Stanley Feld M.D.,FACP,MACE

MICHAEL POLLAN wrote an inspiring article about climate change in the April 20, 2008 issue of the New York Times Magazine section.

I have substituted the word healthcare system in my minds eye every time he mentioned climate change. Mr. Pollan is describing exactly what has to be done for the healthcare. His major point is every individual has to get involved. The individual has to be aware of the issues and then act in his self interest and do his small part. The parts will add up to the necessary change.

Why bother? That really is the big question facing us as individuals hoping to do something about climate change, (healthcare) and it’s not an easy one to answer.

Al Gore’s “Inconvenient Truth” is scary, if true. Let us assume global warming is true for this argument. Al Gore’s suggestion to me as an individual seemed bizarre. I am happy to say it was also depressing to Michael Pollan, a person I admire.

“ No, the really dark moment came during the closing credits of Inconvenient Truth, when we are asked to change our light bulbs. That’s when it got really depressing. The immense disproportion between the magnitude of the problem Gore had described and the puniness of what he was asking us to do about it was enough to sink your heart.”

In thinking about it in terms of healthcare and general behavior we as individuals can make a big difference. People are social beings. They need other people. If we can create a trend we can make a difference even if others choose not to follow.

“ But the drop-in-the-bucket issue is not the only problem lurking behind the “why bother” question. Let’s say I do bother, big time. I turn my life upside-down, start biking to work, plant a big garden, turn down the thermostat so low I need sweater, forsake the clothes dryer for a laundry line across the yard, trade in the station wagon for a hybrid, get off the beef, go completely local (with my food purchases).”

If no one else did the same the only impact you would have is for yourself and your self interest. You would save money and improve you wellness. I was terrified to read about tilapia fish farms in Indonesia. How can we allow our government to allow its import? We have no idea of the conditions in Chilean fish farm where “Chilean Sea Bass” comes from. Restaurants make Chilean Bass sound romantic, sexy and expensive. However the details of these fish harvests are chilling.

If we the people change and do little things to improve our health the payback is beyond personal virtue. If everyone does the same the change in society will be enormous.

“ A sense of personal virtue, you might suggest, somewhat sheepishly. But what good is that when virtue itself is quickly becoming a term of derision? There are so many stories we can tell ourselves to justify doing nothing, but perhaps the most insidious is that, whatever we do manage to do, it will be too little too late.”

This is nonsense as science is beginning to show us. Nonetheless, we tell ourselves all kinds of stories to justify our weight, our food intake and our lack of exercise. We can make a difference in our health and healthcare cost if we are determined to change our behavior. Small changes in society’s trend setting can help change behavior for the better.

“ So do you still want to talk about planting your own gardens? I do. Yet it is no less accurate or hardheaded to say that laws and money cannot do enough, either; that it will also take profound changes in the way we live.”

We have seen money and laws cater to vested interests and not societal interests as they should. Individual actions add up. The most profitable center in a hospital is the Bariatric Surgery Center. Hospitals are reformatting themselves to all have Bariatric Centers. They would go out of business if we conquered obesity. This victory can only happen on an individual basis.

“Whatever we can do as individuals to change the way we live at this suddenly very late date does seem utterly inadequate to the challenge.”

So why bother? We should bother because we have a responsibility to ourselves and our children and grandchildren. We have a responsibility to repair the healthcare system before the ability to deliver the greatest healthcare on the planet implodes. We, the people, have to drive the change and make the politicians respond. Politicians are responding to the secondary vested interests.

“ The Big Problem is nothing more or less than the sum total of countless little everyday choices, most of them made by us (consumer spending represents 70 percent of our economy), and most of the rest of them made in the name of our needs and desires and preferences.”

This is the reason we need to own our healthcare dollar. We have to be motivated to drive the change.

“For us to wait for legislation or technology to solve the problem of how we’re living our lives suggests we’re not really serious about changing — something our politicians cannot fail to notice. They will not move until we do. Indeed, to look to leaders and experts, to laws and money and grand schemes, to save us from our predicament represents precisely the sort of thinking — passive, delegated, and dependent for solutions on specialists — that helped get us into this mess in the first place. It’s hard to believe that the same sort of thinking could now get us out of it.”

Michael Pollan hit the nail on the head. Whether it is climate change or healthcare we need to be responsible to ourselves. The inspiration lies in his next example.

