Stanley Feld M.D.,FACP,MACE

President Obama, here we go down the road of unintended consequences and wasting taxpayers’ money.

“Baylor Health Care System plans to ask for some of the state’s federal economic stimulus money for two of its multimillion-dollar projects.”

You have given states economic stimulus money without control over how it is to be spent. Is a grant to Baylor Health Care System going to stimulate the economy? Is this going to repair the healthcare system?

Baylor’s request reminds me of a story about the University of Texas, Southwestern Medical Center’s legendary former chief of medicine Donald Seldin M.D., MACE.

In 1952, at the age of 33, was named chief of medicine at Southwestern Medical School. He came to Dallas from Yale as an accomplished nephrologist. Southwestern Medical School’s physical facilities at the time were a group of Quonset huts.

At that time Dr. Seldin was invited to attend a meeting on how to cure arthritis in the indigent community. The committee for the cure of arthritis had already decided on it plan for cure.

The plan was presented by a retired army general. He said the city fathers had to fund twenty fully equipped ambulances at $20,000 each. The ambulances would bring indigent people to Parkland Memorial Hospital for treatment.

As the story goes, Dr. Seldin had one of his now famous outbursts. He told them it was totally illogical and a grand waste of 1952 dollars. He said city fathers should grant Southwestern Medical School $200,000 for him to establish an annuity. With this annuity he would bring one of the most famous arthritis researchers in the country to Dallas to find the cure for arthritis. Somehow he convinced the city fathers of his logic. He had an endowment to bring Dr. Morris Ziff to Dallas to head a new form Department of Rheumatology. In his lifetime Dr. Ziff almost found the cure for rheumatoid arthritis. He trained hundreds of Rheumatologists. They will find the cure.

“Baylor is seeking money for a cancer center to be built near downtown Dallas and a diabetes center in South Dallas. Baylor would not say how much it intends to request.”

President Obama, your stimulus money should be going to finding a cure for the dysfunctional healthcare system, not throwing money at an old system.

“A request for stimulus money could raise eyebrows because Baylor has said it has enough money for the projects. The stimulus money, if granted, would be used to hire more people from within the community, said Kristi Sherrill, Baylor’s vice president of government affairs.”

Isn’t that a sweet answer? The money will be used by Baylor to build a facility. In turn Baylor will charge the government for care of the patients that come to the clinics.

"Any additional funding granted to these two projects, both already under way, would be used to directly help patients fight two of the biggest health issues affecting North Texans," cancer and diabetes, said Sherrill.”

Doesn’t this sound like the rheumatoid arthritis story? It seems like someone in the state of Texas gets it. It is not clear whether Governor Perry gets it.

“Talmadge Heflin, director of the Center for Fiscal Policy at the Texas Public Policy Foundation in Austin, said his organization believes that stimulus money should be used for one-time projects.”

"We believe they should not use the money in a way that would create an ongoing obligation for the state," Heflin said. "And we don’t believe the money should be spent just because you can get it."

Think about it President Obama. You gave the money to the states. The states are going to spend it as they wish. It might not comply with your good intentions to repair the healthcare system or stimulate the economy. Your goals are good. The route you are taking neither repairs the healthcare system nor stimulates the economy.

The most pointed statement was made by a comment at the end of Jason Roberson in the Dallas Morning News article revealing Baylor’s intentions

“Watch all the little piggys run to the big, fat Federal teat.
I got a hog pen that needs finishing. Could I get some stimulus funds for that? It would be the compassionate thing to do.”

Enlightened Rogue

Baylor does not need the money. They have plenty of funding and creditworthiness. Nonprofit hospitals already receives 32 billion dollars in subsidies from the federal government to service the indigent. The nonprofit hospital only spend 5 billion retail dollars in service.

“Regardless of what economic stimulus money it receives, Baylor appears to have the money and creditworthiness to complete its projects.”

President Obama, a request of this sort has plenty of destructive unintended consequences. I suggest you hire people to figure out the cure of the healthcare system and not throw taxpayers money out the window for worthless ambulances that will neither cure the problems nor stimulate the economy.

