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,MACE

The media publishes sensational stories of abuse in the healthcare system. The goal is to sell newspapers. More valuable would be an analysis of the significance of the abuse. Additionally the media should stimulate discussion about remedies for the abuse.

The New York Times lead article about William McGuire’s excess pay from United Healthcare reached a settlement with the S.E.C. on December 8, 2007

“In one of the largest corporate pay give-backs ever, William W. McGuire, the former chief executive of UnitedHealth Group, has agreed to forfeit at least $418 million to settle claims related to back-dated stock options. William W. McGuire built UnitedHealth into a giant.”
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Mr. McGuire had previously returned $198 million dollars. The total amount of the excess payment was $1.6 billion.”

“As part of the settlement with the S.E.C., Mr. McGuire will pay a $7 million fine and will be barred from serving as a director of a public company for 10 years. He will, however, be allowed to keep stock options valued at more than $800 million, including many that have been sharply criticized.”

The retention of eight hundred million dollars is not a small change. The value of the $800 million in stock options could double in the next year.

Federal regulators are the protectors of the public and stockholders’ interest. They have claimed victory over corporate management abuse of the public and stockholders. They are stemming the abuse of the over use of backdate stock options. The regulators are presently investigating 120 companies.

“The developments are the most significant to date since federal regulators started looking into the backdating of stock options. More than 120 companies have come under scrutiny for granting options to executives on dates when the company’s share price was low, a tactic that guaranteed the maximum profit when the options were exercised.”

“The settlement comes a year after the furor over compensation forced Mr. McGuire’s resignation from UnitedHealth, the nation’s largest health insurer.”

“In a statement yesterday, Mr. McGuire said that he was pleased to put the controversy behind him.
“The last 18 months have been an extraordinarily challenging period for my family, and I am pleased to have reached a resolution,” he said.

I bet Mr. McGuire is happy to have this behind him. His liability for this abuse is over. He still owns $800 million dollars in backdated stock options that have a chance to appreciate further.

“UnitedHealth remains embroiled in the scandal over improperly granted options. The S.E.C. said its inquiry at UnitedHealth is continuing. So far, the company has restated its earnings by $1.5 billion and announced a $55 million settlement with the Internal Revenue Service.”

Let us think about this settlement of $55 million for a minute. Fifty five million dollars sounds like a lot of money. At the maximum corporate tax rate of 38% the corporate tax for $1.5 billion in profit would be $570 million. I would say United Healthcare received excellent settlement terms. The IRS only collected a little more than ten cents on the dollar. The settlement seems to be a pretty good way of avoiding corporate taxes. The $55 million settlement does not seem to me to be a deterrent to future corporate tax evasion.

What happens to the $515 million dollars United Healthcare saved by the settlement? I assume it is applied to United Healthcare bottom line and be subject to a future corporate tax payment. Nevertheless United Healthcare keeps increasing healthcare insurance premiums on large and small businesses. The premiums increase by up to 15% a year. The premium increases are justified by increasing costs and decreasing profits. The premium increases are putting healthcare insurance out of the range of most small companies and inaccessible to a single individual.

Shouldn’t there be some restraint on profit? The government has given United Healthcare a bye on their tax liability. Their executives have been judged to do illegal things. Has United Healthcare suffered? No! The consumer has suffered. Should consumers put this behavior out of business? An immediate question is how?

The simple answer to the consumer is; do not buy United Healthcare insurance. Additionally, every state has the ability to restrict the sale of insurance in their state by the issuance of licenses for insurance companies to sell insurance. This would be a deterrent to other healthcare insurance companies and regulate obscene profits and premium increases. The state governments have been hesitant to do this for some reason. Unfortunately it is going to take consumer pressure to force state government agencies to do their job and protect the consumer from this kind of abuse.

Citizens have been ripped off by the healthcare insurance industry long enough. The answer is not a single party payer because the same abuse would exist. The administration of Medicare is outsourced to the healthcare insurance industry.

The real point the media should be discussing is how we can correct the abuse. We have to make it clear that we are not interested in the abuse being a sensational spectator sport. We must have a serious debate on where the most significant abuses are and how are we as a nation can change the healthcare insurance industry’s behavior?

