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Stakeholder Mistrust

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President Obama; If You Really Want To Reduce Healthcare Costs, Effectively Reform The Medical Malpractice Tort System ?: Part 1

April 7, 2009
inDisinformation and the healthcare system, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

President Obama, you have not discussed the need for medical malpractice reform. Without medical malpractice reform you will not be able to reduce the cost of healthcare and increase the quality of medical care. It will be difficult because malpractice reform goes against the vested interest of some of your major supporters, plaintiffs’ malpractice attorneys.

There is at least one trillion dollars of waste in our $2.3 trillion dollar healthcare system. One hundred fifty million dollars ($150 million dollars) is wasted on excessive administrative costs by the healthcare insurance industry. The remainder is generated by the practice of defensive medicine and cost of malpractice insurance.

“Much of this waste is generated or justified by the fear of legal consequences that infects almost every health care encounter. The legal system terrorizes doctors. Fear of possible claims leads medical professionals to squander billions in unnecessary tests and procedures.

Physicians and nurses are afraid to speak candidly to patients about errors. They try to explain the risk reward ratio of treatments for fear of assuming legal liability. The result is the practice of defensive medicine and over testing to cover every possible contingency. This legal anxiety is also corrosive to the therapeutic magic of the physician patient relationship.

It would be relatively easy to create new rules that would provide a reliable system of justice for patients harmed by medical treatments and procedures without encouraging costly litigation. If a new system was in place it would decrease the costs of defensive medicine significantly. It would encourage physicians use of clinical judgment rather than expensive tests and improve the physician patient relationship.

“ The good news is that it would be relatively easy to create a new system of reliable justice, one that could support broader reforms to contain costs.”

Everyone makes mistakes in every walk of life. The legal liability threat could generate further unnecessary errors. Physicians, nurses and hospitals are advised not to offer explanations about a mistake. Sometimes errors are concealed to avoid a legal ordeal. The hidden error could be compounded by additional mistakes.

“Even in ordinary daily encounters, an invisible wall separates doctors from their patients. As one pediatrician told me, “You wouldn’t want to say something off the cuff that might be used against you.”

There are cost multipliers created as mistrust accelerates between the patients and physicians. You would like physicians to adopt electronic medical records. Some physicians avoid using EMRs because the information could be misinterpreted and used against them. There is an increasing use of second opinions. Every examination requires an observer for the examination to avoid legal liability. Every problem requires multiple laboratory tests to rule out something that might have been missed. An example is a CAT in the Emergency Room for even the slightest head trauma.

“Medical cases are now decided jury by jury, without consistent application of medical standards. According to a 2006 study in the New England Journal of Medicine, around 25 percent of cases where there was no identifiable error resulted in malpractice payments.

“Nor is the system effective for injured patients — according to the same study, 54 cents of every dollar paid in malpractice cases goes to administrative expenses like lawyers, experts and courts.”

These are the major tort reform issues. They must be addressed to decrease wasteful expenditures in the healthcare system. Malpractice lawsuits are a growth industry for defense attorneys, a burden to physicians having to defend themselves and a significant cost to the healthcare system. Malpractice reform is essential to any meaningful healthcare reform. President Obama, I think you know it. The question again is will to take the correct route to reform the malpractice tort system.

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

  • Ted Howard • April 7, 2009

    My girlfriend is a first year ER resident. She recently did her cardiology rotation. She admitted the same homeless crack addict three times in one week because his chest hurt and his triponin was elevated. Those are symptoms of his crack smoking, not an MI. They had to admit three times before they could start telling the ER that they refused to admit him. The hospital was his hotel. He paid his bills with unspoken threats of malpractice claims, threats he didn’t even know he was making.
    Seen this? http://seattletimes.nwsource.com/html/jerrylarge/2008969201_jdl02.html

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Consumers’ Must Control Their Healthcare Dollars

March 15, 2009
inMedicaid, Medicare, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

I. Consumer Control of their healthcare dollars:

     A. How would a medical savings account work to reduce cost, while encouraging physicians, hospitals and the healthcare insurance industry to become more competitive and efficient?

1. By creating a system in which consumer’s demands drive competition and efficiency because they are spending their own money.

2. The government’s role should to support assets designed to teach consumers to drive the healthcare system’s efficiency so that consumers could save their own money for retirement.

     B. The cost of healthcare insurance for a family of four is presently over $12,000 per year. Who should be the payers for healthcare?