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

Stanley Feld M.D.,FACP,MACE

America’s present healthcare crisis is neither a Democratic nor a Republican issue. It is an American issue. It can be solved logically and swiftly using common sense. Let the American consumers control their healthcare dollars. Provide consumers with financial incentives for wise healthcare purchases and education for good health maintenance to prevent the onset of a chronic disease.

President Obama’s healthcare team is setting up a healthcare system where the government will make the healthcare choices for Americans. Ultimately government will ration care.

Daily, Americans are overwhelmed by bad news sound bites. For years we have heard that our healthcare system is broken. It is broken because the government has broken it. Only 20% of the people are sick at any one time. The other 80% do not think there is a problem with the healthcare system. In the last 25 years most Americans have heard of or experience horror stories about the dysfunctional healthcare system. The goal should be to repair the problems and not impose another dysfunctional healthcare system on us.

First, it was HMO’s and the restrictions of access to care. Then, it was Managed Care. Managed Care turned out to be managed costs and restrictions on access to care. Then, it was the ever increasing healthcare insurance premiums. Now, it will be the government‘s experiment with a single party payer system. An experiment that is destined to fail.

The Bush administration did nothing about repairing the healthcare system. Correction. Everything President Bush tried to do the congress rejected. The healthcare insurance industry and its executives made grotesques profits while restricting access to medical care and decreasing physician reimbursement.

Medicare and Medicaid’s costs have continued to rise. The healthcare insurance industry controls Medicare’s dollars. The Bush administration did nothing to stop it. The Bush administration recognized that bureaucratic entitlements would destroy our economy. The administration tried to get rid of the Medicare entitlement by providing a bonus to the healthcare insurance industry for the takeover of Medicare with Medicare Advantage and Medicare Part D. The cost to seniors and the profit to the healthcare insurance industry has been huge.

Neither Republicans nor Democrats in congress have done anything logical to fix the healthcare system. The executive and legislative branches have only generated greater mistrust among all the stakeholders in the healthcare system.

Congress knows the increasing Medicare costs are unsustainable. The Congressional Budget Office predicts a 100 TRILLION dollars per year deficit for Medicare alone in 50 years.

Why would a responsible member of congress or the executive branch want to increase an entitlement that does not work to included the entire population?

Today’s sound bites have frightened most of the population. Americans are anxious to be rescued by anything that sounds good. All that is needed is a well crafted public relations campaign of sound bites promising salvation.

Liberal Democrats have put together such a public relations campaign. President Obama has captured the lead to be society’s savior. It does not matter whether his proposals are logical or if they will work. It sounds good. America is ready to go for it.

Republicans are feeling overwhelmed. They intuitively understand that a government controlled single party payer system will not work. Massive government programs have not worked effectively in the past. Why should they work now? Consumers should be empowered to make their own decisions. Government should not make decisions for them.

An organization call the “Leadership Conference for Guaranteed Healthcare , the national single pay alliance” has crafted such a public relationship program. They have cobbled together a group of social networks to express the anger and fears felt by the American public. Their sound bites are compelling.

President Obama will play off these social networks to force his change in the name of goodness and justice for all. It is Tom Daschle’s doctrine. Most of the proposals will fail. They will fail not because they are unjust. They will fail because the route to achieve them is wrong. The costs will be unmanageable as we have seen in the Massachusetts experiment..

The sound bites are indeed compelling:

