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Making Medicine Function: Five (5) Key Elements From Stanley Feld M.D.,FACP,MACE : Repairing the Healthcare System

Scott Becker of Becker’s Healthcare asked me to write an article on Element needed to Repair The Healthcare System. Becker’s Healthcare is the leading source of cutting-edge business and legal information for healthcare industry leaders.

His portfolio includes five industry-leading trade publications:

  • Becker’s ASC Review
  • Becker’s Infection Control & Clinical Quality
  • Becker’s Spine Review
  • Becker’s Hospital Review
  • Becker’s Dental Review

My article appeared in the latest addition and with permission from Scott Becker. I am reprinting it on my site. Becker’s Healthcare is a valuable information site.

Making Medicine Function: Five (5) Key Elements From Stanley Feld M.D.,FACP,MACE : Repairing the Healthcare System

Patients, physicians, hospital executives, healthcare insurance executive and government all believe the healthcare system is dysfunctional and unsustainable in future years.

All the stakeholders are unhappy with Obamacare.

Clinical Endocrinologist, Stanley Feld, MD, FACP, MACE, is a physician who believes Obamacare’s business model is seriously flawed. He also believes that Obamacare has accelerated the dysfunction in the healthcare system.

Dr. Feld believes Obamacare has increased the healthcare system’s unsustainability by causing an increase in bureaucracy, a decrease in efficiency and encouraging the gaming of the healthcare system by all stakeholders.

The Obamacare business model must be changed to a consumer driven healthcare business model with the consumer in charge and in the center of the healthcare system, not the government or other secondary stakeholders.

Consumers must be taught and incentivized to use all the 21st century technology tools available including smart phones. The goal must be to improve medical care and treatment outcomes, not improve the measurement of medical process outcomes.

Dr. Feld became interested in the causes of the healthcare system’s dysfunction in 1991 while he was on the steering committee of a nascent medical organization, the American Association of Clinical Endocrinologists (AACE).

He became AACE’s third President and was chairman of the Type 2 Diabetes Guideline committee. He was the chief author of “A System of Intensive Self-Management of Type 2 Diabetes Mellitus.”

In 1991 there was little government and healthcare insurance industry support for the concept of teaching the Type 2 Diabetics how to be the “Professor of Their Disease” even though there was a Type 2 Diabetes epidemic.

The epidemic was the result of lack of understanding by consumers (patients) of how to prevent and treat Type 2 Diabetes Mellitus. Uncontrolled Type 2 Diabetes causes complications that are coronary heart disease, kidney failure, blindness and amputations. Quality of life of is decreased. The complications are costly to the patients and the healthcare system.

America was in the midst of an obesity epidemic. The epidemic continues today. Obesity predisposes consumers to Type 2 Diabetes Mellitus and its subsequent complications.

Dr. Feld said everyones goal for the healthcare system is to have a healthier population at an affordable price. The goal can be accomplished by putting consumers in control of their health and healthcare dollars. Consumers must also be given financial incentives to control their health. No one is focused on the consumer’s responsibility to lower cost in the Obamacare business model.

Dr. Feld believes Obamacare’s business model has too many faults to repair. Each time President Obama alters the business model to fix a fault, the healthcare system becomes more costly, dysfunctional and unsustainable.

Dr. Feld developed a business model that would accomplish the goal of providing a functional and efficient healthcare system at an affordable cost to consumers, employers, healthcare insurance companies and the government.

Dr. Feld’s business model would eliminate most of the government’s inefficiency that absorbs 40% of the healthcare dollars. The inefficiencies must be eliminated or at least significantly decreased.

Here are Dr. Feld’s five key elements necessary to Repair the Healthcare System.

All the key elements listed are explained in detail in Dr. Feld’s blog “Repairing the Healthcare System”. Each link will have a full list of my blog posts on the topic.

  1. The Ideal Medical Savings Accounts (MSAs).

Dr. Feld’s Ideal Medical Savings Account is the insurance model in his business plan.

Medical Saving Accounts are different than Health Savings Accounts. Health Saving Accounts are the fastest growing healthcare insurance plans. Medical Saving Accounts provide consumers with more financial incentive.

The Ideal Medical Saving Account transfers the premium dollars saved by consumers into a tax-free retirement trust that is not restricted to medical care. The financial incentive will cause consumers to be responsible for the control of their health and wisely spend their healthcare dollars.

The Ideal Medical Savings Accounts are democratic. The employer, the individual or the government could fund the Medical Savings Account. The deductible must be high enough to provide enough financial incentive for consumers to be motivated to become responsible for their health and their healthcare dollars. Once the deductible is reached the consumer receives with first dollar coverage for an illness.

If the deductible is not spent the consumer gets it tax-free in their retirement trust.

Ideal Medical Savings Accounts provide consumers the choice of physician. The environment is created where consumers decide on who will provide the best value for their healthcare dollars rather than the government, the healthcare insurance industry or the government.

MSAs would create a Consumer Driven Healthcare System with the benefit of consumers creating competition among the stakeholders in the healthcare system rather than stakeholders deciding for consumers. For greater details go to this link.

  1. The Importance of Tort Reform

Most politicians have ignored the importance of Tort Reform. They have been led to believe that Tort Reform is an insignificant cost to the healthcare system.

Dr. Feld points to study by the Massachusetts Medical Society. Every practicing physician believes the data of this study. The resulting data is an excellent and truthful indicator of the huge cost of over-testing to prevent malpractice claims.

The lack of Tort Reform costs the healthcare system $200 billion to $750 billion dollars a year as a result of over testing by physicians to avoid malpractice suits.

Physicians who order a test usually do not receive the profit built into the test he/she has ordered.

  1. The Importance of Self-Management of Chronic Disease

The unsuccessful management of chronic diseases results in 80% of the cost of care for those diseases. Most important is to prevent the chronic disease from occurring in the first place. Diseases with the highest costs are Diabetes Mellitus, Heart Disease, Hypertension and Cancer. Obesity and consumer’s genetic makeup are responsible for most of these chronic and costly diseases.