1. Both consumers and employers should be able to pay for healthcare insurance with pre tax dollars.

2. Medicare and Medicaid should be abolished. Both Medicare and Medicaid are unsustainable entitlement programs that must be restructured to create a sustainable system. They should replaced by The Ideal Medical Savings Account. Medicare recipients should pay a means tested premium directly from their monthly Social Security check. It should be paid with pre-tax dollars.

3. The government should subsidize the uninsured using economic means testing methodology similar to the economic means testing used to determine Medicare premiums. The premium should be paid monthly rather than yearly. The more you earn the more you pay.

4. Consumers who were Medicaid would not pay a premium. They would be totally subsidized by the government as they are presently. They would get the identical healthcare insurance that other consumers have.

The physicians’ and hospital systems’ fees have already been negotiated or imposed by the healthcare insurance industry or government. There are many reimbursement overpayments and underpayments in the system that can be corrected. There are many prices for healthcare services. There are retail and multiple discounted prices.

Presently, uninsured consumers are charged retail price for healthcare services. Under appropriate rules with real price transparency, consumers can negotiate an affordable price acceptable to all. If a consumer elects to overpay it reduces the money in the consumer’s Medical Savings Account. The government’s role should be to support a variety of assets to provide consumers with education. The government should enforce appropriate rules and regulations to protect consumers. The Ideal Medical Savings Account will create incentives for consumers to save their money and maintain their health.

II. Healthcare System Errors

        A. The healthcare system does not provide payment for prevention care.

        B. There are no good criteria defining preventive care.

        C. There is no payment for systems of medical care that will prevent the complications of chronic diseases.

        D. There are duplications of testing and costs in the system due to perverse incentives and lack of appropriate information technology.

        E. There is overpayment for some procedures and tests and underpayment for others.

This can be fixed by a system of both government and consumer education. Government must educate consumers to be wise purchasers of medical care. It can be done with effective websites. .

III. Mechanics Of The Ideal Medical Savings Account:

      A. Goal: Provide consumers with incentives to become wise purchasers of medical care and maintain good health.

1. Employers are willing to pay $12,000 per year for healthcare premiums. Presently it costs $15,000

2. $6,000 of the $12,000 should be put into a medical saving trust account. The second $6,000 is for first dollar insurance coverage beyond the initial $6,000.

3. At the end of each year the unused portion should be transferred to a retirement account.

4. All consumers would be motivated to have healthcare insurance. They benefit from money saved, if they remained healthy.

5. Government subsidies should be available to self employed and uninsured consumers who could not afford healthcare insurance. Universal coverage would be instantaneous. Consumers would maintain free choice. Each consumer would be his own deterrent to abuse of his health and overuse of the healthcare system

6. It is to society’s benefit to maintain a healthy and fit population.

7. Consumers with a chronic disease should be motivated to learn to avoid acute or chronic complications of the disease.

        a. For example: A diabetic could be motivated to learned how to avoid acute complications eliminating costly emergency room           visit. Continuous control of blood sugars would reduce complications by at least 50%.

         b. Diabetics need maintenance with follow up care. If they maintain perfect control he would spend part of the $6,000.

         c. If they spent $4,000 but avoided hospitalization or a complication of his disease his employer or the government could afford to give him a   $2,000 bonus. Their total retirement account deposit at the end of the year would be $4,000 rather than $2,000. They would have avoided hospitalizations and ER visits . Diabetics would be on the way to avoiding the costly complications of their chronic disease.

         d. They would enjoy good health and increase their retirement account. The government or their employers would save money decreasing   their premium costs.

Simply providing healthcare insurance (private insurance or public insurance) will not solve the problem of the ever increasing cost of care.

Motivating and teaching consumers to take care of their health short term and long term will decrease healthcare costs.

8. Ideal Medical Savings Accounts would make actuarial sense to the healthcare insurance industry if it could get past its desire to control the first healthcare dollars. It would be able to reduce premiums because fewer people would get sick.

If the Ideal Medical Saving Account would come to pass America would have a positive impact on our epidemic of obesity, environmental pollution and lung disease.

America let us force our politicians to finally do something that makes sense.

 

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

  • Medical Billing Software • March 29, 2009

    Consumer must care about its present health rather than the money for retirement. Government should give some rebate on the medical billing.

  • Sara Hoffman • April 21, 2009

    Where did you get your information, “The cost of healthcare insurance for a family of four is presently over $12,000 per year. Who should be the payers for healthcare?

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Consumer Driven Healthcare Plans Trickle

March 11, 2009
inMedicaid, Medicare, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust, Universal Healthcare
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Stanley Feld M.D.,FACP,MACE

 

As the healthcare debate heats up the meaning of consumer driven healthcare (CDHC) needs repeating. The true meaning of CDHC has been bastardized by the healthcare insurance industry as represented by Health Savings Accounts (HSA).