1. Everybody In, Nobody Out. Universal means access to health care for everyone, period.
2. Portability. If you are unemployed, or lose or change jobs, your health coverage stays with you.
3. Uniform Benefits. No Cadillac plans for the wealthy and Pinto plans for everyone else, with high deductibles, limited services, caps on payments for care, and no protection in the event of a catastrophe. One level of comprehensive care for everyone, regardless of the size of your wallet.
4. Prevention. By removing financial roadblocks, a universal health system encourages preventive care that lowers an individual’s ultimate cost and pain and suffering when problems are neglected and societal cost in the over-utilization of emergency rooms or the spread of communicable diseases.
5. Choice. Most private insurance restricts your choice of providers and hospitals. Under the U.S. National Health Insurance Act, patients have a choice, and the provider is assured a fair payment.
6. No Interference with Care. Caregivers and patients regain their autonomy to decide what’s best for a patient’s health, not what’s dictated by the billing department. No denial of coverage for pre-existing conditions or cancellation of policies for "unreported" minor health problems.
7. Reducing Waste. One third of every private health insurance dollar goes for paperwork and profits, compared to about 3% under Medicare, the federal government’s universal system for senior citizen healthcare.
8. Cost Savings. A guaranteed health care system can produce the cost savings needed to cover everyone, largely by using existing resources without the waste. Taiwan, shifting from a U.S. private health care model, adopted a similar system in 1995, boosting health coverage from 57% to 97% with little increase in overall health care spending.
9. Common Sense Budgeting. The public system sets fair reimbursements applied equally to all providers, private and public, while assuring that appropriate health care is delivered, and uses its
   clout to negotiate volume discounts for prescription drugs and medical
   equipment.
10. Public Oversight. The public sets the policies and administers the system, not high priced CEOs meeting in private and making decisions based on their company’s stock performance needs.

Who can argue with any of these points? The major question is can a government bureaucracy administer this system effectively without impinging on citizens’ choices, rights and freedoms.

Is this the solution to the high incidence of chronic disease and the dysfunctional healthcare system?

My answer is no. Americans are being duped once more by cool sound bites.

The Alliance has put together interesting groups. They have used the internet to leverage the Alliance. They have used the same technique that President Obama used to become President. They have formed giant social networks and put them together. President Obama can easily play off this coalition as evidence for the need by the public for a single party payer system.

The social networks and President Obama have outflanked common sense. They have created a false hope and it will fail to repair the healthcare system. .

Leadership is needed to formulate a common sense strategy to solve the healthcare system’s dysfunction for all American at every socioeconomic level. Neither the Democrats or the Republicans have such a plan.

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

Stanley Feld M.D.,FACP,MACE

I have called for real price transparency from all the stakeholders. The healthcare insurance industry has stated that it will become more transparent. So far its pricing has been opaque. There are many levels of opacity to its pricing.

The Texas Medical Association (TMA) has taken a historic leadership position in defining what it thinks the healthcare insurance industry code of conduct should be in 2009. It is very complete. I hope it is adopted by the state of Texas and every other state in the nation. It will serve to lower the cost of healthcare insurance and increase the insurance coverage of many of our citizens.

“Health Insurance Code of Conduct 2009

“These measures would ensure transparency and accountability in the way health insurance companies conduct business:”

• “Health Coverage Cancellations: Require an independent review of all decisions to cancel an individual health insurance policy prior to the actual cancellation.”

Each point in the TMA’s code of conduct peels off a level of price opacity. The TMA should call to abolish the healthcare insurance industry’s ability to cancel healthcare insurance.

• “Calculation of Premium Quotes: Subject health insurers to “file and use” requirements at the Texas Department of Insurance (TDI), like other kinds of insurers.”

The Texas Department of Insurance (TDI) controls permits for the sale of insurance in the state of Texas. The TDI has never had the same pricing information from the healthcare insurance industry as they have from other insurance vehicles.

• “Calculation of Medical Loss Ratio: Require health insurers disclose how they spend the patient’s premium dollar.”

The healthcare insurance company will not only have to disclose how they spend the patient’s premium dollar, they will have to prove it. This is an area in which expenses are inflated by the healthcare insurance industry.

• “Unregulated Secondary Networks (Silent PPOs): Regulate how a physician’s contract information is sold, leased, or shared among health insurance companies.”

Unregulated secondary networks must be regulated because the healthcare insurance industry has long practiced price fixing. Price fixing does not work and leads to further system abuse and mistrust.

• “Physician Rankings: Require health insurance companies to use scientifically valid criteria to evaluate physicians’ performance and disclose those criteria in advance.”

I do not believe physicians are afraid of being evaluated. I believe they are afraid of being judged by defective criteria leading to reimbursement penalties.

• “Claims Processing: Prevent health insurance companies from reverting to their old, unethical ways of processing claims.”