Consumers are in control of the development of obesity. They must be responsible for preventing it. However all of our cultural stimulation encourages obesity. Consumers must make a choice. Government can provide public education programs to help consumers make the correct choice. When consumers are educated and are at financial risk for developing obesity, they will become responsible and avoid becoming obese.

The reformed healthcare system could prevent the onset of complications of these chronic diseases. The cost of the complications of chronic disease is 80% of the cost of treating that disease.

These teams must be an extension of their physicians care and responsible to their physician.

  1. The Magic of the Patient/Physician Relationship.

Obamacare tries to quantify patient care. Twenty thousand rules and regulations have been produced so far to measure the care delivered by physicians to patients.

Maybe the measurement criteria for quality care are wrong? Maybe the government is measuring the wrong thing.

There is no quality measurements made about patients’ compliance or adherence. There are no rules to measure the patient/physician relationship.

These would be important measurements for bureaucrats to measure in order to quantitate the effectiveness of care.

If one wanted to commoditize the delivery of quality medical care, consumer responsibility for compliance with their treatment is an important measurement.

The patient/physician relationship is magical. It can result in improved patient compliance and self-management of both acute illness and avoidance of the complications of chronic diseases. The end result is that it can decrease the cost of healthcare by at least 50 percent. The healthcare system would then be affordable.

As the government and healthcare insurance companies try to decrease their cost they have decreased reimbursement and increased regulations and paperwork for physicians

A physicians work product is intelligence, skill and time. Physicians do not have enough time to develop a patient/physician relationship today.

The patient/physician relationship is difficult to measure. It cannot be commoditized into a universal report that a computer program can generate.

  1. The Rule of Information Technology

Physicians are not opposed to information technology. They are against information technology generating data that is being used as a tool to judge their clinical competence and reimbursement by bureaucrats. Many times the “big data” is inaccurate.

Information technology should be used as a tool to extend a physician’s ability to patients. It should be used as a tool to improve physicians’ care.

In order to reduce the cost of medical care and increase the patient’s ability to be a “Professor of Their Disease”, medical care must be delivered by a team approach.

Information technology must be a part the team with the consumer being in the center. Physicians must be the coach; the other members of the team must be physician extenders (assistant coaches).

There are many websites generating both good and bad information. As the manager of the team the physician and his assistant managers should pick the websites for his/her patients to use.

Physicians and his/her healthcare management teams should develop social networks so his/her patients can relate to each other and learn the subtleties of their chronic disease from each other. Physicians and his patient extenders would monitor and correct any false information generated through the social network.

These social networks would be very effective in motivating consumers to be responsible for their care and their healthcare dollars.

These are five elements that would decrease the cost of America’s healthcare system. They would avoid the trap and unintended consequences of a single party payer system.

The real cost curve has not been bent downward. It has been bent upward in the actual cost to taxpayers. The government is not measuring all the costs, including new taxes, as payment for Obamacare.


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

 All Rights Reserved © 2006 – 2015 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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I Told You What To Do 8 Years Ago: Part 4

Stanley Feld M.D.,FACP,MACE

This is the last of the series of blogs I wrote in 2007 explaining what should be done in repairing the healthcare system.

The issues causing the dysfunction in the healthcare system have been explained, expended and simplified by detail throughout the succeeding eight years.

The result was the business plan for an alternative future state of medicine in 2020.

If one follows the logic of this plan carefully understand that Obamacare has escalated the pre Obamacare problems in the healthcare system one will visual this potential alternative future state business plan not only achievable but successful..

When reading Part 4 it must be remembered that 2007 was pre Obamacare.

Nothing has changed since 2007 except consumers are more aware that they are continuing to be shafted by the government, the healthcare insurance industry and hospital systems.

Many consumers believe physicians are shafting them. The reason for this belief is physicians are the stakeholder that consumers make initial contact with in the healthcare system.

Physicians have not made the rules or issued the regulations.

Physicians have been trying to adjust to many of the insane and impractical rules and regulations that have been written.

Consumers are starting to recognize that government says it is there to help and all it accomplices is making the healthcare system worse.

Obamacare, along with its special interest group, the traditional mainstream media, is trying to keep consumers stupid before it is too late for consumers to use their immense power.

Leadership, creativity and vision are missing from the Republicans, Independents, Libertarians and Democrats. The problems in the healthcare system are not a partisan problems.

Americans have been conditioned to go along to get along while many elected officials and officials running for election lie to us and cheat.

Many consumers blindly forgive politicians they elect not realizing that their condition will get worse and their freedom will be compromised.

Please keep in mind that the following comments where written in 2007.


What I Said So Far? Spring 2007 Part 4

Stanley Feld M.D., FACP, MACE

Many people have made the following comments about the healthcare system;

  • “It is hopeless!”
  • “There will be no solution in our lifetime.”
  • “Good luck.”
  • “You are wasting your time.”
  • “We are too far down the road to be able to save this puppy.”
  • “The politics and economics are out of the control of physicians and patients.”

Only 20% of the people are sick at any one time. Therefore only 20% of the people think about the healthcare system and their healthcare insurance policy at any one time.

The uninsured think about the potential cost of getting sick and fear not having health insurance.

When insured people get sick and navigate through the healthcare system is a nightmare for only about 40% of them.

At any one point in time only 8 out of 100 people who have health insurance are having difficulty with the healthcare system. When all the people with healthcare insurance are forced to think about the healthcare system only 40% has experienced a horror of the situation.

The other 60% that did not have a problem think the problems with the healthcare system are over exaggerated.

In August 2006 I received this comment from Cleve:

“Great post and keep it up. After 44 years of perfect health, my 45th was spent with doctors, labs and hospitals …the system is beyond Kafka. I’m no expert but I have a feeling that doctors will have to be the spearhead of change (with patients the driving force maybe?). So keep at it…please!!

Last week I spoke to a friend who had neck surgery two years ago. He was hospitalized for 2 days. He had the opposite comment. He has health insurance with UnitedHealthcare. He thought my comments about UnitedHealthcare were exaggerated.

His hospital bill was $17,500. The surgeon charged him $17,000. I remembered his complaining about how atrocious these two bills were.