The healthcare insurance industry feared that if Medical Savings Accounts dominated it would lose control of the initial healthcare premium dollars. The result would be a decrease in profit and an increase in price competition and real price transparency.

The reality would be America would have universal healthcare in a more efficient healthcare system. The system would be more efficient because it would be driven by the consumer for their benefit and not a third party payer. A more efficient system will maintain healthcare insurance industry’s profit while permitting a decrease in healthcare system costs.

“A lack of consumer understanding has contributed to the glacial growth of consumer-driven plans. Can better information from health plans help CDHPs take hold?”

HSAs place limits on consumers’ incentives. All of the healthcare premium dollars are eventually paid to the healthcare insurance industry.

Our economic recession along with increasing unemployment have set the stage for consumers to accept any help government will provide. Enter a single party payer and all its problems. Since Medicare and Medicaid have proven to be unsustainable, it is foolish to throw money at a failing system. It is time to revitalize the system.

Just the opposite should be occurring. CDHC should be promoted and not be marginalized. President Obama’s universal healthcare with a single party payer system marginalizes CDHPs. The route he is taking to achieve everyone’s goals and will not repair the healthcare system.

“The idea behind consumer-driven health plans is to transform members into healthcare consumers through education and place more responsibility on the individual.”

Health Saving Accounts (HSA) do little to encourage patient responsibility or make patients informed consumers. HSA were a political compromise designed by the healthcare insurance industry. The resulting plan gutted the intent and effect of the CDHC movement.

“ Studies show that the percentage of Americans insured in CDHPs is still in the single digits, largely for two reasons: Consumers simply don’t understand the tax-free savings accounts that are connected to CDHPs, and few health plans are providing cost and quality information to allow consumers to compare doctors, hospitals, and treatment options.”

Wrong!

Consumers do not see a financial advantage of the HSA because there are none. The money has to be used to pay present deductibles and future deductibles. There is no reason the future deductable will not be increased reducing the present value of the money in their health savings account. The healthcare insurance industry wants health savings accounts to fail. It feels its margins are presently excellent and does not need a change.

“More than one-quarter those respondents said that HSAs are difficult to open/manage, or too complicated, or they simply didn’t understand the accounts.”

Consumer driven healthcare is the only thing that can repair the healthcare system. It would take control out of the healthcare insurance industry’s hands. The route to take is the ideal medical saving accounts.

Healthcare insurance would convert to real at risk insurance. Consumer would own and control their healthcare dollar. The government could teach the consumer to use the healthcare dollar wisely. The government could provide clear price and quality transparency. It would force all the secondary stakeholders to compete for the consumers’ healthcare dollar. This competition would force an increase in efficiency and decrease in administrative waste.

The government should act as the facilitator for the competition. The time has come for politicians to do something for consumers and not for secondary stakeholders.

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Another Complicated Mistake By A Different Administration

February 18, 2009
inChronic Disese Management, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

Medicare and Medicaid (run by the states) are both on the brink of bankrupting the country. The present path is unsustainable.

It would be prudent to repair both programs by innovations that would render these societal entitlements sustainable. In order to fix the system the government should focus on solving the causes of the largest costs to the healthcare system (go where the money is).

The money is in preventing the onset of chronic diseases and its complications. Eighty percent of the healthcare dollars are spent on treating the complications of chronic diseases.

The complexity of President Obama’s “economic stimulus bill” for healthcare is going to lead to increased government spending and increased control over physicians’ medical judgment. It will be a deterrent to innovative research and thinking.

“Congress will provide 1.1 billion dollars for clinical research to the federal government to compare the effectiveness of different treatments (drugs, medical devices, surgery and other ways of treating specific conditions) for the same illness.”

A new government body will supervise head to head clinical studies. The clinical studies will test the difference between medication, procedures and other treatments for specific diseases. The government will then decide on the best treatment for each disease.

The stimulus package creates another bureaucracy that could add a level of inflexibility to the delivery of effective medical care. The government’s goal is noble. It wants to increase uniformity of care at the lowest cost of care. This could lead to rationing of healthcare and elimination of patient choice.

“The bill creates a council of up to 15 federal employees to coordinate the research and to advise President Obama and Congress on how to spend the money.”

It is obvious to me that it will not stimulate new innovative medical science. It could also drive physicians away from treating patients in government programs.

President Obama should be investing in research that promotes the development of more effective medical and surgical treatments for various diseases. They should not be comparing old treatments to decide on which are better. Physicians should be allowed to exercise medical judgment. Physicians should be given incentives to choose the most cost efficient therapy and not restrict their intellectual property. Presently incentives promote the least cost efficient therapy.

