Stanley Feld M.D.,FACP,MACE

Several readers commented they were thankful that the healthcare bill passed in the Senate on Christmas eve.

I was curious to know their reason for being thankful when the bill is so flawed. Universally, their reply was “we need healthcare reform and this bill represents a good first step.”

I asked each commenter if the bill makes the healthcare system worse than it is now does that represent a good first step?

Their reply was if we do not take this step now there will be nothing done about healthcare reform again for another 40 years. I believe this is untrue. This is the view of the administrations propaganda machine to get a bill passed. .

The propaganda is flawed for several reasons:

1. The step taken 40 years ago was to enact Medicare. However Medicare has evolved into an unsustainable federal entitlement. Changes in Medicare over the last 40 years have resulted in an unaffordable but necessary program for seniors also.

2. The continuous band-aid fixes to the structurally flawed entitlement program has not solved the economically unsustainable problem.

3. Expanding enrollment in both Medicare and Medicaid is going to make both programs more economically unsustainable.

4. Medicaid is a failed program. Expanding Medicaid for a renewed definition of poverty is not going to fix Medicaid’s failure. Medicaid reimbursement is so low that it is difficult to get providers to service Medicaid patients.

It takes creative physicians practices’ to generate more revenue than expenses seeing Medicaid patients. These practices have initiated cries of fraud by many government officials and healthcare policy wonks.

It might be fraud in some cases but the fraud was initiated by the reimbursement structure.

Medicaid physicians are reacting by asking the question “why bother seeing these patients?”

This attitude has produced a physician shortage for Medicaid patient services.

Why would Senators and congressmen believe suddenly expanding Medicaid eligibility will alleviate this physician shortage?

The Urgent Care Clinics staffed by nurse practitioners and physician assistants and owned by private corporations are cash for profit businesses.

Medicaid does not reimburse for 30 to 60 days. Its reimbursement is less than the Urgent Care Clinics’ and physicians’ offices cost of doing business. Medicaid patients cannot afford to pay cash. The Urgent Care Clinics and physicians offices cannot afford to see these patients.

States are responsible for part of the Medicaid coverage. Most States are on the verge of bankruptcy. President Obama’s Healthcare Reform Bill will not provide increased funding for the increased Medicaid spending. Senator Ben Nelson of Nebraska held his vote out until Harry Reid gave Nebraska 100% Medicaid supplement.

“Many other members of Congress are eager to follow the Nelson example, including one from South Carolina: Representative James Clyburn, a Democrat. Mr. Clyburn told The A.P. that he wanted to get more money for his state when the Senate and House begin negotiating a final health care bill.

Mr. Clyburn said he hoped to increase the federal portion of Medicaid payments to his state to 95 percent. That would be up from the 90 percent that most states get — most except Nebraska, which will now get 100 percent of its Medicaid expansion picked up by the federal government, in perpetuity, thanks to Senator Nelson.”

President Obama pledged he will not tolerate earmarks (pork barreling) to gain legislative approval.

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Harry Reid also gave Massachusetts a supplement for Medicaid. The rest of the States are screaming how about me. Arnold Schwartzenegger has been most vocal for California.

Governors across the country have voiced concerns about the national efforts to expand eligibility for health coverage through Medicaid, a federal-state partnership that covers the expense of health care for the poor and disabled.

The net result will be an increased in federal deficit spending.

What is wrong with each version of the bill? Neither bill solves the basic problems within the healthcare system.

“The fundamental problem with the 2,074-page Senate health-care bill (as with its 2,014-page House counterpart) is that it wildly compounds the complexity by adding hundreds of new provisions, regulations, mandates, committees and other arbitrary bureaucratic inventions. “

Overlooked is the fact is that all these bureaucratic interventions, provisions, regulations, mandates, committees are going to increase expenses. All President Obama has to do is ask any practicing physician. This is going to make President Obama’s healthcare reform bill more unsustainable and increase the federal deficit without an increase patient care.

“Worse, all of this bureaucracy is packed into a monstrous package without any regard to each other. The only thing linking these changes — such as the 118 new boards, commissions and programs — is political expediency. Each must be able to garner just enough votes to pass. There is not even a pretense of a unifying vision or conceptual harmony”

It is obvious that the bill is irredeemable. Howard Dean said Kill the Bill.

"This is essentially the collapse of health care reform in the United States Senate," Dean told Vermont Public Radio. "Honestly the best thing to do right now is kill the Senate bill, go back to the House, start the reconciliation process, where you only need 51 votes and it would be a much simpler bill."

