also want continuing medical education to improve their practices. They do not want government surveillance.

Physician Comment

Right now I am just devastated by the changes.

The end of consult codes is very devastating for endocrinologists. If I was done paying off my student loans, I would not feel as bad.

That’s my only debt! I have lived so frugally in order to save and invest and be debt free and because I want a great education for my child.

So all of the sacrifices that I have made mean nothing now. I delayed fertility for my profession. Thank God I have a beautiful 2 year old son, but he will be an only son because I recently lost a baby after 3 weeks in the NICU (he was born premature at 28 weeks b/c/o placenta abruption).

I keep thinking that if I had chosen another profession and had children before the age of 35 that may not have been the case.

For my sacrifice, I feel like the envy of the ignorant public fueling the greediness and power hunger of politicians. Politicians are out to destroy our profession, our prestige, our hard work.

As you can see, I am in a very negative state of mind. I’m glad to have read something that has a positive outlook.

The medical profession needs hope. President Barack Obama is not representing that hope.

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

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