“Sometimes you have to act as if acting will make a difference, even when you can’t prove that it will. That, after all, was precisely what happened in Communist Czechoslovakia and Poland, when a handful of individuals like Vaclav Havel and Adam Michnik resolved that they would simply conduct their lives “as if” they lived in a free society. That improbable bet created a tiny space of liberty that, in time, expanded to take in, and then help take down, the whole of the Eastern bloc.”

We have a government for the people by the people. We have tremendous power to influence our government. Our health is our most important asset. It is our responsibility to demand the infrastructure to help us maintain our health.

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

Stanley Feld M.D.,FACP,MACE

My son, Brad, had an interesting item in his blog of December 23, 2007.

“And – if you need more for your inner cynic, how about the article in today’s Rocky Mountain News titled Clouds hover in ethanol sky. E85 (assuming you can find it) apparently costs 78% less than regular unleaded gas but gets 71% less per gallon. Since its 85% ethanol, it presumably is less polluting (assuming that the total ethanol lifecycle consumes less energy than gasoline) but doesn’t save the consumer any short term money.”

I believe there is an invisible but real hand manipulating the corn for fuel debate. Each of the powerful stakeholders is simply pursuing its vested interest. The government “sovereign” of Adam Smith should make appropriate rules for the common good. Then the sovereign should get out of the way and let the stakeholders pursue its vested interests.

Several things are clear. Americans are becoming more obese each year. As Americans become more obese they develop more chronic diseases such as heart disease and diabetes mellitus. The increase in these diseases result in an increase in these diseases complications. These complications consume 80 to 90 percent of our healthcare dollar. We do little to nothing to support the prevention of these diseases or complications. The infrastructure of healthcare is on the verge of collapse. It is threatening America’s economic viability.

A large contributor to obesity and diseases resulting from obesity is the ubiquitous processed food. Processed food depends heavily on corn, corn oil and corn syrup. America’s dependence on foreign fossil fuel (oil and gasoline) is also threatening the sustainability of our economy. If we could shed ourselves of this fuel dependence and use renewable fuel sources our economy could remain viable.

A few weeks ago I suggested that our government ban the use of corn products in our food stuff. America should restrict is use for renewable energy only. This rule could solve our obesity problem and energy problem at the same time.

The food industry was bothered by this suggestion because the profit margin on processed foods, though difficult to calculate because costs are so opaque, is tremendous compared to the profit margin for producing fuel from corn. The farm industry could even genetically engineer corn to be 6 feet tall and generate more fuel per seed without adverse public opinion.

If the food industry produces corn for fuel plus foodstuff, they have an excuse to mark up food even higher than they have in the past year.

The fuel industry claims that the amount of fossil fuel to produce corn fuel (ethanol) results in a net increase in the cost of ethanol. Has the fuel industry never heard of solar and wind power to produce electricity to power the production of ethanol? One hundred years ago America used water power mills to generate electricity to manufacture all sorts of products. Water power represents another free electricity generating power source.

The point of the Rocky Mountain News article is that ethanol contains less energy than fossil fuel. Therefore the cost of the fuel is a wash. The cost of producing ethanol would be less if we used renewable sources such as wind and solar power to produce the ethanol. The government would have to make the appropriate rules and provide subsides for renewable sources. However, we would not run out of it or be dependent on others for it.

Recently, the automobile industry fought the government’s requirement for auto fuel efficiency.

I suspect it would be very easy to make ethanol fuel efficient cars. Toyota will show us how to do it. I would bet that our automotive industry could produce engines that would increase the energy output of fuel ethanol by simply modifying the fuel injectors. (Popular Mechanics 2007)

The point is none of the powerful stakeholders want to do any of the above. The government and politicians dependent on backing from these powerful stakeholders will not step forward and make these innovative changes.

We have not heard one presidential candidate from either side make any of these points. Americans are very good at spinning a story to manipulate public opinion and marginalize the value of these innovations to protect its vested interest.

It will take counter spin by the public to force the politicians to make policies that are for the public good. Now is not the time to complain and be cynical. It is time to act. America has the infrastructure to act in the internet and blogosphere. If social networking gets serious the power will return to the people.