Democrats should make a serious deal with the Republicans. The deal should be made to fix the structural defects in the healthcare system and focus on helping the people who elected them. Otherwise members of both parties should lose their job.

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

Stanley Feld M.D.,FACP,MACE

It is easy to introduce bias into poll results and surveys. Most people are cynical about polling results

However, when every one of the major polling services’ come up with the same answer, one must believe the results represent unified public opinion. The Democrats in the House of Representative, the Democrats in the Senate and President Obama are ignoring the fact that the American public is against President Obama’s healthcare reform plan.

There is no question that America needs healthcare reform. It does not need President Obama’s version of healthcare reform as I have discussed in the past. Most importantly President Obama’s healthcare reform system will not work. It ignores the basic problems and defects in the present healthcare system.

President Obama continues to say his healthcare reform bill will provide universal coverage, affordable coverage and increasing quality of care. None of those results will be achieved with his healthcare reform plan. The American people know this and are afraid of the increased taxes and the restrictions on our freedom.

The composite polling data express the sentiment of the American public. The progression of these polling data can be seen by clicking See All Obama and Democrats’ Health Care Plan Polling Data

Polling Data

The Democratic controlled Senate version of the bill also contains some sinister amendments. Many organizations are lining up to challenge the constitutionality of the bill.

Buried in Harry Reid’s massive amendment to the Senate version of Obamacare is Reid’s is Section 3403 designed to prevent any future Congress from repealing a central feature of this monstrous legislation.

“Section 3403 reads in part: "… it shall not be in order in the Senate or the House of Representatives to consider any bill, resolution, amendment or conference report that would repeal or otherwise change this subsection."

Do you think all the Democratic Senators understand the implications of this maneuver? If section 3403 remains in the bill and President Obama signs this measure into law, Harry Reid intends that no future Senate or House will be able to change a single word of Section 3403, regardless whether future Americans or their representatives in Congress want to change it.

The subsection at issue is the regulatory power of the non elected Medicare Advisory Board to "reduce the per capita rate of growth in Medicare spending." It is an open ended grant to a regulatory agency granting power to control costs, quality and quantity of healthcare coverage.

“And Reid wants the decisions of this group of unelected federal bureaucrats to be untouchable for all time”.

Harry Reid makes compounds the problems of Section 3403 by ignoring two centuries of Senate rules. He passed the measure in the dead of night in less than 48 hours. I suspect few Democratic Senators who voted for this bill have read and understood the implication of Section 3403.

“The final Orwellian touch in this subversion of democratic procedure is found in the ruling of the Reid-controlled Senate parliamentarian that the anti-repeal provision is not a change in Senate rules, but rather of Senate "procedures." Why is that significant?

Becau
se for 200 years, changes in the Senate’s standing rules have required approval by two-thirds of those voting, or 67 votes rather than the 60 Reid’s amendment received.”

Few Democratic Senators have listened to the wishes of the American people. President Obama refuses to listen to the wishes of the American people.

How many points made about the healthcare reform bill by President Obama correct?

Should Americans be angry? Yes. What can we do? Throw the bums out when you go to the polls next November.

After the New Year I will resume twice a week entries. I wish all a happy and healthy New Year.

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

Stanley Feld M.D.,FACP,MACE

Dr. Val Jones publishes Get Better Health a smart health an excellent healthcare website. http://getbetterhealth.com/

It is composed of a selection of many of her chosen healthcare bloggers. Val publishes blog entries of many contributors in her network daily. Val published my December 19^th entry. It generated the following comment.

“Comment:
I am surprised that a diabetes doctor let his politics permeate his opinion of the AHRQ? We know that over 50% of the time patients don’t receive the standard of care and I would be interested to know what the numbers are like in his practice?
If he had given any research or documentation to his claims (the CBO for example predicts 130 billion dollar drop in the deficit) so he lost all credibility in his first few sentences. Does his practice have better outcomes than the standard of care? Is he worried that he will lose income for practicing medicine that makes huge profits but doesn’t increase lifespan or other measurable outcomes?
This blog seems to be a little bit behind the times. Quality matters and is here to stay. Guys you not only lost the election but large employers and other purchasers know that what we have been paying for doesn’t work.”

The commenter would do well to follow my blog at http://stanleyfeldmdmace.typepad.com/. He might learn something about what is necessary and effective to repair a broken healthcare system.

 President Obama’s healthcare reform plan will not achieve his goals.  “The legislation has no master plan for dealing with the problem of soaring medical costs. And this is a source of deep unease.” It also does not have a master plan to deal with the dysfunction in the healthcare system

It is unnecessary for the commenter to take pot shots with sound bites on issues whose details are ignored.