I have pointed out abuses that have occurred in several states. Minimal monetary fines do not deter this abuse. It must be stopped. The healthcare insurance companies should lose their privileges to sell healthcare insurance in the state.

• “Timely Health Insurance Information: TMA’s “Health Insurance Product Labeling Plan” would require health insurers and their brokers to use standardized reporting measures to help employers and individuals make direct, side-by-side product comparisons.
• Once a plan has been selected, patients should have convenient access to benefit information when they are making their health care   decisions. Health insurers should make this information easily available. Almost every card in your wallet has some ability to provide data — except your health insurance card. There is absolutely no reason why health insurers cannot provide accurate, real-time information regarding the different benefits and exclusions.”

Buyers of healthcare insurance should have the ability to know the provisions of their insurance clearly and not be surprised by their lack of coverage when they get sick.

• “ Routine Medical Care for Clinical Trials
  Texans participating in a clinical trial should be able to use their health insurance to pay for routine medical costs — especially when they are suffering from a life-threatening disease or condition.”

Many states have this provision. Texas does not. Patients have had to spend out of pocket expenses unexpectedly.

• “ TDI needs authority to require health plans to disclose the methods and data they used to set “maximum allowable” amounts for out of network services.”

There is a tremendous burden place in our mobile society on citizens if they get sick while traveling for business or pleasure.

• “TMA opposes health plans’ attempts to prohibit balance billing or to establish wholly inadequate payment rates for non-network physicians and hospitals.”

I disagree with the TMA balance billing position. We have to have total transparency from all stakeholders. I have maintained often that all stakeholders have to be subject to real price transparency including physicians

• “ Regulation of Preferred Provider Organizations (PPOs)
  Currently the discounted rates physicians negotiate with health plans are being hijacked by unregulated PPOs. These entities, called “silent” and “rental” PPOs, shop around to find the lowest rate a physician has agreed to with any health plan. Then the PPO sells, resells, or leases that discounted rate to insurance companies, discount brokers, and other unregulated health care businesses without the physician’s knowledge or permission. Fourteen states outlaw these arrangements. Texas should, too.”

Few healthcare policy wonks know about this practice. It is a very effective practice by the healthcare insurance industry to create price controls. The results in further distortions in the healthcare system.

If the Texas legislature passes all these proposals it will make the state of Texas a more attractive state for large multinational corporations to set up corporate headquarters. Presently a powerful stimulus is our low tax rate.

I believe these proposals should be national for the benefit of all Americans. It will go a long way toward Repairing the Healthcare System.

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

Stanley Feld M.D.,FACP,MACE

The Congressional Budget Office report states that President-elect Obama’s healthcare plan would carry a high price tag. The healthcare plan would generate only modest savings.

“Mr. Obama and other Democrats have not been precise about the cost of their proposals, nor have they said in detail how they would pay for them.” Some of the options, including proposals to increase taxes on cigarettes and nondiet soft drinks, are sure to meet stiff political opposition.

President-elect Obama has not been precise about any of his proposals on purpose. Both political parties say they will make a serious effort to overhaul the health care system in 2009. In our current economic crisis it is essential to that. As unemployment rises the uninsured population will rise. The fear in the population will create pressure on congress to pass any bill that promises hope and relief.

However, President-elect Obama’s transition team is going about the overhaul of the healthcare system the wrong way. I am positive they think they are doing it the right way.

“One bright spot in a generally bleak picture was the estimate of potential savings from a requirement for doctors and hospitals to use health information technology (EMR), including electronic medical records, as a condition of participating in Medicare.”

Such a requirement could save the federal government $7 billion in the first five years and a total of $34 billion over 10 years, by reducing medical errors and avoiding unnecessary tests and procedures, the budget office said.

President-elect Obama does not plan to create a universal electronic medical record. Electronic medical records are essential to repair the healthcare system. The administrations healthcare transition team believes it can force physicians to purchase, install and service electronic medical records most physicians cannot afford. The government plans to make EMR a condition to participate in Medicare. Many physicians would not mind being forced out of Medicare.