I assured him the adjudication of the bill would look nothing like the retail charges.

UnitedHealthcare paid both the hospital and the surgeon $3,500 each. He was responsible for nothing. He was relieved and pleased with the system. He said the hospital and surgeon seemed satisfied.

What about Denise?

Remember her. She did not have health insurance. She was self- employed with a preexisting condition. She did not qualify for health insurance.

If she needed emergency neck surgery she would have been responsible for the entire $34,500. Both the hospital and doctor would have been unrelenting in the pursuit of payment.

If the hospital and doctor would settle for $3,500 with the insurance company they should settle for the same with Denise. However, she would probably go to the collection agency and if she did not pay, her credit would be destroyed.

Denise could not get information for the price of a simple x-ray from the hospital. This precipitated her frustration and letter to then Texas gubernatorial candidate Kinky Friedman, the comedian cowboy, running for governor.

My goal is to help people who are not sick understand the problem with the healthcare system. I believe the only thing that will repair the healthcare system is people and their purchasing power.

Matthew Huebert wrote:

“There is something meaningful about blogs and RSS that I’ve only begun to understand recently, and this post describes and exemplifies it well: you are a thinking person, putting yourself ‘out there’, introducing outsiders into your own world and adding depth to a discussion that matters to you and matters to society.

For me, it is writing like this that is an antidote to the superficial sound bytes that obscure possibilities for change by avoiding the “Why?” questions.

I think what’s finally hitting me is the fact that these conversations simply wouldn’t be happening if RSS did not exist! What you’re doing is inspiring. Thanks for the great post.
Matthew Huebert”

A huge barrier to real repair is the lack of awareness of 60% of the insured population.

The 46.7 million uninsured are a mere abstraction to these people. The horror of the 40% insured is also an abstraction. If the trend continues the system will cave in all at once and everyone will be affected.

People have to be stimulated to action now and demand the solutions.

I outlined in the last three blogs.

We are approaching a Presidential election year. We will hear all sorts of noise from “leaders” who in my opinion have little serious knowledge of the problem or the solution as seen in recent initiatives in California
and Massachusetts.

Our leaders are not stupid. The problem is the input of information is coming from the facilitator vested interest groups and not the people in the street.

Perhaps I can capture the imagination of all of the stakeholders. If we could all focus on the higher goal of excellent medical care at an affordable price rather than improving the financial results of facilitator vested interests, all of the stakeholders could all flourish with the minimum of pain and maximum creativity.

Nothing has changed because we the people have not made the correct demands.

All that has happened is that Obamacare has made the healthcare system worse. Obamacare Is going down in tubes.

It is time for Consumer Power to act.

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

 All Rights Reserved © 2006 – 2015 “Repairing The Healthcare System” Stanley Feld M.D.,FACP,MACE

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EMRs Real Politics.

Stanley Feld M.D.,FACP,MACE


Dr. Jerome Groopman and Dr.Pamela
Hartzmen uncovered the real politics of EMRs.
 They are both on the staff of Beth
Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical

 Dr. Groopman wrote a best seller “How
Doctors Think.”

In a Wall Street
Journal article they wrote,

 The electronic medical record (EMR) is touted
as the key to containing costs, reducing errors, improving quality, and
simplifying administration: an “elegant exercise in wishful thinking

Dr. Groopman and Pamela Hartzman debunk the 2005 RAND study. The
RAND EMR study of 2005 led to President Obama’s belief that EMRs will save $81
billion dollars a year for the healthcare system.

Groopman and Hartzman show that there is little evidence to
support the president’s belief.

The RAND analysts claim that more than $350
billion would be saved on inpatient care and nearly $150 billion on outpatient
care over a 15-year period of time.

Unfortunately, data from three other studies, a cardiology
group, a Harvard group and Canadian group showed there is no savings difference
between paper records and electronic records.

Dr. Groopman claims the RAND study is self-serving to EMR software
companies that sponsored the study.


Healthcare Solutions
, the Cerner Corporation and Epic Systems of Verona, Wis. are the major EMR software companies.

 In February 2009, after years of behind-the-scenes lobbying by
Allscripts and others, legislation to promote the use of electronic records was
signed into law as part of President Obama’s economic stimulus bill.

“But today, as doctors and hospitals struggle to make new records
systems work, the clear winners are big companies like Allscripts that lobbied
for that legislation and pushed aside smaller competitors.”

At Allscripts Healthcare
solutions, annual sales have more than doubled from $548 million in 2009 to an
estimated $1.44 billion last year.

At the Cerner Corporation of Kansas City, Mo., sales rose 60 percent during that

“Current and former industry executives say that
big digital records companies like Cerner, Allscripts and Epic Systems of
Verona, Wis., have reaped enormous rewards because of the legislation they
pushed for.”

Unfortunately, many of the
EMR systems bought by large hospital systems and physician practices are not
fully functional. They do not fit the administration’s criteria of meaningful-use
EMRs. These EMRs are requiring additional hospital systems and physicians;
practices outlays of cash to make them fully functional.

City-based Pain Clinic of Northwest FL filed a purported class action lawsuit
on Dec. 20, 2012 against Chicago-based Allscripts (NASDAQ: MDRX).

“The purported class action
lawsuit says that about 5,000 small group physicians were sold an EMR called
MyWay from 2009 until late last year, when the company stopped supporting the

“The company was also hit with
a federal shareholder class action securities fraud lawsuit in the Northern
Illinois District last year over allegations that it misled investors about the
performance of its EHR programs.”

 The MyWay EMR cost about $40,000
per physician. ThePain Clinic of Northwest Florida claims it was misled by
Allscripts Healthcare Solution.  The
Clinic stated that MyWay has “shortcoming
and inherent defects,”  

complaint says Allscripts was unable to obtain “meaningful use” bonus status
for MyWay because of the problems with the program. The lawsuit claims that

 “Allscripts has been unjustly enriched by
retaining the money paid by MyWay purchasers and users without delivering an
EHR software product that performs as it was intended to work,”

 These costs are always
passed on to the consumer
. Drs. Groopman and Hartzman  go on to say,

president and his health-care team have yet to address these difficult and
pressing issues.