I refer the commenter to my summary blog category section

My guess is the commenter is a salaried surgeon in a comfortable subspecialty that fixes things that are broken and does not practice preventive medicine.

It is not necessary, in a surgeon’s world, to understand that medicine needs to develop systems of care that put patients in charge of the care of their disease in order to prevent disease complications. Doing that will generate great savings because 90% of the healthcare dollars are spend on the complications of chronic diseases.

Patients need to be taught how to be responsible for their own care.

I am an Independent voter. I am apolitical and have never been affiliated with either Party. I voted for President Obama. I thought it was going to be a good thing when he promised to fundamentally reform America’s way of doing things following the wishes of powerful vested interest as opposed to the vested interests of the people. He has been a catastrophe.

I am a retired Clinical Endocrinologist. I have no economic vested interest in the financial aspects of the practice of medicine. I do have a vested interest in keeping medical practice a highly regarded profession and maintaining the patient physician relationship.

I oppose medical care becoming a commodity.

The secondary stakeholders (the healthcare insurance industry, big pharma, and the hospital systems and big government) have taken over healthcare. They have made medical care a commodity.

President Obama has played right into the hands of these vested interests in order to increase the scope of government. The devil is always in the details.

The details of his healthcare reform bill will tax all income groups, increase the budget deficit, decrease access to care and increase out of pocket expenses. It has been done in a non transparent way ignoring the wishes of the majority of Americans.

The healthcare reform bill does not consider to malpractice reform. Defensive medicine and unjustified law suits are wasteful and costly.

I suggest the commenter read critically some of the guidelines the USPHTF has written with an emphasis on Breast Cancer, Coronary Artery Disease and Osteoporosis.

He should study some of the defects in the clinical research studies the Task Force has chosen.

Our medical care system needs flexible standards of care that are disseminated to the medical community in an educational fashion and not in a punitive and disruptive way. Evidence medicine is ever changing and these changes need to be integrated in a physicians work flow in an education way. The Breast Cancer guidelines have been implemented already by California

No one has defined quality care effectively to this point or developed systems to measure the financial impact of care. In diabetes for example, the definition of quality medical care should not be defined as the measuring HbA1c’s four times a year. It is measuring clinical outcomes against financial outcomes and comparing its value. It should be defined by patient compliance with treatment. Claims data analysis is meaningless.

President Obama’s healthcare plan makes medical care worse for patients and physicians, not better. His plan is going to produce unintended medical and financial consequences that will render effective care more difficult for physicians to give and patients to get. There is plenty of evidence that it will make care more expensive, raise taxes, and increase the deficit.

None of the secondary stakeholders will be hurt as badly as patients and physicians. Reading my blog and following the links will give the commenter an in depth understanding of my reasoning.

I had hoped President Obama would provide a transparent administration as promised and not an administration for vested interests and lobbying groups. Unfortunately, this has not happened. This point is demonstrated by many examples including Tom Daschle’s access to the White House and private Democratic congressional meetings.

President Obama’s healthcare reform is about increasing government control over the healthcare system and commoditizing medical care. It will fail. The government has been unsuccessful at this as demonstrated by Medicare’s mounting deficits.

Secret Democratic caucus sessions and 2000 page bills that have to be evaluated in less than 72 hours are not my idea of transparency. My vote for President Obama was a big mistake.

If the commenter studied the various scorings by the CBO, I am sure he would not use the invective against me and challenge my credibility.

The CBO changed its scoring from a one trillion dollar deficit increase in ten years to a 130 billion dollar reduction in deficit overnight. These estimated are based on the changing assumptions provided by either Harry Reed or Nancy Pelosi. The last estimate was based on increasing taxes from 2010-2014 and not providing benefits until 2014. Ninety eight percent of the benefits will kick in after 2014. The CBO states its scoring can be in error because the assumptions provided could be wrong.

The $130 billion dollar decrease in the deficit is another trick play. It seems everyone within the Beltway understands this trick play.

Entitlement programs always cost more than estimated.

Primary care physicians’ and all cognitive subspecialists’ intellectual property is undervalued and underpaid. Cognitive intellectual property provides the most valuable element of medical care. It is embedded in the patient physician relationship.

The details in President Obama’s healthcare reform plan will undervalue cognitive services even further through punitive mechanisms. It could increase its value through educational mechanisms.

The healthcare insurance industry will not take a big hit because antitrust exemption and Medical Loss Ratio are not dealt with effectively.