Most installed EMRs in large hospital systems are not fully functional. Many do not have total functional cross hospital system compatible interfaces that would allow efficient flow of information. Most EMRs do not allow for real price transparency that can stimulate efficient use of healthcare system resources.

If the government requires physicians to buy an EMR by penalizing them, physicians will drop out of the Medicare program. The result will be the creation of a shortage of physicians. The government should make available a fully functional EMR free of charge. It should not require a capital outlay. Physicians would pay by the click monthly.

Without action by Congress, the report said, health costs will continue to soar, the number of people without insurance will rise by nearly one million a year, to a total of 54 million in 2019, and spending on health care will increase to 25 percent of the gross domestic product in 2025, up from 16 percent in 2007.

All agree that something must be done to repair the healthcare system. The Congressional Budget Office (CBO) must work with the data they have even if the data is incomplete. CBO’s estimates are modest. During our present economic recession I think the number of uninsured will rise to 54 million by the end of 2009, not in ten years.

“Lawmakers from both parties said they would pay close attention to the cost of new federal subsidies for health coverage because these subsidies — unlike the one-time bailouts for banks and other financial institutions — would be recurring federal obligations for years to come.”

A large problem is that all the proposals would force a stakeholder to do something. In order to accomplish real change the government needs to provide incentives for stakeholders, not mandates. Historically, mandates never work.

1. Requiring employers to provide health insurance to their employees.

1a. or pay a fee to the federal government would bring in $47 billion of new federal revenue in the next 10 years, the report said.

The savings of 4.7 billion dollars a year is insignificant in a healthcare system that has 150 billion dollars of administrative waste a year. The government should go after the administrative waste.

A proposal to establish a national insurance pool for people who cannot obtain coverage on their own in the individual market would cost $16 billion in the next decade in subsidies.

The real issue is the need to put the individual market on a level playing field with the group market. Secondly, it is essential consumers be in charge of their healthcare dollar. Presently the healthcare dollar is owned by the healthcare insurance industry. Ownership of the healthcare dollar will remain with the healthcare insurance industry in a President-elect Obama’s administration.

Mr. Obama and many other Democrats want the government to negotiate with drug manufacturers to get lower prices for Medicare beneficiaries.

This is an important action. Medicare Part D is a structural disaster. Medicare Part D has to be restructured to be in favor of the consumer, not the healthcare insurance industry. Part D was a good idea turned into an overpriced plan. The plan does not improve patient compliance because patients cannot afford the medication. The result is that it will not decrease the complication rate of chronic disease.

But the budget office said Medicare could save $110 billion in the next 10 years if Congress simply imposed a form of price controls, requiring drug makers to provide the government with a 15 percent rebate, or discount, on brand-name drugs covered by the new Part D of Medicare.

Historically price controls do not work. Incentives and competition work, if Medicare Part D was structured correctly there would be no overcharging for medication.

Under the current proposals the saving would be insignificant compared to the rising cost because President-elect Obama’s team is trying to fix the wrong things.

Doing what they are proposing is going to result in a more expensive healthcare system. The result will be cost overruns and a decrease in access to care and quality of care.

We have all experienced inefficient government rules and regulations. We must brace ourselves for the worse and start understanding the deficiencies now so we can speak out with one voice.

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

Stanley Feld M.D., FACP, MACE

A major defect in our healthcare system is that the healthcare insurance industry controls the entire healthcare dollar. In California, Nevada and Hawaii the healthcare Medicare vendor has held back physician reimbursement and restricted access to care.

Private healthcare insurance companies have done the same.

Government funded healthcare programs such as Medicare and Medicaid outsource their administrative services to the healthcare insurance industry. The federal government provides Medicaid funds to state governments. State governments outsource their administration services to the healthcare insurance industry. The healthcare insurance industry controls these dollars.

A recent headline in the Dallas Morning News read, “Is Texas looking out for you? Health-care Outsourcing is rolling on, but many patients suffer from silent treatment.”

Evercare of Texas, a unit of the giant UnitedHealth Group, is the Medicaid administrative services vendor for more than 80,000 elderly, blind or disabled North Texans.