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Stanley Feld M.D.,FACP,MACE

Newt Gingrich and John Kerry have written a bipartisan article on the way to modernize the healthcare system.

“In the age of the Internet, is it any less inexcusable that we have yet to modernize and transform our health care system?”

Who is to blame for this shortcoming? My answer is all the stakeholders are to blame. There has been increasing mistrust among stakeholders. Physicians have been the weakest political action group along with patients. Physicians are the most vulnerable to attack.

“We have talked long enough about using technology to cut costs and improve the quality of care. Now is the time to act–and the place to start is preventable medication errors.”

I totally agree. Accurate electronic prescribing information would decrease prescription filling errors.

“According to the Institute of Medicine, Americans average one medication mistake for every day spent in a hospital, accounting for more than 1.5 million injuries each year. Medication errors will kill at least seven thousand Americans this year. Of the more than three billion prescriptions written each year, doctors report nearly one billion require a follow-up between providers and pharmacies for clarification. The cost to our health care system is in the billions.”

“One reason for this mess is that 95 percent of prescriptions are transmitted using five-thousand-year-old technology: pen and paper.”

“That is unacceptable. The deaths and inefficiencies of paper prescriptions can be nearly eliminated if we use the same technology that we use in other aspects of our lives. Electronic prescriptions can replace handwritten, misread, and mismatched prescriptions with online, automated, and expert technology.”

I agree with Gingrich and Kerry. However, they do not examine the barriers that have prevented electronic prescription writing. One barrier is physicians must have computer equipment and appropriate software to send an electronic prescription to a pharmacy. Another barrier is the pharmacy must have the ability and willingness to accept and fill the electronically signed prescription. The pharmacy might not have software compatible with the physicians’ software.

“A new study by the Department of Health and Human Services estimates that if 18 percent of doctors in Medicare adopt e-prescribing, the government will save $4 billion and nearly three million adverse drug events can be prevented over five years.”

I believe e-prescriptions are essential and should have been implemented years ago. Let us extend the Department of Health and Human Services estimates. If 100% of physicians would use e-prescriptions and 100% of pharmacies would fill the electronically signed prescriptions Medicare would save $22.5 billion and nearly 16.5 million adverse drug events can be prevented over 5 years.

Gingrich and Kerry put the burden on physicians and suggest penalty for non compliance.

“The problem is that very few doctors use the technology. Of those four hundred physicians polled, only 7 percent actually transmit prescriptions electronically. And 63 percent say implementing the technology is not a priority. Why? It is not always in their immediate financial interest to do so.”

I can sympathize with the physicians who do not want to implement the technology. Many physicians are struggling to make a living even though their retail prices for services seem high. The retail fee is never the fee physicians collect from the third party payers. If a patient is uninsured many physicians will accept the steeply discounted fee Medicare allows.

Let us think about it. Gingrich and Kerry are demanding that physicians who do not have the technology and software spend money to save Medicare $22.5 billion over the next five years. If physicians were willing to spend the money there is no guarantee the pharmacy have compatible software.

“That must change. The federal government can lead by requiring that doctors who do business with Medicare convert to e-prescribing. If a majority of doctors do not e-prescribe a few years down the road, the government should require all doctors to adopt e-prescribing or face financial penalties. E-prescribing should become a condition of doing business with Medicare.”

With Medicare reimbursement declining and start-up costs for computer equipment and programming increasing, many physicians can not afford an isolated system for e-prescriptions. Many clinics have invested heavily in installed legacy systems that do not permit a universal interface with the pharmacies’ equipment. Many physicians are reluctant to spend money on systems that are quickly obsolete and have little payback.

Another issue is the potential abuse of the e-prescribing system by unauthorized persons using the physicians prescribing privileges. Ignored are the costs of installing adequate security and the service contracts.

A simple solution to the problem is to provide the physicians and the pharmacies with free downloadable stand alone compatible programs that can be used for electronic prescription use by licensed physicians and registered pharmacists. These programs could be downloaded from the internet with the appropriate security.