 Our culture adores technology, so it is not
surprising that the electronic medical record has been touted as the first
important step in curing the ills of our health-care system.

this notion is an overly simplistic and unsubstantiated part of the solution.

It is important to note Drs. Groopman and Hartzman’s total
and refreshing frankness.

“We both voted
for President Obam
a, in part because of his pragmatic approach to problems,
belief in empirical data, and openness to changing his mind when those data
contradict his initial approach to a problem”.

We need the
president to apply
scientific rigor to fix our
health-care system rather than rely on elegant exercises in wishful thinking.”

Please note that Drs. Groopman and Hartzman said it not

a new study The RAND Corp has backed off on its 2005 study earlier this year
and withdrew its estimate of saving to the healthcare system of $81 billion
dollars annually.

In the
RAND Corp’s view, the disappointing performance of health IT to date can be
largely attributed to several factors:


  1.  “Sluggish
    adoption of health IT systems
  2.   Coupled
    with the choice of systems that are neither interoperable nor easy to use;
  3.   The
    failure of health care providers and institutions to reengineer care processes
    to reap the full benefits of health IT.
  4.  We
    believe that the original promise of health IT can be met if the systems are
    redesigned to address these flaws by creating more-standardized systems that
    are easier to use,
  5.  EMR are
    truly interoperable,
  6.  Afford patients more access to and control
    over their health data.
  7.  Providers must do their part by reengineering
    care processes to take full advantage of efficiencies offered by health IT, in
    the context of redesigned payment models that favor value over volume.”


It should not be a blame game.

General Electric sponsored this new RAND study.  It is important to note that GE is a major
Allscripts competitor.

There is true value in the EMRs to patient care. However the
focus of the marketing and development is on the wrong customer.

The RAND still does not get it. Perhaps
it does not want to get it.

EMRs should be for the benefit of physicians and their
patients. It must be at a price physicians can afford to pay. It should not be
for the benefit of the government, the healthcare insurance industry and
hospital systems.

It should be a tool to
continually educate physicians and patients. It should not be a tool used by
secondary stakeholders to penalize physicians and patients.

Patients and physicians control My Ideal Electronic Medical
Record. It should be seriously considered to achieve the maximum benefit of EMRs’

I believe it would be of value to interested readers to go
to this link.

 Those articles will
not only describe the problems with EMRs, problems which I have predicted and are
now recognized. These articles will also outline real  solutions to having universal adoption of

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

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Business Model For Medical Care 2020. The Ideal Future State

Stanley Feld M.D.,FACP,MACE


Please click on all the links to study
the references to each spoke. It will help you visualize the power of the business

The ideal future state business
model for the healthcare system must include the execution of ideas in the specific spokes outlined below.. These spokes
will serve to align all of the stakeholders’ interests.

The business model must
contain appropriate rules for a consumer driven healthcare system, an ideal
electronic medial record, and an ideal medical savings account.

The ideal medical saving
accounts can work optimally when there is significant tort reform and patients
take full responsibility for their health and healthcare dollars.

Consumer education is critical to the business
model of the future. Educational modules can be available to consumers 24/7 via
the Internet. These educational modules must be an extension of consumers
physicians’ care in order to be effective. The education can become available
using a series of social networks.

Chronic disease self-management education can
be achieved by the use of interactive online teaching programs. Patients can be
linked to share their disease experience through private social networks.

Most believe that the healthcare system must
have greater integration of care. This integration of care can be done
virtually through a series of private integrated networks.

Effective integration can be achieved without
disruption of the entire healthcare system. Obamacare has been disruptive to
the entire healthcare system.

Obamacare is forced integration by the
government will be slow, costly and unsuccessful.

Physicians must be compensated for the presently
uncompensated time necessary to execute each one of the spokes of the wheel.

Each spoke is necessary to convert the
healthcare system into a system that once more makes the physician patient
relationship paramount.

The future business plan removes control of the
healthcare system from the government. It permits the patient to have the freedom
to choose his own healthcare course.   

Tort reform is vital to the 2020 business model.
It will decrease costly over-testing to avoid frivolous malpractice suits.
There are many ways to set up a tort reform system that truly protects patients
from real harm while eliminating over-testing. It limits the malpractice
litigation system. Punitive damages must be lowered. Losers in lawsuits must
pay all fees. These two provisions will decrease lawyers’ incentive to sue.


Consumer driven healthcare will create a system
that promotes personal responsibility by the consumers’ for their health and
health care dollars.


The major spoke necessary to successfully
accomplish a consumer driven healthcare system is my ideal medical saving



The ideal medical savings accounts would
provide the financial incentive for consumers to drive the healthcare system.
It would dis-intermediate the healthcare insurance industry’s grasp on first
dollar coverage and profits. The insurance industry would realize that its
profit margin would increase under this system.

In order for consumers to be in a position to
lower the cost of healthcare they must be taught to understand how to self
manage their disease and be responsible for the decisions they make in their
choices for medical care.


In order to decrease patients’ dependency on
the government and increase  being
responsible for themselves, a system of education using information technology
as an extension of their physicians’ care has to be developed and put into

Social networking is in its infancy at present.
It must be developed and used as an educational tool between physicians, patients
and physicians, and patients and patients.

All the social networking must be an extension of
the physicians’ medical care
to their patients. Social networking must be
developed to enhance and promote the physician/patient relationship because
this relationship is critical, at its core, to successful medical treatment.

Social networking and information technology
can extend physician educational resources for patient care.


Systems of care for the self-management of chronic
disease as an extension of their physicians care
have already been developed.
The unsuccessful chronic disease self-management systems are the programs that
are not an extension of physicians’ care. The reason these third party systems
are unsuccessful is because they undermine the patient physician relationship.

President Obama has done pilot studies using
those third party self-management companies to prove that chronic disease
self-management systems work. They have all failed to reduce the cost of care.

Therefore the administration has reached the
conclusions that self-management of chronic disease does not work. Nothing
could be further from the truth. The government simply does not understand the
magic of the physician-patient relationship.