Government regulated and supported research has already judged the therapeutic safety of medication and procedures in a limited and artificial way. President Obama’s healthcare team should learn from the experience in other countries before wasting this money.

“Britain, France and other countries have bodies that assess health technologies and compare the effectiveness, and sometimes the cost, of different treatments.”

“Comparative effectiveness is a useful tool in the tool kit, but it’s not the answer to anything,” Andrew Witty, the CEO of GlaxoSmithKline said in an interview. “Other countries have fallen in love with the concept, then spent years figuring out how on earth to make it work to save money.”

Mr. Witty is the CEO of a stakeholder company that is threatened by President Obama’s initiative. His comments can easily be dismissed by clinical researchers because the comment threatens their vested interest. However it is a common sense comment.

Federal government officials can see this as a way to control costs. However not one has looked at its practical effect in countries that have used this approach. It certainly would restrict access to care.

For many years, the government has regulated drugs and devices and supported biomedical research, but the goal was usually to establish if a particular treatment was safe and effective, not if it was better than the alternatives.

The money for healthcare research should focus on medical and financial outcomes in real time in the real world. Most clinical research studies are short term (1 year to 3 years) with limited follow-up evaluations and no long term financial outcome comparisons. Some clinical research studies are poorly designed and the conclusions can be detrimental to good medical care.

A non surgical approach can be as effective as a surgical approach short term. Long term the patient might need a surgical approach. This is what a physician’s clinical judgment is about. The data that will be captured by this new agency using comparison clinical research protocols is limited and can yield poor conclusions.

An example of a disastrous clinical trial is the Women’s Health Initiative. Both the protocol and the statistical analysis were defective. I believe that the defects in the study will lead to more female morbidity and great healthcare cost in the future.

I believe the “clinical research” is going to result in confusion, senseless debates and inaccurate conclusions.

The government will find the incidence of chronic disease has because obesity and environmental pollution has increased.

Obesity is directly linked to diabetes mellitus, hypertension and hyperlipidemia and back problems. Environmental pollution is directly linked to chronic obstructive lung disease and asthma.

The complications of chronic disease absorb 80% of the healthcare dollars. These are the areas government ought to be spending money to inspire innovative thinking.

The $1.1 billion dollars can go a long way toward controlling chronic disease.

The cost of head to head comparisons makes this endeavor a meaningless waste of money. I was hoping the new administration would have the curiosity and common sense to repair the healthcare system correctly.

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

  • electronic medical records • March 22, 2009

    Your absolutely correct,
    Preventing disease and even death should be priority when dealing with any type of virus or disease.Raising awareness and utilizing standard preventative practices and methods is a surefire way to generate lower healthcare costs.

  • Medical Billing Software • March 29, 2009

    The involvement of the government in deciding the treatment for the patients is not good.It should be the doctors to decide the medication according to their requirement.

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More Medicaid: Is This What We Want For Our Healthcare System?: Part 2

February 11, 2009
inDisinformation and the healthcare system, Medicaid, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

There are always problems with federally funded programs. They are bureaucratic, inefficient, and always seem to contain loopholes that can be taken advantage of by stakeholders.

Most states are desperate for additional funding this budget year. They have large budget deficits despite increasing state tax rate. States raising taxes do not seem to be the solution. People move out of the state as in California. President Obama providing an additional 100 billion dollars to the states for Medicaid bailout is not the solution to Medicaid’s problems or the uninsured problem. .

“The federal and state governments are equally culpable for the program’s troubles. The federal government matches state Medicaid spending, paying an average of 57% of costs. States expand enrollment in order to qualify for more federal aid.

The barriers to medical care listed in Part 1 have resulted in extreme shortfalls in physician coverage for Medicaid patients.

a. A government survey in 2002 for the Medicare Payment Advisory Committee found that "approximately 40% of physicians restricted access for Medicaid patients" because reimbursement rates are so low.

b. Only about half of U.S. physicians accept new Medicaid patients, compared with more than 70% who accept new Medicare patients.

c. Several recent studies trace the difficulty in getting Medicaid patients seen by specialists to low fees and payment delays.

d. Technologies are also restricted. Many expensive but important drugs aren’t paid for under various state drug formularies.

Newspaper headlines continue to point out Medicaid fraud by various stakeholders.

“ James Mehmet, New York’s former chief Medicaid investigator, was quoted in the New York Times as believing that at least 10% of state Medicaid dollars were spent on fraudulent claims, while 20% or 30% more was siphoned off by what he termed "abuse."”