If this were done we would see how quickly the transformation to e-prescribing would occur. An added incentive to the physician could be patient driven. After the government has provided the universal software it could penalize patients if they try to fill a paper prescription by putting a surcharge on the prescription. Those patients should then be given an explanation of the surcharge and instruction on how their physician could remedy the surcharge by a simple internet download. Taking this approach would align the patients’, the physicians’, and the pharmacies’ incentives rather than setting up an expensive bureaucratic system to enhance suspicion and mistrust between stakeholders.

We should learn a lesson from the airlines. The airlines have made us prosumers. The airlines provided the software and education, and got us to do their work. We produce the e-ticket with our own paper and consume the e-ticket with our credit card payment at little cost to the airline. We do the work for the airlines.

I am surprised at Mr. Gingrich and Mr. Kerry advocating a penalty system that could be costly to administer when the solution can be so simple and utilizes the physicians’ patients to enforce a necessary system. You can be sure they did not discuss their idea of penalty with physicians before they wrote their article.

Stanley Feld M.D.,FACP,MACE

It is my belief that innovative entrepreneurs are going to develop systems that will provide consumers with control over their healthcare dollar. These systems will provide the infrastructure to help patients prevent the complications of chronic disease and also result in decrease in cost to the healthcare system.

If patients have control of their healthcare dollar the decrease in cost will be an extra dividend to patients. Other innovations will be stimulated by a consumer driven system. We are starting to see some good ideas.

Here is an example of a good idea: Dallas retirees J.T. and Phyllis Dunkin, both 78 years old, are paying more for their health insurance (MediGap insurance) but enjoying life more. They live in a retirement community in North Dallas. Like many seniors, the Dunkins have supplemented their basic Medicare coverage by purchasing a Medigap insurance policy. Medigap reduces their sizable potential out-of-pocket health care expenses not covered by Medicare. Mr. and Mrs. Dunkin pay $250 per month each in premiums for the added coverage. Medicare has deductibles and co-pays that can be a great burden. I will provide more details on these deductibles and co-pays in the future. The Dunkins pay about $90 a month more than the typical Plan F Medigap insurance but the added benefits of chronic disease management more than compensate for the increased price.

“ Dr. Mary Norman, Highland Springs’ medical director is instantly available to patients in the retirement community for acute medical illness. “

“Afterward, Mrs. Dunkin didn’t have to make sense of the bills by herself or spend hours on the phone with a customer service representative. Instead, she sat down with the health plan’s benefits counselor, who answered her questions right then and there. “

Interpreting bills and figuring out liability on the ocean of hospitals’ and physicians’ charges is a stress that many elderly patients cannot handle. The stress often leads to depression.

“Best of all, the couple live just a three-minute walk down the hall from their doctor’s clinic in the Highland Springs senior-living community”

“When we tell our friends, they don’t believe us,” Mrs. Dunkin said. “Medicare isn’t supposed to be this easy.”

It is common knowledge among seniors that Medicare is an extremely confusing system.

“Medicare is usually not so easy. The Dunkins, who are in their 70s, are part of a pilot project in which their senior-living company has teamed up with a health insurance company, with Medicare’s approval, to provide supplemental coverage.”

Their supplemental insurance is not the garden variety supplemental insurance.(Medigap) The goal of their supplemental insurance is to teach patients how to manage their chronic disease. It also provides instant physician availability. The idea is that they will avoid costly hospitalization. Ninety percent of the Medicare costs for seniors are spent on the complications of chronic disease. With this goal in mind this entrepreneurial system is already working to decrease complications of chronic disease.

Experts say the project may become a national model for improving the care of chronically ill Medicare beneficiaries while holding down costs. Early cost savings have been promising.

It is obvious to me that one of the keys to the Repair of the Healthcare System is to effectively teach patients how to manage their chronic disease. The result will be a decrease in the complications of chronic disease and a decrease the cost of care enabling the seniors to live a happier and healthier life.