In order to decrease the cost of medical care,
medical care must be integrated. At present, primary care physicians recommend
specialists. The primary care physicians know whether the specialists are doing
a good job by the specialists’ treatment results with their patients.

Most of the time physicians do not know their
specialists’ fees. These fees must be totally transparent to primary care
physicians and their patients. The primary care physicians can then be in a
position to help their patients choose appropriate specialists.

It will also reduce the specialists’ prices
because they will be forced to become competitive by the patients in a consumer
driven system.

Hospital fees must also be transparent. One of
the reasons I am opposed to hospital systems hiring physicians and paying them
a salary is the hospital systems would then be able to develop a monopoly in a
town or area of town. This would permit the hospital system to raise prices
without informing patients or physicians.

Hospital systems could erase physicians’ choices
and hindered patients from having the freedom to choose a hospital or
specialist of their choice with their primary care physicians. It devalues the
patient physician relationship.  


The way President Obama is going about
developing a universally functioning electronic medical record is foolish and
Most physicians cannot afford a fully functional electronic medical
record. This fact is being used to drive physicians into being employees of
hospital systems. The problem is hospital systems are paying hundreds of
millions of dollars for electronic medical records that are not fully

Many of these records are hard to use and
provide inflexible data. The inflexible data leads to healthcare policy
decisions that are wrong. The data is also used to commoditize medical care.

Commoditized medical care is not the best quality
of medical care.  

If the government is so smart it should develop
a fully functional electronic medical record and provide it to all hospital
systems and practices for free.

The EMR should be put in the cloud. Providers
should be charged by the click. The government can service and upgrade the EMR
in one place and improve the quality of data collected. The data should be used
for educational purposes only and be owned by the patients and physicians. It
should not be used for punitive purposes. The inaccurate data is now used for
punitive purposes. The result has been a lack of physician cooperation.


The healthcare journey to an ideal future state
must begin in an orderly way. The principle goal is to be consumer centric. It
must be consumer driven and force the secondary stakeholders to be transparent
and competitive.

This journey will wring the excess costs out of the healthcare
system. It will create a democratic system affordable to all.

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

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Great Questions!

Stanley Feld M.D.,FACP,MACE

A reader wrote,


If the Supreme Court watchers are correct, it appears the court will strike down parts or possibly all of Obamacare later this spring.

If that happens, it is a good thing?

And if so, where do we go from here?” 


The court should overturn Obamacare. In my view Obamacare is unconstitutional.  President Obama deceived the congress, the public and the Congressional Budget Office about the true costs and intent of the law.

I hope the Supreme Court overturns Obamacare. Obamacare will be a disaster. Obamacare will destroy healthcare in this country. The public, media, and congress cannot yet understand it.

Many congressmen said they did not read the entire bill. Nancy Pelosi said “Don’t worry, we will understand what is in the bill once it has passed.”

 Democratic spin-doctors and the traditional media accused the Internet page-by-page summaries of the bill as being anti-Obama propaganda.

President Obama disguised the costs and intent of Obamacare in a deceptive and clever way. It is a bill that puts America on Hayek’s Road to Serfdom.  

Obamacare promotes dependence on the central government as it expands a failed entitlement.

It eliminates initiatives and incentives.

It decreases freedom of choice.

It expands an entitlement that America cannot afford.

America cannot afford to keep paying for the entitlement (Medicare) at the present enrollment. The states cannot afford the Medicaid entitlement much less its expansion.

President Obama ignores this enormous cost burden whose real cost estimates   increase monthly by the CBO as the impact of Obamacare’s rules and regulations increase. Non-elected officials without a congressional oversight mechanism make rules and regulations.

How would you like to be told which doctor or which hospital you can go?

How would you like your physician to treat you in a certain way dictated by the federal government?

Medical science is changing rapidly. Best practices change quickly. The bureaucratic machinery implements change very slowly. Decisions for best practices and payment will be made by committee and not individualized by your physician using his best clinical judgment.

How would you like to put your health and healthcare needs and decisions in the arbitrary hands of some government institution that is being forced to save money? 

How would you like to be forced to purchase a government insurance policy that has the right to restrict access to care and ration care?

How would you like the government to make all your healthcare decisions for you?

How would you like to not have freedom of choice and the right to participate in decisions about your health and healthcare decisions?

How would you like to be paying taxes for a very inefficient bureaucracy that does all these things to you?

Obamacare has already demonstrated that it is inefficient, wasteful, plays favoritism at the government's whim with no recourse by the individual.

An overriding goal of President Obama is central control of one sixth of the economy. He is pasting his healthcare reform act on top of a doomed 2011 business model. 

Obamacare is accelerating the collapse of this doomed business model. Obamacare must be repealed or eliminated.

This has been healthcare journey so far.



Figure 1 shows the path of the healthcare business models since 1945



Figure 2 describes the hairball of interference by the government and the healthcare insurance industry in the physician patient relationship. It also describes the fragment view of the patient as a result of this hairball.

 If the reader is interested in the reasons this all came about click on the underlined heading to read the source material in figure 3.



Figure 3: This is an easier figure to click on the source material and reference. The chasm between the patients and physicians must be eliminated in order to have an effective healthcare system.



Figure 4: America is at the critical turn now. All of the mistakes President Obama is making to Repair the Healthcare System are listed. He is going to accelerate the collapse of the healthcare system. The mistakes are referenced in the underlined headings. The references can be read by double clicking on the underlined headings.



Figure 5: My proposed future direction can be seen in this figure. The detail below these headings can be read by double clicking on each heading. Some of the headings are included in Obamacare. President Obama’s problem is he is going about implementing them in the wrong way.



Figure 6: The spokes of the business model that must be implemented in the correct way are outlined in this figure. Details of the future state business model have been described in previous blogs.


I hope I have answered the reader's questions

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

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Healthcare Reform Should Be About Motivating Self-Responsibility Not Dependence

Stanley Feld M.D,FACP,MACE

Last week I heard a lecture about Accountable Care Organizations by a physician leader working for one of the major hospital systems.

His discussion made me realize that large physician organizations and hospitals are spending lots of time solving problems of quality medical care. In my opinion quality medical care has not been adequately defined.