Citizens have to create an environment where we are no longer a sound bite society. We must understand the details, and create the paradigm shift through public opinion for the public good. We have seen this happen rapidly. It is time to stop being manipulated by the invisible hand that uses media spin to manipulate us.

America can and must solve its healthcare problem and fuel crisis. We can do it with innovative thinking and appropriate rules.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.
Stanley Feld M.D.,FACP,MACE

Stanley Feld M.D.,FACP,MACP

Universal Healthcare coverage is an important idea. It is not synonymous with a single party payer as some would like us to believe. When Mitt Romney was governor of Massachusetts he had a bipartisan bill passed for universal healthcare coverage. The coverage was going to be provided by multiple insurance companies. Governor Romney’s goal was to achieve universal healthcare coverage using the private sector. Market forces were supposed to control costs and there would be no need for government single party payer.

I predicted the Romney plan would not work. The reason is simple. The rules of the game were not changed for the insurance industry, the hospital systems and the physicians. The reason this important idea cannot work is because the program was superimposed on the rules of a broken healthcare system.

The patients thought they were going to get a good deal because now they had guaranteed coverage. Mitt Romney was a hero of the people. As soon as the legislation was passed the insurance industry was fighting over the premium price. The premium is expected to rise next year.

“Enrollment in the state’s new subsidized health plan is growing so quickly that the state could face a funding gap as large as $147 million by the end of the fiscal year, according to a state projection.”

The subsidized program is part of the state’s unprecedented initiative requiring nearly all residents to have health insurance. Even if the gap reaches $147 million, there is no indication it would cripple healthcare reform.

“It’s too early to make any departure from the health reform plan,” said Leslie Kirwan, secretary of administration and finance and chairwoman of the Commonwealth Health Insurance Connector. “We will follow the trends and adjust, if needed.”

This is a lame bureaucratic statement preparing the state of Massachusetts for a tax increase.

“Financial pressures will grow for fiscal 2009, which begins July 1, since insurers who participate in the subsidized program are expected to ask for significantly higher payments from the state. In addition, there is uncertainty about how much the federal government will contribute toward the total cost.

The enrollment booms “is a sign of success, not failure,” said John McDonough, executive director of the advocacy group Health Care for All. “The sky is not falling. There’s a budget challenge.”

Massachusetts has a lot of “budget” challenges.

“McDonough also said the higher enrollment suggests that there are more uninsured people in Massachusetts than state surveys showed.

Hospital officials are concerned about getting stuck with unpaid bills.
Boston Medical Center and Cambridge Health Alliance negotiated a special deal in the health reform law that guaranteed them $287 million a year through 2009 in fees and increased Medicaid rates
“This is one of many warning signs, especially in tandem with the projected state budget deficit and the skyrocketing cost of healthcare in the state,” said Alan Sager, professor of health policy and management at the Boston University School of Public Health. “The [healthcare] law is very shaky on the revenue side.”

Mitt Romney’s plan does not include price transparency on the part of all stakeholders. The plan does not provide consumers with ownership of their healthcare dollar. The plan does not encourage competition. The result of the plan has to be failure with cost overruns using the rules of the present healthcare system.

When the plan fails the healthcare wonks who promote a single party payer system will claim the failure of the Romney plan has proven that universal healthcare has to be regulated by the government as the single party payer

The only thing the Romney plan demonstrates is a governments lack of understanding of the problems in the healthcare system. The plan does not speak to the issue that 80% of the healthcare dollar is spent on the complications of chronic disease. This is where the most saving can be achieved.

It does not face the issue that we have to deal with the obesity problem in the country.

It does not deal with the insurance industry’s abuse of its power or the abuse of all the stakeholders.

It does not deal with patients’ responsibility for their care or their need to own and control their healthcare dollar. A Romney like plan will only succeed when we deal with these defects in the healthcare system.

It deals only with the concept of how much money we are going to put in the system and whom we will penalize. If the plan had been constructed correctly and motivated patients to create a competitive healthcare system, the universal healthcare concept of Romney and Schwarzenegger would have a chance to succeed.

Hillary Clinton’s healthcare proposal is similar in that it is also built for failure. Failure proves the concept does not work. The replacement will be a single party payer.

The consumer is the only one who can force politicians to understand the problems in the healthcare system.