I believe it is much wiser to aim and carefully learn the real details before firing.

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

Stanley Feld M.D., FACP,MACE

If President Obama’s healthcare bill is passed there is certain to be an increase in taxes, an increase in the budget deficit and a rationing of healthcare.

The President promised an increase in funding for preventative medicine. The term preventative medicine should mean discovering a disease process before it manifests itself through its complications. After discovering the disease it should be treated in the best possible way available.

The federal government is going to spent billions of dollars expanding a bureaucracy to further evaluate best practices.. The Agency for Healthcare Research and Quality was created to standardize the practice of medicine. The organization encouraged medical specialty organizations to write guidelines for the care of diseases in their specialty. A National Clearing House was created that published these guidelines. These guidelines are to be updated every five years.

I was suspicious of the intent of the AHRQ. Medical knowledge changes at about 10% per year. I believe that physicians in a specialty area have an obligation to physicians in all specialties to help them keep current. Guidelines are usually devoid of clinical judgment.

I was afraid the AHRQ would use guidelines as a weapon to punish physicians who were not current.

I was chair of the AACE guidelines for the treatment of Type 2 Diabetes Mellitus. I was also the co chair for AACE’s guidelines for hyper and hypothyroidism, thyroid nodules and thyroid cancer.

My goal was to help primary care physicians understand the Clinical Endocrinologists’ interpretation of the state of the art diagnosis and treatment of endocrine diseases. AACE had no ulterior motive. I hoped the AHRQ had no ulterior motives.

The U.S. Preventive Services Task Force is a branch of the Agency for Healthcare Research and Quality. USPTF started writing its own guidelines for diagnosis and treatment of many diseases. The USPTF does not seek input from subspecialty groups. The panel selects major articles on diseases from the literature and grades these articles. From the grading of the selected articles it develops guidelines on the use of procedures and treatments.

There are several problems with this method of developing guidelines. There is a danger that the best articles are not selected by non experts in that disease. There is also a danger that the natural history of the disease is overlooked. The natural history of many diseases is not considered in many “major” articles.

A vivid example of this is in the Women’s Health Initiative.

The most important defect in the USHPTF guidelines is it disregards the most important element of medical care, namely physicians’ clinical judgment.

The USPFS guidelines disregard clinical judgment and the patient physician relationship. In fact they destroy these critical elements in the therapeutic relationship between physician and patient.

USPHTF guidelines have rationed access to care for several years. President Obama is extending the USPHTF’s scope in rationing healthcare.

“Think Congress is regretting having allocated over a billion dollars to let the government generate studies to tell us what medical tests and procedures should be covered under Obamacare?”

I am most familiar with the US Preventive Services Task Force’s guidelines for the diagnosis and treatment of osteoporosis. I did not recognize one expert in the task force’s panel to evaluate the evidence for the diagnosis and treatment of osteoporosis.

The panel might be experts in evaluating the statistical power of the clinical studies chosen. However if clinical studies were not done to evaluate diagnosis and treatment of males with osteoporosis the USPHF conclusion would be there is no evidence for this diagnosis and treatment. The government would not approve bone density studies for elderly men even though there is an abundance of clinical evidence that hip fractures are as common in men as they are in women.

Most large clinical studies are funded by the pharmaceutical industry. Most of the osteoporosis studies have been done on women. Therefore there are no large studies in males. There it is easy to arrive at the conclusion that there is no evidence for diagnosing and treating males. The government will not pay for the evaluation and treatment of males for osteoporosis.

Experts in osteoporosis who understand the natural history of osteoporosis would disagree. The panel of U.S. Preventative Task Force did not ask osteoporosis experts for an opinion about the guidelines and disregarded the guidelines written by experts in the area.

Similar defects occurred with the USPTF’s recommendations for breast cancer. The breast cancer recommendations reviewed only 10 studies. The reviewers admit their conclusions cannot be generalized to individual forms of breast cancer and different groups of patients.

“No sooner had the Health and Human Services Department’s U.S. Preventative Services Task Force recommended against mammography for women under 50 than Secretary Kathleen Sebelius rushed to say don’t worry. The decision had "caused a great deal of confusion and worry among women," she said, promising that no policies would change.”

Secretary Kathleen Sebelius said no policy would change today. It will change in the near future. The bankrupt State of California already has changed its policy.

“Although women ages 50 and older will still be eligible, women ages 40-49 will no longer be screened.”

I will have more to say about the USPHTF and its Breast Screening Guidelines in the future.

In the meantime watch what they do. Don’t listen to what they say.

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