A working definition right now is to decrease hospital stays, efficient medical care for a disease at lower cost, avoidance of medical errors in the hospital, and avoidance of hospital acquired infections.

These are important goals. They must be attached to monetary incentives. Many of these problems can be solved now. The solution demands the development of processes of care. An important question is how much money will process improvement save? I estimate that this process improvement could save an estimated 7 to 10% of the healthcare dollar.

The real question should be focused on how to repair the healthcare system by decreasing costs while improving the health of Americans.

This problem is not only about hospitals and medical practices reimbursement. It is about problems created by all the stakeholders. It is about aligning all the stakeholders’ incentives. The solutions to the healthcare system’s dysfunction must be initiated at the same time. You cannot try to fix one problem because it will result in a problem getting worse in another area.

The key to the solutions is to incentivize consumers of healthcare to control their health and be in charge of their healthcare dollars. Consumers can force secondary stakeholders to adjust swiftly to their demands and make them compete for consumers’ healthcare dollars.

Consumers must have incentive. They should be able to keep anything they do not spend of the first $7500 dollars of healthcare coverage. In our present healthcare system consumers do not control their healthcare dollars. They get first dollar coverage with variable deductible expenses. If the deductible is too high they will avoid necessary care and medications.

Society should not want that to happen because patients will get sicker and cost more to treat. Third party payers control the healthcare dollar. This control has contributed to increase the cost of healthcare. .

Some claim the only incentive consumers (patients) should need is to maintain their health. This claim has turned out not to be true.

Where do all the healthcare dollars go?

1. 65% of each healthcare dollar goes to the healthcare insurance industry for overhead for administrative services and insurance reserves whether it is private or government insurance.


2. Only 35% of the healthcare dollar is actually spent on medical care.

3. 80% of the healthcare dollars spent for medical care is spent by 20% of the people.

4. Most of those 20% have chronic diseases.

5. 80% of those dollars are spent on the complications of their chronic diseases.

6. Some claim there is 40% waste in the healthcare system due to uncoordinated care and duplication of care.

7. Much of the excess testing is due to the fear of malpractice claims and the practice of defensive medicine.

Let us follow the healthcare dollars with consumers being in control of their healthcare dollar.

If a moderate size company of 67 employees were willing to pay $15,000 dollars per employee for healthcare insurance it would cost $1,000,000 dollars. If the employer did not provide healthcare insurance the government penalty ($2,000 per employee) would be $134,000 dollars. This would represent a savings to this moderate sized company of $866,000 dollars per year. It would be the logical path to take. The formula I propose will work for the individual buying insurance.

Assume employers were willing to buy healthcare insurance for their employees. They would put $7,500 per year in a trust for each employee. The employee would be responsible for his healthcare dollars. The fees would be pre-negotiated fees by the government as the healthcare insurance industry does presently with physicians and hospitals. Hospitals and physicians might even want to compete among each other for the consumers’ dollars.

If the employee did not spend all the healthcare dollars in a year the remaining dollars would go into his retirement fund. It would not be used for future medical care.

A new equation for driving healthcare costs would be born.

There would not be a 65% overhead for administrative services for the first $7500 dollars because the healthcare insurance industry would not be administering the first $7500 dollars. The savings would be $4875 dollars.

Patients and physicians would have an additional $4875 dollars working toward direct medical care. The 65% overhead for administrative services for the remaining $7,500 of high deductible coverage could remain the same. The high deductible insurance would provide first dollar coverage after $7,500. The risk to the healthcare insurance industry would be less and so its insurance reserves could be less.

The government pays the same amount for administrative services to the healthcare insurance industry. The government could use the same formula for Medicare and Medicaid.

Consumers would have a monetary incentive to decrease their risk of getting sick (preventing obesity and increasing exercise). If consumers drove the healthcare system the consumption of snack foods and fast foods would decrease with proper education. Those fast food companies would be forced to sell healthy food to stay in business. Consumer would be driven by monetary incentives to stay healthy.

The onset of chronic disease would decrease. The complications of chronic disease would also decrease.

If a patient had a chronic disease at the onset of this new system and controlled their disease well in order to avoid acute and chronic complications of the chronic disease the healthcare system could reward them with a bonus at the end of the year. They would avoid costly hospitalizations.

Consumers would demand and pay to be properly educated to avoid complications of their chronic disease

An added benefit is that there would be less doctor visits and hospitalizations. This would increase healthcare capacity. It would enable the country to provide care for the entire population rather that force the healthcare system to abs
orb additional patients and create shortages resulting in rationing and decreasing access to care.

When people are motive by monetary incentives they are innovative. Innovation stimulates efficiency and decreases costs. It is important to have consumers be responsible for themselves and not dependent on the government.

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

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Summary Blogs to Repair the Healthcare System


Stanley Feld M.D.,FACP,MACE

I am posting what I consider summary blogs. It would be difficult to read all the summaries in one sitting. I compiled this list for people who have just started following “Repairing the Healthcare System.” The links are intended to get you started and to be used as a reference.

The links below are my view of the policies that must be adopted to Repair the Healthcare System. The letters written to President-elect Obama and then President Obama were written when he promised that everything was on the table and he was open to all ideas. It is now clear to me that nothing was on the table. He will expand a government entitlement the country cannot afford and most people would not want. President Obama should be concentrating on the real problems in the healthcare system.

If you follow the links in each article you will understand my views on the policies needed to repair the healthcare system. I believe it can be repaired without enlarging unaffordable entitlements and the resultant increase in public debt. I have proposed specific policy changes that will enhance quality, improve coverage and decrease costs.