Stanley Feld M.D.,FACP,MACE

The real problem with raw medical claims data is that it will be misleading to the public. Its use will not measure the quality of medical care accurately.

In the meantime “Health insurance premiums up 6.1%, fast outpacing inflation and wages”.

During a recent lecture a physician asked me why are healthcare insurance rates rising at such a rapid rate and I have not received a reimbursement increase in 8 years? The answer is simple. All the other stakeholders are increasing the cost of healthcare.

I have discussed price transparency in detail. The error in using raw medical claims data is it is creating another false hope. It will not reveal overhead costs of the healthcare insurance industry or the actual costs for the delivery of care by hospital systems. Other sources are available to reveal hospital system charges and reimbursement. We do not have a way to evaluate hospital system costs. We have mentioned the $11 aspirin built into hospital charges, the one million dollar plus annual salaries of hospital administrators, the ten million dollar plus annual salaries of healthcare insurance company administrators. These numbers increase each year without explanation or analysis of its impact on the cost to the healthcare system. We must demand the analysis of these costs.

“These data are not so transparent and certainly not beside the point. Real healthcare data is hard to find and define.
Everybody wants a clear view of the cost and quality of healthcare. But defining this “transparency” is not an easy task. It is a task that physicians, insurers and the federal government continue to struggle with. These days there’s a lot of talk about making the cost and quality of health care more understandable to patients. But this transparency, like beauty, is in the eye of the beholder. While physicians and insurers each express support for transparency, there is a battle over what measures and techniques should be used to achieve it. Even the definition of price transparency is in flux.”

“ There is a concern among physicians that without physician clear direction and input, transparency initiatives aimed at the physician might mislead patients into thinking that healthcare insurance plans are paying doctors more than they actually are and that physicians are overcharging. Physicians also worry that plans are not using the correct and most complete information to rate quality, thus misrepresenting doctors, particularly those who take high-risk cases.”

In the discussion of medical claims data the real issue of the increase cost to the healthcare system is avoided. Remember, eighty percent of the healthcare dollars are spent on treating the complications of chronic disease. Neither insurers nor the government adequately do anything to support the prevention of chronic disease. Let us suppose the insurers did support the prevention of the complications of chronic disease. The additional monetary support would lead to the development of innovative techniques to prevent the onset of chronic disease.

Patients need to work hard to prevent the onset of chronic disease. Patients with a chronic disease have to be taught to be the “professor of their disease’ and work hard to prevent the onset of the costly complications of chronic disease. This can be done with the aid of their physician assuming he has the economic incentive to help the patient manage their chronic disease. These educational processes are not adequately supported economically at the present time.

Patients are ultimately responsible for their lifestyle behaviors. Patients are not doing a good job preventing chronic disease or the onset of the complications of chronic disease. Obesity is at the root of precipitating many chronic diseases, yet obesity in America is growing at an alarming rate.

Are patients to blame for the obesity in America? The answer is they are partly to blame. However, they are bombarded with external stimuli that promote obesity. My solution to obesity in America is for congress to pass a farm bill that does not subsidize mega farm corporations for producing harmful foodstuff. If congress passed a farm bill that banned the use of corn, corn products, soy and soy products as well as sugar and sugar products in food and shifted its foodstuff use to produce oil we would go a long way to solve America’s obesity problem as well as our dependence of foreign oil. I would also subsidize public education through public service campaigns to promote healthy food intake, increased exercise and healthy lifestyle changes. The public is needs this information. It broadly support the megavitamin and supplement industry in an effort to promote its good health.

Neither the insurance industry nor government supports programs that enhance compliance or adherence to medical therapy. Innovative programs rewarding patients are relatively easy to construct if industry and government would support these programs. Nationally, patient adherence to medical therapy is about 50%. Wal-Mart’s generic drug program has gone a long way to increase the affordability of drug therapy and increase adherence.

The issue of transparency and raw medical claims data can now come into focus as being inadequate to judge the quality of the therapeutic interaction. We are only going to reduce the cost of healthcare if we decrease the complications of chronic disease and not by evaluating quality medical care inaccurately.

This is going to take co-operation of all the stakeholders. The way to motivate patients to control cost is to have them own their healthcare dollar and provide incentives for them to use those dollars wisely. If we took the steps outlined much of our healthcare costs would decrease and the health of the nation would increase.