Think about this. The implication is that physicians are at fault but the states are the entities siphoning off large amounts of money for “other uses” and not for medical care.

40% of physicians did not accept Medicaid patients in their practices in 2002. I am sure the percentage is higher today. 50% of the 60% remaining physicians who have Medicaid patients in their practices do not take new patients. Medicaid patients do not have the choice of their physicians. Their choice is limited to the remaining 35% of the physician workforce. This workforce is overburdened with Medicaid patients.

Some of these physicians see many patients a day or restrict access to care. A small percentage of these physicians have figured out how to leverage their practice. They see an unserviceable number of patients a day. Many call these practices are called Medicaid mills by healthcare policy wonks. In some locations they are the only practices available to service Medicaid patients.

Newt Gingrich has complained about these physicians. He has called them fraudulent. My guess is that less than 10% of the 35% (3.5%) might be fraudulent. Newt’s solution is force all physicians have an EMR so the government can capture “fraud” instantaneously.

“ Even if the federal government wanted to hold states more accountable for peoples’ health, Medicaid claims data is poorly gathered in most states, making meaningful oversight hard.”

I would suggest that the states get better electronic data systems. I believe EMR’s are essential in physicians’ practices but not for the punitive reason expressed by Mr. Gingrich.

“Barack Obama’s team and Democratic leaders plan to change the federal matching rate to reduce the amount of state funding that is required for maintaining a given level of federal Medicaid spending.”

The issue of states receiving increased funding for Medicaid is very complicated. Some states are trying to change the definition of poverty to include people earning up to 63,000 dollars a year. The rationale is the states need to encourage low paid workers to stay in their state. Other states are keeping the 1955 definition of poverty and siphoning money that should be spent on Medicaid care for “other uses”.

If someone had the desire to do it right, the government would change the criteria for the definition of poverty. President Bush was uninterested. He wanted to eliminate Medicaid as a federal entitlement and put the burden on the states.

“ Mr. Obama would give Medicaid tens of billions more in federal dollars as part of the fiscal stimulus bill. And he wants to extend Medicaid to some unemployed workers, with the federal government paying the entire cost — a watershed expansion of the program.”

President Obama,s healthcare advisors do not understand that throwing money at the Medicaid system will not fix the system. It will reduce the number of uninsured. It will increase the number of people who have inadequate healthcare insurance..

The “stimulus” will not increase the quality of medical care delivered. I fear the biggest accomplishment will be to increase the incentive for the misuse of more taxpayers’ dollars. Medicaid’s open ended funding must stop.

a. The states must be held accountable for their healthcare subsidy spending .

b. The states must be held accountable for providing incentives for patients to sign up for this healthcare insurance.

c. The states must be accountable for providing incentives for patients to become responsible for their own healthcare.

d. The states must be accountable for decreasing environmental risks to their citizens (stop developing coal burning plants).

e. The states must be accountable for giving physicians incentives to participate in the system.

The ideal medical savings account in the Medicaid system would be effective. It would put patients in charge of their healthcare dollar and their health care. The states and federal government would be responsible for helping patients be responsible purchasers of their medical care.

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

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You Can’t Change The Practice Of Medicine With Demand-Side Reforms. Let Us Put An End To Pay For Performance (P4P) Initiatives: Part 1

January 25, 2009
inChronic Disese Management, Consumer Driven Health Care, Medicare, Medicine: Healthcare System, Pay for Performance (P4P), Quality medical care measures, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

MEDICARE "PAY FOR PERFORMANCE (P4P)" INITIATIVES

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

HOSPITALS

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

2. Premier Hospital Quality Incentive Demonstration

PHYSICIANS OR INTEGRATED HEALTH SYSTEMS

1. Physician Group Practice Demonstration (BIPA 2000)

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

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

DISEASE MANAGEMENT/CHRONIC CARE IMPROVEMENT

Chronic Care Improvement Program (MMA section 721)

ESRD Disease Management Demonstration (MMA section 623)

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

Disease Management Demonstration for Chronically Ill Dual Eligible
Beneficiaries

Care Management For High Cost Beneficiaries

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

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

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

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

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

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

  • Call CareNet • April 20, 2009

    I have always gone to Call a Nurse for all of my health concerns. Whenever I have a question I call Call a Nurse and they are always very polite and knowledgeable.

  • Rhinoplasty Beverly Hills • May 28, 2010

    This is quite a comprehensive and interesting posting on the approach to put an end to the system of Pay for Performance Initiatives. This approach may turn out to be effective in the end.