“We help make it easier to get the care you deserve,” the company promises on its Web site.”

The state has received hundreds of complains about its administrative services vendor. Evercare’s excuse is the same as Palmetto’s excuse in California

“Evercare said it experienced the normal start-up problems associated with a program that serves tens of thousands of people.” “It was a massive undertaking,” said Beth Mandell, regional executive director of Evercare of Texas.

Evercare has been servicing Texas for a while now. It was fined 1 million dollars in 2007 and $400,000 in 2008.

A few horror stories can be expanded to many. The healthcare insurance industry controls the healthcare dollar. They are in the business of making money. It would be much easier and less costly if patients controlled their healthcare dollar.

“Willis Stewart, a 61-year-old carpet layer who had his teeth pulled during treatment for mouth cancer, said he has waited three months for Evercare to approve the dentures that will allow him to eat solid food again.”

“ Steven McGee, a 55-year-old truck driver disabled by multiple sclerosis, said he phoned the company for seven months without reaching a medical coordinator.”

“Mary Hunt, a 72-year-old widow, said she has waited months for dental care. “They ought to call them ‘Nevercare,’ “ said Hunt, among the hundreds of people who have complained about denied or delayed medical care.”

Physicians have experienced the same difficulties with reimbursement that patients have experienced with receiving care.

“North Dallas doctor William Walton says caregivers must be vigilant in working with UnitedHealth, parent company of Evercare of Texas.”They’re dishonest, and they’re sneaky,’ Walton said.”

The state’s recourse is to fine Evercare. However the fines are insignificant compared to the money made by Evercare while exercising this behavior.

“UnitedHealth caught the front end of the Texas outsourcing wave launched by Gov. Bush. Since 2003, the state has paid the company’s Evercare and United Healthcare units more than $1.2 billion to provide managed care to more than 255,000 Texans under four programs.”

Fines are not high enough to be a deterrent to the abuse of patients, physicians and other vendors.

“The state has fined Evercare, more than $1 million in the last year, ordering it to increase staff and fix other problems. The most recent fines, totaling nearly $400,000, were in reaction to the mounting complaints about the North Texas program.”

The healthcare insurance industry does this all over the country. No one seems to connect the dots. The only recourse governments have exercised is to fine these companies. The fine is usually minimal compared to the healthcare insurance company’s financial gain.

President-elect Obama and HHS secretary Tom Daschle plan to provide universal healthcare coverage. Federal universal healthcare coverage in the present healthcare system will result in an expansion of outsourced administrative services. The state of Massachusetts has expanded outsourcing of administrative services. It has experienced massive cost overruns with little evidence of improvement in the delivery of care.

I fear that if and when the present Obama/Daschle plan provides universal healthcare to our entire population, Americans will suffer the same abuse with massive cost overrun and without appropriate recourse.

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

Stanley Feld M.D.,FACP,MACE

Consensus is usually defined as a general agreement by groups of people. Consensus decision-making is the process of developing a consensus. A consensus is theoretically inclusive, participatory, cooperative, and egalitarian. Egalitarian means all stakeholders in a consensus decision making process should be afforded equal input into the process. All stakeholders should have the opportunity to table, amend or block proposals.

The consensus decision making process should be solution oriented. It should strive to be all inclusive, promote compromise and resolve positions of difference.

President-elect Obama issued an important challenge to forming a consensus.

"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."

The consensus decision making process has been contaminated by President-elect Obama’s healthcare transition team in order to arrive at Tom Daschle’s predetermined solution. The results of the consensus building will be molded to fit the ideas the Secretary designate of HHS has to repair the healthcare system.

Dr. Val Jones had a Healthcare Community Discussion in her home. It seems the healthcare transitions teams goal is accumulate as many horrible healthcare interface stories as they can to use as evidence of the need for the new bureaucracy to be imposed on the healthcare system.

“President-elect Obama and Secretary of HHS designate, Tom Daschle, invited concerned Americans to discuss healthcare reform in community groups across the country. My husband and I hosted one such group at our home in DC yesterday. Although we had been instructed to compile a list of compelling stories about system failures – instead we decided to be rebellious and discuss “what’s right with the healthcare system” and compile a list of best practices to submit to the change.gov website.

