Stanley Feld M.D.,FACP,MACE

This blog is dedicated to Joan Colgin R.N., MSN the best Diabetes educator I have ever met. Joan Colgin R.N. is dedicated to the nursing tradition that the patient is first. She is dedicated to helping the physician help the patient.

You recall I asked you to image you have discovered you have Type 2 diabetes. I have provided you with an understanding of the pathophysiology of Type 2 Diabetes Mellitus. You understand why you have an elevated blood glucose level. I reviewed the devastating effects an elevated blood glucose level can have on your eyes, kidneys, nerves and heart.

Now I need to tell you what must be done to enable you to control your blood glucose level to prevent the chronic complications of Diabetes. I understand some people learn faster than others. Some people have so much fear and anxiety about diabetes that they have a very difficult time understanding what has to be done.

The basic educational process initiated by the physician must be reinforced by the Diabetes Education Team (DET). The DET must be an extension of the physician’s care in order for them and the educational process to be effective. It is very important that there are no contradictions in the educational process.

In 1995 the American Association of Clinical Endocrinologists (AACE) published Diabetes Guidelines: Medical Guidelines for the Management of Diabetes Mellitus: The AACE System of Intensive Diabetes Self-Management.

These guidelines were updated in 2002. This system of care was developed by Endocrine Associates of Dallas P.A. We developed a Diabetes Education Center within the practice. Joan Colgin R.N.,MSN. was the chief nurse educator. The physicians, the nurses and the dieticians worked together as an integrated team. We learned a great deal from patients and from each other. We figured out how to teach patients with various learning skills how to become the professor of their diabetes.

We learned that the patient must make a commitment to become as knowledgeable as possible. The patients had to learn how to self-manage their disease and understand the meaning of the results of home glucose monitoring. You will see in the AACE guidelines a Patient Physician contract. (p78)

Patients have to commit themselves to become the professor of their disease and the physician and his team commit themselves to teach the patients how to control their disease.

The AACE guidelines also contain as series of test questions of the patients’ knowledge. (p71-77). The correct answers are starred. Patients are tested at the onset of the education process and at the end of the course. The recommendation is that the education should be given on an individual basis so teaching can be customized to the patient’s learning skill. The test is repeated at 6 months to determine how much the patient has retained. If there are areas of weakness in understanding they can be addressed.

In the process of follow up with the physician the patients are taught to question their reaction to medication and make suggestions to the physician about changes in therapy.

If the physician discovers areas of patient misunderstanding that will hinder the patient’s self-management, the DET can reinforce the education in that specific area. The goal is to normalize the HbA1c in order to avoid complications of Diabetes Mellitus.

This is a very powerful process of care. The difference between the 2002 AACE Diabetes guidelines and other chronic disease guidelines are they are patient centric. Most guidelines are physician centric. Empowering the patient can improve control of blood glucose levels and thus prevent the complications of diabetes.

It introduces the process of rapid cycle improvement into the care of chronic disease management. The care of the patient is led by the patient’s input and participation in the treatment decision making process. The adjustments to therapy are not led by periodic static testing in the physician’s office. Periodic testing is simply a snapshot of the disease process. It tells us the results of the previous care. It is not proactive and tells us little about the changing disease process.

It has been stated most patients are not smart enough to learn about their disease and participate in the care of their disease. I recently received a comment from Dino Ramzi’s expressing this.

“I also know patients who do not have the intellectual capacity to understand the information they are being presented, despite our use of video, comic books and printed material to explain the principles of self-care. Some are too financially constrained or socially overwhelmed to do the right thing. Sometimes paying the rent and putting some food on the table is more important than exercising or taking your pills. Other patients are too depressed to motivate themselves to proper self-care. Others seem to have had some unpleasant interactions with the healthcare system or perhaps a personality disorder (this is a somewhat charitable way of describing the peculiar dysfunctional manipulations of a sorry minority).

The grand fallacy of relying on personal responsibility is that people have at their disposal all the choices to be made. The worst can’t do better.”

I agree with Dino Ramzi’s comment to some extent. However, many people who fit into his categories have not been given the opportunity or financial incentive to learn about their disease. Some patients cannot be motivated to self manage their disease because of their social circumstance. However, with focused training and financial incentive a great number of these people will respond.

However, these patients represent a very small minority of the patients with Type 2 Diabetes Mellitus. Our present system is not effective in decreasing their complications of diabetes. These patients will have complications in any system.

I am talking about the patients that want to learn and self manage their disease. The goal is to educate and motivate the great majority of people who are capable of learning and taking responsibility for their care.

Michelle Sobel, chief creative officer for Emmi Solutions, Inc, a Chicago-based company that produces interactive patient education videos expressed the concept beautifully, “The engaged patient is more than an informed patient. The engaged patient is activated. She understands information critical to her health, communicates effectively and confidently with her clinical team, complies with instructions related to her treatment, and is positively transformed by her experience with care.”
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You will recall the adherence/compliance rate for the treatment of most chronic disease has been studied to be only 40-50%. By engaging patients to be proactive in the care of their disease the adherence/compliance rate increases to up to 90%. Only with the appropriate treatment and the appropriate patient adherence to treatment will we decrease the costly complication rates of chronic diseases.

Stanley Feld M.D.,FACP,MACE

My son, Brad, has done it again. He is continuously giving me new ideas.

During our most recent visit to Boulder he said “Dad, your blog is great! You are explaining the problem and expressing ideas that should be adopted by the healthcare system. However, the blog is missing your personality.” I was perplexed. He went on to say that my blog needed to express more of my personality. “You have so many great stories about your past which reflect your personal development. These stories should be shared with your audience because they are funny and educational. These “Feld-isms” have inspired me and others. Your blog will then reflect your personality and have greater impact.”