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Obama Will Ration Health Care!: Wake Up America: Part 2

January 18, 2009
inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust, Universal Healthcare
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Stanley Feld M.D.,FACP, MACE

Mr. Obama has promised a quick, hard push to overhaul the healthcare system. Americans can expect a quick push to build a larger federal bureaucracy, impose price controls, restrict the use of new medications and technologies, boost taxes, mandate the purchase of health insurance, and expand government control of health care. This is the promise Mr. Daschle made in his book "Critical: What We Can Do About the Health-Care Crisis,"

If Mr. Obama continues on the present path the prognosis is horrible for patients, physicians and taxpayers. Tom Daschle’s excuse is the present system is an intolerable status quo. An intolerable status quo is not an excuse to destroy the healthcare system in America.

“In his book, Mr. Daschle proposes a National Health Board to regulate the way health care is provided. This board would have vast powers in regulating the massive federal health-care system — a system that includes Medicare, Medicaid, and other programs.”

Healthcare coverage will likely expand to greater government healthcare control. Businesses and corporations are anxious to get out of the business of providing healthcare coverage for their employees. They would rather pay the penalty proposed than provide unaffordable healthcare insurance for their employees. The result will be defacto socialized medicine before we know what hit us. Socialized medicine is Mr. Daschle’s plan for all Americans even though America can’t afford it. He is going to claim this is the plan the people want. I would add until the people realize the consequences of his plan.

“Given the opportunity, Mr. Daschle would likely charge the board with determining which treatments and drugs are cost effective and therefore permissible to use for patients covered by the government.”

“It is nearly certain that the process of determining which drugs and which treatments would be approved for use would be quickly politicized.”

The Federal Health Board will be made up of “expert clinicians” from academic centers who will determine what physicians can and cannot do. The enforcement of these rules will be impossible. The punitive weapon will be withdrawal of physician reimbursement. I have said over and over again that punitive measures do not work to force a workforce to comply.

“In his book, Mr. Daschle complains about overuse of new technology and praises the United Kingdom’s National Institute for Health and Clinical Excellence (NICE), a rationing system that controls government costs.”

Mr. Daschle believes that America needs to ration new technology and drugs because the cost of care is skyrocketing. Another reason is the government cannot afford to provide access to care. The result will be rationing of care rather than giving patients the freedom of choice. The British system is well known for restricting access to drugs and medical care.

He is ignoring the waste in administrative services outsourced to the healthcare insurance vendors. He is ignoring the inefficient billing practices of hospital systems. He is ignoring the responsibility patients have to adhere to treatment medications prescribed and the maintenance of their health. He is ignoring the fact that patients should be responsible for their health and their healthcare.

“Health care is personal and voters will pressure lawmakers on access to care. Americans will not put up with such limits, nor will our elected representatives.”

Mr. Daschle is claiming that through his community home meetings in December people are demanding the changes he is proposing. I believe once the voters realize what he is proposing the will voice the opposite opinion.

Managed care of the 1990’s was nothing more that managed cost. It provided the healthcare insurance industry with the opportunity to place restrictions on access to care and decrease reimbursement to vendors. It temporarily reduced the increase in the costs of care. However, managed care failed work because the public objected to the restrictions and it did not hold down costs. The HMO experiment failed for the same reason.

Tom Daschle has learned something from these lessons. He learned that he has to strike quickly and deflect the decisions about rationing of care to a “neutral board” and not the market. It is clear he does not respect the intelligence of the consumer. He does not understand the responsibility of the consumer. If he was doing this right he would be going after the abuses in the system and not the decision making engine in the system.

Tom Daschle is in the process of creating a giant HMO. It will fail as the Massachusetts experiment has failed.

“Mr. Daschle’s model is Massachusetts. But Massachusetts’s plan is an unfolding disaster and demonstrates how Mr. Daschle’s private/public model is merely a stalking horse for government-dominated health care.”

Massachusetts helped 442,000 people obtain healthcare insurance. However an additional 80,000 people were put on Medicaid. 176,000 people were put on government subsided healthcare insurance. The cost to taxpayers has exploded because the basic cause of increased cost of care has not been addressed. The healthcare insurance industry control over the healthcare dollar has to be reduced. The onset of chronic disease and the reduction of the complications of chronic disease must be attacked effectively.

“Costs have exploded, requiring additional tax hikes and the entire system is only possible due to sizable transfers from the federal government. The plans are so unaffordable that in 2007, 62,000 people were exempted from the individual mandate.

So much for universal coverage. It could work if the consumer controlled their healthcare dollars with the government protecting the consumer.

The only way the Massachusetts plan will survive is with continued and increasing federal subsidies -that is, tax revenue from the residents of other states.