Even in Val’s attempt to be rebellious she had only one physician in her group.

“The event was attended by a wide range of healthcare stakeholders, including a government relations expert, FDA manager, US Marine, patient advocate, health IT specialist, transportation lobbyist, real estate lobbyist, health technology innovator, Kaiser-trained family physician, medical blogger, and EMR consultant. Here is what they thought was “right” with the healthcare system:”

The deck is intentionally being stacked against the private practice of medicine. It ignores the fact that eighty percent of the medical workforce is in private practice. Uwe Reinhardt said do not get your workforce mad. I would think private practicing physicians as a stakeholder should have significant input into forming a true consensus.

“President-elect Obama has picked up a hardheaded political strategist in Tom Daschle for his push to overhaul the nation’s healthcare system.”

I believe President –elect Obama has a great chance of overhauling the healthcare system. The problem, in my opinion, is elements of Tom Daschle’s overhaul are wrong. The public opinion manipulation will probably get some legislation passed, but will it be the best?

“ Learning from Clinton’s mistakes, the nominee for Health and Human Services secretary favors going on the political offensive to bring about reform.”

A common denominator in this consensus building is everyone agrees something has to be done to fix the healthcare system. The next administration is close to developing this common denominator. They are not building a consensus on what should be done. This issue has already been decided by Mr. Daschle. It does not matter if what is done is wrong.

“Guided by lessons from President Clinton’s healthcare debacle 15 years ago, Daschle has put a premium on cooperation between the White House, Congress and major healthcare interest groups, many of whom agree that major action on healthcare is vital.”

Bertrand Russell said it perfectly.

“What a man believes upon grossly insufficient evidence is an index into his desires — desires of which he himself is often unconscious. If a man is offered a fact which goes against his instincts, he will scrutinize it closely, and unless the evidence is overwhelming, he will refuse to believe it. If, on the other hand, he is offered something which affords a reason for acting in accordance to his instincts, he will accept it even on the slightest evidence. The origin of myths is explained in this way.”

Naomi Klein in the Shock Doctrine said in times of economic or political upheaval policies are enacted that could never have been passed in ordinary times. We are not living in ordinary times.

“Tom Daschle favors moving decisively to seize political momentum and, if necessary, cut off opposition, something he said Clinton failed to do in 1993.”

"This means going on the offensive," he wrote in "Critical," his recent book about healthcare,”

I do not believe Tom Daschle is going to repair the healthcare system. He does not fully comprehend the problems in the healthcare system. Brute force will not work. Aligning stakeholders’ incentives is the only thing that will work.

Stanley Feld M.D.,FACP,MACE

The role of patients with chronic diseases and their physicians must be clear to both patients and physicians. Physicians are coaches. Patients are players. They live with their disease 24 hours a day. Day to day fluctuations occur in the management of chronic disease. An excellent example is patients with hypertension. Blood pressure fluctuates all day long. A single blood pressure measurement during a visit to a physician once every six month is meaningless. Patients must continually monitor their blood pressure to evaluate the effect of their medication. Physicians have to help patients evaluate these data points to make logical medication adjustments.

Patients must to be inspired to manage their chronic disease. This requires patients having confidence in their coaches. It is hard work for patients to monitor their blood pressure daily and learn the meaning of the fluctuations in their blood pressure.

Only day to day blood pressure control is going to prevent the complications of a stroke or a heart attack. Physicians along with the patients’ input must make the necessary adjustments. An effective physician and patient team can make appropriate day to day adjustments.

This idea of mutual trust and confidence between coach and player is illustrated by something that happened between a teacher and me in high school. It illustrates the essence of an effective physician-patient relationship.

It was a rainy day in the spring of 1953 during my junior year in high school. I was on the high school baseball team. The team could not practice that afternoon because of the weather. The team was sent to the Study Hall for the 8^th period.

Ms. W. was one of the 8^th period Study Hall teachers. She was my geometry I and II teacher. I thought she was the greatest. I never missed a question in class or on a test. She came over to me that rainy spring day to say hello. She asked how I was doing in trigonometry.