The Healthcare System’s Problems Part 1

The Healthcare System’s Problems Part 2

The Ideal Medical Savings Account

The Ideal Electronic Medical Record Part 1

The Ideal Electronic Medical Record Part 2

E prescriptions

Real Price transparency

The Definition Of The Physician Patient Relationship Part 1

The Definition Of The Physician Patient Relationship Part 2

Dear President Obama Part 1

Dear President Obama Part 2

Dear President Obama Part 3

Dear President Obama Part 4

Dear President Obama Part 5–elect-barack-obama-part-5.html

Dear President Obama Part 6

Rationale for Effective Malpractice Reform Part 1

Rationale for Effective Malpractice Reform Part 2

Electronic Medical Record Stimulus Fiasco Part 1

Electronic Medical Record Stimulus Fiasco Part 2

Electronic Medical Record Stimulus Fiasco Part 3

Call to Action


Dear President-elect Obama : Part 3


Stanley Feld M.D.,FACP,MACE

A huge problem in the healthcare system is mistrust between all the stakeholders. Medicare Part D is one example of abuse to consumers by the healthcare insurance industry and the government.

Physicians mistrust the government and healthcare insurance industry because of delayed Medicare reimbursements. The government outsources administrative services for Medicare claims to the healthcare insurance industry. The government pays these companies for claims processing.

The government states that Medicare overhead is only 2%. The healthcare insurance industry has published an overhead of 15%. Does this mean the healthcare insurance industry overhead without a surcharge is passed on to Medicare? In that case Medicare’s total overhead would be 17%. My guess is Medicare’s total overhead is closer to 20% including an added surcharge.

The vendor for Medicare (the healthcare insurance industry)  in California, Nevada and Hawaii is holding back physician reimbursement. In the late 1980 physicians were promised they would be reimbursed within 10 days by Medicare if they electronically billed. The billing software was provided free of charge and installed by the vendor. Now in California, Nevada and Hawaii there is an unpaid claims backlog of up to nine months.

Doctors across California and in two other Western states are owed millions of dollars in backlogged Medicare reimbursements, leading some physicians to turn away elderly patients and pushing others to the brink of bankruptcy.”

How did this happen? The problem has resulted in a California Medical Association law suit. Law suits only add to the cost of medical care as well as an increase in mistrust.

California is not the only state in which this has happened. It has happened to many physicians in Texas also. I suspect the delay in reimbursement is happening in many other states as the administrative service providers (vendors) try to hold on to the float of the cash as long as possible.

“In the most extreme cases, doctors have not been paid since February. Others are owed hundreds of thousands of dollars. Doctors who serve high numbers of Medicare patients say they are defaulting on rent, laying off staff and begging drug suppliers not to stop shipments. One cardiologist said she’s even resorted to doing the office laundry to cut costs.

“Economic stress leads to mistrust.” This should not be happening as everyone should be working together to repair the healthcare system

“Medicare owes Dr. Tim Ganey and his Bay Area practice of oncologists $750,000 in outstanding claims. He sought grace periods from vendors for his drug payments, but now he’s running out of time. He won’t be able to order more chemotherapy treatments unless he pays his bill.
“The things that we’re dealing with, they’re not elective things,” Ganey said. “They’re pertinent to people either fighting their cancer or being cured of their cancer.”

Physicians are always given excuses when Medicare or Private insurance misdeeds are highlighted. There are two excuses published in this case of delayed reimbursement.

“The holdup is twofold. By May, doctors were supposed to be using a new universal identification number assigned by the Centers for Medicare and Medicaid Services. Without the new number, which is like a Social Security number, doctors can’t get reimbursed. Scores of doctors still waited for those numbers.”

Most physicians are using the new physician identifier (NPI). There was a long delay by the government in setting a deadline for its use because of delays in physicians applying for it . Now most states will not renew physicians’ medical licenses without an NPI. A NPI can be obtained instantly on a government web site. I suspect this point is an excuse.

The second excused presented;

“In September the federal agency switched to a new claim processor for its 90,000 California providers. The move to Palmetto GBA in South Carolina, part of a national effort to reform Medicare contractors, compounded the billing issues and left even doctors who had their universal identification numbers waiting months for reimbursement.”

This does not make sense. If the government was moving to a better administrative service organization (healthcare insurance company DBA ASO) why is this ASO worse than the old one?

“This is just a complete disaster,” said Dr. Dev Gnanadev, medical director and chairman of the Department of Surgery at Arrowhead Regional Medical Center in Colton and president of the California Medical Assn.”

“Rep. Henry Waxman (D-Beverly Hills), whose office was contacted by at least two dozen doctors, called the transition to the new contractor “marred by missteps.””

Nevada has the fastest-growing Medicare population in the nation and physicians there are having the same problem with Palmetto.

“If we’re still dealing with this in January or February, Medicare patients are going to have serious access problems,” said Larry Mathies, executive director of the Nevada State Medical Assn.”

I am sorry. Excuses do not work any more. If the previous vendor was insufficient, why hire a vendor that almost paralyzes the medical profession’s ability to deliver care.

President elect Obama, beware of what your goal is with your national insurance exchange and your plan to expand Medicare Part C in its present form. The healthcare insurance industry is going to be your administrative service provider and the costs of healthcare will continue to escalate. They will control consumers healthcare dollars that the government will be providing and abuse your physician workforce.

It is much wiser to let consumers administer the first $6,000 of the healthcare dollar needed for a family of four and provide real healthcare insurance with the second $6,000 while creating incentives and education in order for consumers to be wise and fugal consumers. Any government subsidies for healthcare system with this design will be money well spent and reduce the cost of healthcare.

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Dear President –Elect Obama : Part 2


Stanley Feld M.D.,FACP,MACE

In my first letter I said repairing the healthcare system was simple. I pointed out the problems in our industrialized food system and its impact on the environment, our energy dependence and our healthcare systems’ costs. The industrial food industry contributes at least 300 billion dollars in increased cost to the healthcare system.

A healthcare cost saving of at least $150 billion dollars could occur if the complications of chronic disease could be decreased by 50%. The practices of chronic disease management using prevention of disease and evidence based medicine makes this promise possible.

The problems in the healthcare system are great. The initial question is who is at fault. All the stakeholders are at fault. The stakeholders are the healthcare insurance industry, the government, the hospital systems, the physicians and most importantly, the patients.

The primary stakeholders are patients with physicians a close second. Without patients or physicians we would not have a healthcare system. Healthcare insurance companies, the government, and hospitals are secondary stakeholders.