Tom Daschle’s plan is going to follow the same misguided path. The problem is worse the healthcare system becomes the harder it will be to dig our way out.

Wake up America

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

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The Therapeutic Magic Of The Physician Patient Relationship: Part 1

December 22, 2008
inConsumer Driven Health Care, Innovations in Healthcare, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

A positive physician patient relationship has magical therapeutic powers.

I believe I can best describe it with two very difference personal experiences.

Both are reminiscences of events that occurred long before I was a physician. Both gave me incite into the power of a physician patient relationship and stimulated my desire to be a doctor. One experience was doctor related, the other was teacher related.

During 30 years in private practice as a clinical endocrinologist I always tried to treat my patients remembering the therapeutic effect of those experiences. Those experiences had magnificent healing powers for me.

The first episode occurred when I was a first grader in the Bronx. The year was 1946. In those days being left handed was thought to be a curse. My first grade teacher forced me to write with my right hand to avoid the destiny of the curse. I remember the difficulty I had writing with my right hand. I was forced to persist. I made many mistakes and had great difficulty learning to do anything academically.

I had difficulty learning anything new, especially reading and arithmetic. I thought I was a pretty smart kid. My impression was confirmed by my father when he continually told me I was a smart kid. I was told not to listen to my teacher’s impression of me.

I was never a difficult child at home but something agitated me in school. I remember being a difficult first grader. My teacher considered me a trouble maker. She did not understand why I did certain things.

Finally, my teacher called my mother in for a conference. I was forced to listen to the conference. The teacher told my mother she was positive I was a disturbed child and needed psychiatric attention. I was behind in reading, writing and arithmetic and was not adjusting socially. She told my mother she should act immediately before I was permanently damaged. She said if this continued I could be expelled from school.

My mother was beside herself. She did not know what to do. I felt her anxiety but did not know what to say. I did not know what a psychiatrist was. I was told we could not afford a psychiatrist. I thought the solution to my problem was to be allowed to write with my left hand. No one would listen to me. Everyone, including my parents believed that left handed people were cursed.

My father’s boss suggested we go to Dr. Schultz, a family practice doctor, in the West Bronx. I remember the look of Dr. Schultz’s street. It was tree lined with two rows of attached single family houses with and concrete steps. We lived in a 4 room apartment in a walkup apartment building on Bristol Street across the street from the Boston Post Road movie theater.

The first room we entered was a living room with couches used as a reception area. At six years old I was impressed and terrified. My mother was just terrified.

Dr. Shultz’s office had a desk, a few chairs and a mirror behind the desk. He asked my mother what was wrong. She repeated the teacher’s report almost verbatim. He asked some detailed medical history and took notes. When he finished he turned to me and asked me what I thought was wrong.

This is the first time anyone had asked me to express my opinion. He saw I was nervous and frightened. He calmed me down and told me usually the patient can tell him what is wrong if the patient is given a chance to express himself.

I told him that the teacher made me write with my right hand because left handed people were cursed. He said he heard that was a common superstition but there was no proof it was true. He then asked me to write my name and my brother’s name on a piece of paper with both my right and left hand. I did and he said “son, there is nothing wrong with you.”

My mother looked in disbelief. He then picked up the paper and showed it to my mother. She still did not understand. He then put the piece of paper in front of the mirror. My right handed entry was legible now and the left handed writing which was legible at first was now backward. I was mirror writing.

He told my mother that that problem was the result of the strain put on me being forced to write right handed. After I was permitted to write left handed for a while my ability to write, read and do arithmetic would straighten out. My behavior problems would also vanish. He suggested that my mother listen to my complaints in the future. He wrote a note to the teacher ordering her to let me write with my left hand.

Then he got up from his chair, came over to me and gave me a big hug. He also told me to show everyone they were wrong about me. I felt like a million bucks. All the tension left my body. I felt I could achieve anything.

There is no question in my mind that this approach to medical care and the therapeutic effect of the positive physician patient relationship saved my academic life.

The pressures on physicians today to see more patients, to test for everything so you do not miss a diagnosis, the lack of reimbursement for cognitive therapy, the constant threat of financial penalties and continuous assault on physicians’ judgment has served to decrease the ability of physicians to relate in a human way.

“There is considerable healing power in the physician-patient alliance. A patient who entrusts himself to a physician’s care creates ethical obligations that are definite and weighty. Working together, the potential exists to pursue interventions that can significantly improve the patient’s quality of life and health status. “

The simple way to put it is medical care has and is being commoditized and dehumanized. These attributes are the common denominator to patients’ complaints about the medical care system in 2008. I cannot justify or condone physicians’ behavior.