This innovation can easily be incorporated into my ideal medical savings account plan. The cost savings must be shared with the patient to make them even happier and stimulate further compliance with treatment

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 AMA has put forward four broad strategies to reduce health care spending and improve the value of medical care. The facilitator stakeholders have not asked practicing physicians what they think should be done to improve the quality of medical care and decrease the cost of the healthcare. I must confess that I am proud of the AMA for publishing this opinion editorial. Maintaining the status quo and focusing on price transparency using inaccurate methodology is simply the wrong way to control cost. The result will be another complicated mistake.

Is it possible to change the status quo? The editorial’s initial statement is; “A fundamental first step is to properly address the issues of cost, value and efficiency in the U.S. health care system.”

The latest rise in health insurance premiums and the $2 trillion annual health bill is a timely example of why attention turns so quickly to rising health care costs. “The figures, compiled by the Kaiser Family Foundation, represent the smallest rate of premium increase since 1999. But that’s a dubious distinction given that the rise is more than twice the overall inflation rate of 2.6% and far ahead of the 3.7% increase in wages.”

As insurance costs go up at that rate, we can expect a rise in the number of uninsured Americans.
“Another of our page one headlines, only two weeks before the premium news, announced a dramatic increase in the latest U.S. Census Bureau tally of the uninsured — to 47 million.”

“When insurance rates rise, according to researchers, fewer workers can afford to pay premiums and medium- and small-size firms give up offering coverage. One striking figure: In 2001, 68% of firms smaller than 200 workers offered health benefits; at last count it was 59%”.

“It’s essential to note that much of the increase in what’s spent on health care in America is for necessary care.”

The meaning of necessary care is when someone is sick and needs to be treated rather than preventing them from becoming ill.

“ By one count, from a 2004 study in Health Affairs, treated prevalence of disease — basically, the underlying prevalence of illness and often evolving treatment resources used to address it — alone accounts for an estimated two-thirds of the recent growth in health costs. But there are a number of studies indicating inefficiencies due to overuse and under use of services. On top of that is non-clinical waste, including bureaucratic burdens and excessive third-party profits.

The answer is not willy-nilly hacking away at costs, but defining and moving forward with a focus on better value in our health care spending. Focusing on value would likely lead to a slower growth of costs.”

“Value can be thought of as the best balance between benefits and costs (i.e., efficiency, in economic terms), and better value as improved clinical outcomes, quality, and/or patient satisfaction per dollar spent.” AMA Delegates adopted four broad strategies, presented in the report, to contain health care spending and improve value:
• Reduce the burden of preventable diseases. This includes preventing the onset of chronic illnesses such as diabetes and improving patient compliance with medications.
• Make health care delivery more efficient. Better coordination of care and reducing unnecessary services fall into this category.
• Reduce non-clinical health system costs that do not contribute to patient care. For example, reducing excessive spending on administration, profits and marketing.
• Promote “value-based decision-making” at all levels. This involves improving the process used to make decisions so that cost and benefit — particularly clinical outcomes — are taken into account.

Do any of these proposals sound familiar to readers of this blog? A lot of physicians know what to do. The changes necessary are counter to the vested interests of the facilitator stakeholders who control the healthcare system. The facilitator stakeholders do not ask the practicing physicians’ opinion because it might decrease their profitability.

“Patients and stakeholders inside and outside of the health care arena will be needed to bring about the transformation to a more value-driven system. And physicians have an opportunity to be a key component in the change. Physicians have the most contact with members of the public every year, putting them in a unique position to help patients help themselves, such as by adopting healthier lifestyles.”

With some effort, motivation and sincerity on everyone’s part, headlines on future stories could proclaim health care costs under control and improved health care for all Americans.

If we could focus on these four principles and align all stakeholders’ incentives so that there was mutual trust, respect, and effort, using American ingenuity we could repair the healthcare system. Developing processes such as P4P, report cards, evaluation of physician care using artificial and inaccurate data can only lead to a more dysfunctional healthcare system.

No one has asked for practicing physicians’ input or put practicing physicians in a position to offer advice on the Repair of the Healthcare System. There are many physicians out there who know what to do. The tools to do it must be provided to them to make it happen.

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.