The healthcare insurance industry has turned out to be the biggest villain. It has taken advantage of the dysfunction of the government and weakness of patients and physicians as lobbying groups. The control of power in healthcare is in the hands of the healthcare insurance industry. The rules and regulations must be changed so that patients gain control of the healthcare system.

The healthcare insurance industry has abused this power. It has manipulated congress and the administration to serve its own vested interest.

The result is grotesque salaries for executives and excess administrative fees. Our healthcare system is supposed to be for the benefit of the consumers (patients), not for the benefit of the healthcare insurance industry.

The healthcare industry has restricted access to care and has made interpretation of payment for care impossible. It has decreased physicians’ reimbursement and withheld payments for services rendered without explanation or justification.

The government outsources the administration of Medicare and Medicaid to the healthcare insurance industry. The government calls them vendors. There are many examples of healthcare insurance industry abuse of the healthcare system. Medicare Part D fees for 2009 have just been published with the consent of the government. These new fees are abusive to seniors. It is difficult to understand the government regulators reasoning.

Seniors on fixed incomes need a reliable drug coverage plan. The healthcare insurance industry worked for four years to figure out a system that would be to its advantage and not the seniors’ advantage.

The government subsidizes Medicare Part D. Yet the government does not have the right to negotiate drug prices. I have exposed the abuses of Medicare Part D in detail. The abuses stem from the high deductibles and a doughnut hole that does not cover drug costs after a certain amount is spent by seniors for drugs.

Humana and United Healthcare rushed to insure for Part D because they visualized the money making opportunity quicker than most. Both companies also realized that as healthcare insurance premiums increased in the private sector there would be more uninsured consumers. The less lives covered the lower its profit. Therefore a drug plan leveraged in their favor sponsored by the government would cover the decrease in profit in the private sector.

United Healthcare paid AARP over 4 billion dollars to be their exclusive carrier for AARP senior members. There is no shortage of complaining from AARP’s seniors. The payment for sponsorship has not been fully disclosed nor it’s ethics been investigated.

UnitedHealthcare made a profit of $4.7 billion dollars last year from Medicare Part D at patients’ and the government expense. Despite this profit the monthly fee has increased over the last three years from $15 to $27 and in 2009 to $38 a month with the government’s permission.

UnitedHealthcare convinced government regulators they needed a premium increase in order to cover a shortfall. UnitedHealthcare compromised by changing the drug benefit before hitting the doughnut from $2300 to $2700 and lowering the amount you have to spend getting out of the doughnut from $5200 to $4700.

A careful analysis of the math is in favor of the healthcare insurance companies. Seniors have flocked to Wal-Mart and others to buy $4.00 per month generics paying cash and not using Medicare Part D “insurance”. They are paying cash for rather than putting their prescriptions on their Medicare Part D plan. If they put the prescription on Medicare Part D their co-pay would be $6.00 for a month’s supply of medication rather than $4.00 to Wal-Mart. The prescription could be charged between $20 and $50 toward the doughnut even though the healthcare insurance company probably only paid Wal-Mart $4.00. None of these prices are transparent.

President-elect Obama, the problems with Medicare Part D would be a good place to start to understand the abuse of this non transparent system. Similar abuses occur with government outsourcing Medicare Part A and B and probably government employee benefit Part C.

This is a tremendous waste of government and consumer resources for the benefit of the healthcare insurance industry. Real price transparency is essential if you are going to make any progress in reducing the cost of the healthcare system.

Real price transparency in this case means: What is the cost of the drug to the pharmacy? What is the cost of the drug to the healthcare insurance company? How is the price of the drug calculated toward the doughnut? How does the government subsidize the healthcare insurance companies for administration of the program? What would be a reasonable profit for the healthcare insurance industry?

I suggest before your administration gets busy penalizing patients with decreased access to care and physicians with decreased reimbursement, your healthcare advisors should dig deeply into the abuses of the real villain in the healthcare system, the healthcare insurance industry.

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

  • Alan Shimel

    You are right on here Stan. Government approved hikes in premiums should be pegged to the profit these insurance companies are making. Crying with two loafs of bread under each arm is just not right!!

  • Darrell Pruitt

    Dr. Feld, it is refreshing to hear your voice. Very few have the courage to speak up about ambitious stakeholders in healthcare – stakeholders who would have consumers believe that bureaucrats, healthcare IT executives and insurance MBAs are as critical to healthcare delivery as doctors and patients.
    With all due respect, Dr. Feld, I see that someone has successfully taught you to thoughtlessly accept the label “stakeholder” for yourself and your patients. The label you were pushed into buying brings doctors and patients down to the vendor’s level of importance. It is an old stakeholder trick based on semantics. It has to do with spin and other stakeholder PR talents. These guys are slick. And they are empowered.
    On December 21, 2007, the National Committee for Vital and Health Statistics (NCVHS) – an assortment of stakeholders who tell HHS what HHS likes to hear – submitted a letter recommending actions for “Enhanced Protections for Uses of Health Data” to Secretary Michael Leavitt encouraging the elimination of the term “secondary uses” for patient health records.
    “NCVHS observes that ‘secondary use’ of health data is an ill-defined term and urges abandoning it in favor of precise description for each use of health data.”
    The subtle underlying rationalization is that all stakeholders, including doctors and patients, are equally important in a democracy. Since doctors and patients are intentionally poorly represented in stakeholder committees that report happy things to the HHS, such as the NCVHS, CCHIT and the future AHIC Successor Inc., stakeholders unanimously win their power in fair democratic fashion, again and again. And that is why one can expect things to fall short of swell for doctors and patients.
    We are not stakeholders. As doctors and patients, we are principles and we must aggressively fight for the welfare of patients, just like you are doing. Otherwise patients have no representation at all.
    We must be transparent and doctors must be paid fairly. This is too harsh for some to imagine, much less to say out loud, but consumers should be aware that ethics is not free, and you get what you pay for. There are no bargains in spite of what glossy managed care folders advertise.
    Patients and their doctors are principles, not stakeholders. Healthcare is not a natural, renewable resource and mandates are not windfall profits. Patients always suffer the final bill.
    Keep up the good work, Dr. Feld. We’ll overcome stakeholders. We must. Darrell K. Pruitt DDS

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