Our healthcare system has to change. It must support the humanizing elements or the patient physician relationship. It has to nurture mutual trust rather than distrust between patients and physicians. A healthcare system that supports distrust, physician and patient penalties and adversarial interrelationships does not permit this princely profession to offer the kind of care physicians are capable of.

President-elect Obama and Tom Daschle imposing more bureaucratic controls on the healthcare system is not the answer. It is clear to me that the consumers and their needs must drive us back to a more humanized system.

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Consensus: A Clever Way To Build One, Whether It Is Right Or Not

December 17, 2008
inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust
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Stanley Feld M.D.,FACP,MACE

 

President-elect
Barack Obama is inviting Americans to spend part of the holiday season talking
about health care — and report back to him. He is encouraging average
Americans to host informal gatherings to brainstorm about how to improve the
U.S. system. Thomas
A. Daschle will attend at least one and prepare a detailed report, complete
with video, to present to the next president.

These sessions, are to be held Dec. 15 to Dec. 31. One might be invited if
one made a contribution to President-elect Obama’s presidential campaign.

"In order for us to reform our health care system, we must first begin
reforming how government communicates with the American people," Obama said in a
statement yesterday. "These Health Care Community Discussions are a great way
for the American people to have a direct say in our health reform efforts."

President-elect Obama’s statement is absolutely compelling. I believe his
heart is in the right place. However, he is ignoring the other half of the
primary stakeholder equation, the practicing physicians.

By applying the high-tech tools and grass-roots activism that helped him
win the White
House, Obama hopes to circumvent many of the traditionally powerful special
interests that have quashed previous health-care reform efforts.

I believe Tom
Daschle has decided on his legislative initiative already. Max
Baucus (D) Montana has introduced an identical plan to congress.

Senator Kennedy is next. This call for pseudo public involvement by Barack
Obama is a clever mechanism for claiming a CONSENSUS.

"What
we want to do now is to move to a discussion across the country," Daschle said
in a speech yesterday in Denver. "We want your exact ideas." By seeking
broad public input early in the process, the incoming administration hopes to
avoid some of the mistakes of President
Clinton's failed initiative 15 years ago, said Daschle, who is also Obama's
choice for secretary of health and human services.

"Once we get started, we have to stay focused. Let's finish it, let's not
put it down."

President-elect Obama’s healthcare plan is similar to President Clinton’s
failed plan. Tom Daschle spearheaded the Clinton plan in 1993. The Obama/Daschle
plan is a plan for socializing medicine as the solution to our dysfunctional
healthcare system. It is absolutely the wrong strategy and will make things
worse.

The strategy to get the Obama/Daschle healthcare plan past is clear. I
believe their consensus strategy will be so effective with the American people
it will overwhelm common sense. Even Harry and Louise can not
help. 

John Goodman of the
National Center for Policy Analysis had a brilliant blog concerning
consensus building as it relates to medicine. This blog entry is a worthwhile
read.

He begins by saying lots of Democrats have a health plan (Daschle, Baucus and
Kennedy). “And the chattering class is exuberant over the idea that a
consensus is emerging on health reform. With respect to the twin problems of
cost and quality, just about everyone seems to hold these positions:”

Consensus Point No. 1:

I AM NOT AT FAULT.

Consensus Point No. 2:

Somebody else is at fault; and, not to put too hard an edge on it
and you may have to read between the lines to see this, but a reasonable
inference is that DOCTORS ARE AT FAULT.

Consensus Point No. 3:

Again, not to put too hard an edge on it and you may have to read
between the lines even more diligently, but once you do you will surely conclude
that we must FORCE DOCTORS TO CHANGE THE WAY THEY PRACTICE MEDICINE.

I am afraid Americans are being set up. The “consensus” is going to sweep a
defective healthcare policy through the door. The result will be a very
ineffective form of socialized medicine. The plan will not cure obesity, the
complications of chronic disease, or the abuses to the healthcare system by all
the stakeholders.

When the Obama/Daschle plan is passed we will really have problems. Patients
will not have freedom to choose. Access to medical care will be limited.
Physicians will have further restrictions on their ability to deliver medical
care they think necessary. The government will experience unbelievable cost
overruns.

Tom Daschle’s plan does nothing to repair the dysfunction in the healthcare
system. Doing the right thing seems so easy to me. I can not understand why
politicians who do not understand medicine and the importance of physician
patient relationship do not want to listen to practicing physicians. Politicians
must use common sense. I hope President-elect Obama grasps the concept before it is to
late for the healthcare system.

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

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