I told her I was doing terrible. I could not learn a thing from Mr. B. Mr. B. was the chairman of the math department. He taught trig very descriptively. It had no meaning to me. He did not teach us to understand the logic of trigonometry and its uses. No matter how much I tried to derive meaning from the text book by myself the material covered did not stick. I felt Mr. B. suppressed my ability to learn and problem solve. His goal was to have us memorize the material.

Mrs. W. asked me which period I had trigonometry and lunch. I told her trig 5^th period and lunch 6^th period. She said great she taught trig 6^th period and could get me transferred to her class. I could have lunch 5^th period.

I was thrilled beyond belief. She also said she hoped I was aware there was a departmental quiz being given the next day. I would be required to take it. She said the chances are I would do poorly on the test but she encouraged me to study when I got home.

The most amazing thing happened that night when I started studying for the quiz. All of a sudden I grasped concepts I could not grasp previously. Now that I was in Mrs. W. class I solved problems I could not solve previously. A difficult textbook seemed easy.

The next day I went into her trigonometry class, took the test, and got 100%. I know this has happened to all of us at some time in our life. I know it was the result of my knowing that someone had trust and confidence in me and the conviction that I could do the job.

The magical therapeutic power of the patient physician relationship.

If a relationship is positive with mutual respect and commitment by physicians and patients, patients can learn about the pathophysiology of their chronic disease. In turn they can learn to manage their disease properly.

In practicing endocrinology I developed a patient physician contract to define this patient physician relationship. My son, Daniel, alluded to this contract in his letter to me.

Physicians must be dedicated to teaching patients to be the professor of their disease. Physicians must enable patients to want to be the professor of their chronic disease to avoid the complications of the disease. Eighty percent of the healthcare dollar is spent on the complications of chronic disease.

The lesson of Mrs. W. is a powerful lesson. Mrs. W. did enable me to be comfortable and confident in my learning situation because of her trust. She empowered me to learn by myself with her confidence in me.

Many times patients with a chronic disease are frightened by their disease. This fright makes it difficult to learn how to control their disease to avoid its complications. Physicians must deal with this through a positive physician patient relationship. A positive patient physician relationship can make it easier for patients to learn to control their disease.

Converting healthcare into a commodity is discouraging physician-patient relationships. The healthcare system cannot be repaired without effective chronic disease management. Chronic disease management will not be effective without effective patient-physicians relationships.

AACE Diabetes Guidelines, Endocr Pract. 2002;8(Suppl 1)
a. Sample Patient-Physician Contract
I understand that if I agree to participate in the System of Intensive Diabetes Self-Management, I will be expected to do
the following:
1. Dedicate myself to getting my blood glucose level as close to normal as possible by following the instructions of the
diabetes self-management team
2. Regularly visit the clinic for a physical examination, laboratory tests, and nutrition counseling; follow-up visits will
be scheduled every 3 months or more frequently if deemed necessary by my physician or other members of my
health-care team
3. Bring a detailed 1-day food record to each follow-up visit, provide necessary nutrition information for me and my
dietitian, and adjust my eating habits to meet the nutrition goals established by my dietitian
4. Use medications as prescribed by my health-care team
5. Monitor my blood glucose levels at home as instructed and bring the results to each follow-up visit
6. Follow my prescribed exercise plan
7. Obtain identification as a patient with diabetes, for prompt assistance in case of an emergency
8. Ask my physician and other members of my health-care team to explain any aspect of my care that I do not entirely
understand
I understand that if I do not monitor myself carefully, there is a risk of hypoglycemia.
I also understand that if I do not strive to normalize my blood glucose, I am at increased risk of developing the
complications of diabetes mellitus.
My signature indicates that I have read and understand the above agreement.
__________________________________________
Patient
________________
Date
I agree to provide the leadership for the diabetes self-management team. Team members will be available to answer
your questions and help you self-manage your diabetes. I will continue to encourage you to maintain the best possible
control of your diabetes.
__________________________________________
Physician
________________
Date