Brad’s suggestion came on the heels of my meeting an old friend a few days earlier in an Art Gallery in Santa Fe. I had not seen Tom McConnell in years. Tom McConnell M.D. is a pathologist. He told me about his life long fantasy to become a writer. During his childhood his father rejected his fantasy so he became a pathologist. He recently began a web site called “ Notes from a Life”. His stories are a riot. “Paratrooper Circumcision” is the funniest and a worthwhile read. Our conversation lasted almost two hours and we have a luncheon date on August 24.

Since I was talking about Diabetes Mellitus and how a high blood glucose level pickles proteins in the body I felt it appropriate to tell you about Jake the Pickle Man.

So here goes. Every Saturday afternoon during my childhood my parents and my brother and I went to visit my grandfather (Pop) and my grandmother on Charlotte Street in the Bronx. Charlotte Street was a street perpendicular to Jennings Street. Jennings Street was a street of food markets just after WWII. There were two butcher shops, two milk stores (dairies), two bakeries, and two fruit and vegetable stands. There was only one sour pickle stand. Jake’s Pickle Stand.

Jake’s Pickle Stand was located in the alley between two buildings. Pop taught my brother Charlie and me one our first business lessons. Pop told us when you have two stores selling the same thing it is good for the customers. The store owners have to compete and be innovative to attract the customers’ business. I doubt Pop used the words compete and innovate to a four year old and a seven and a half year old. However, we understood his point.

Jake had a monopoly. He was the only Pickle Man for miles. It probably did not matter whether Jake had competition or not. Jake made the best sour pickles and sour tomatoes in the Bronx and probably in the universe.

However, Jake had a funny way of marketing his product. He did not do any marketing. If he did not like you he charged you a lot for a sour pickle. If he really did not like you he would chase you away from his pickle stand.

My grandmother always made a large Saturday evening dinner for the family. Naturally we needed sour pickles for dinner. Jake did not like my grandfather very much. Sometimes he would give him only one pickle for a quarter.

My grandfather was very smart and innovative in his own right. He decided to send Charlie and me down to Jake’s Pickle Stand with two pickle jars. I got the bigger jar because I was the big brother. My brother was too small to carry the large jar. Pop gave me fifteen cents. He gave Charlie ten cents. He told us to go stand in line and buy sour pickles from Jake. You have to understand that Jake’s pickle line was longer and slower than any Starbucks coffee line in the country.

We both waited in line patiently. Mrs. Jake, with her four diamond rings, noticed us and whispered something to Jake. I was in front of my brother. At my turn I asked Jake for fifteen cents worth of pickles.

Jakes counting methodology floored me. The first pickle in the jar cost four cents. After he put the second pickle in the jar I only owed him two cents. With the third sour pickle I owed Jake five cents. After adding seven more pickles to the jar I had spent the fifteen cents. Jake filled the three quarter full pickle jar with delicious pickle juice.

Next, it was Charlie’s turn. He had a smaller jar and only his ten cents. Jake started counting ten cents worth of pickles for my brother’s pickle jar. Jake stuffed 14 pickles into Charlie’s smaller jar. Jake could hardly fit any pickle juice into that jar. Our family had plenty of pickles for Saturday night dinner and for the next week as well.

Charlie and I did this week after week. The people in line in back of us were amazed. A seven and one half year old and a four year old walked away with a greater number of pickles for twenty five cents than the total number of pickles any six in line would receive for a quarter a person.

There are at least three business lessons the healthcare system could learn from Jake the Pickle Man. Pop understood Jake’s psyche. Jake did not have children. We were cute and bold. He liked us. Therefore he gave us plenty of pickles for a low price. He did not know that Pop was our grandfather. If the vendor likes you for some reason, your chance of getting a better price in a non market driven environment is better than the person a vendor does not like. Therefore the most efficient markets are truly competitive markets. They should also be consumer driven. Healthcare is not a competitive marketplace and it is not consumer driven.

Do not make Jake mad at you. The moral is do not make the people in power angry. They can ruin your goals. It is constructive to present people in power with ideas that will help improve their business. In the healthcare system the idea should be to align the facilitator stakeholders’ incentives with the primary stakeholders’ incentive, namely the consumer of healthcare. It is difficult to force people in power to be reasonable and fair. Jake the Pickle man would not budge if he did not like you. In the healthcare system the consumer and the physicians are starting to realize that they really have the power. The facilitator stakeholders in the healthcare system are forcing them to do things they do not want to do. These actions, I fear, will lead to more trouble for the medical care system.

I believe most events in life have multiple meanings. The story of Jake the Pickle man illustrates this belief. The healthcare system should learn something from the story of Jake the Pickle Man.

Stanley Feld M.D.,FACP,MACE

This post is dedicated to Tom Wageman a very smart person with unique leadership abilities.

Last weekend the Citizens Organizing for Resources and Environment (CORE)” met at Twin Oaks Ranch in Fannin County Texas for a thank you party for the three young people who helped lead the group. CORE was formed originally when several people became aware of TXU’s plan to build a “Dirty Coal Burning Plant” in the backyard of the Savoy Texas Independent School System’s school buildings.

Each citizen recruited friends to join the group and learn more about the environmental hazard of burning dirty coal. The group was interested in learning the effect it would have on our children’s health and on the lakes and soil in both Fannin and Grayson County. A Goggle group was set up and they were off to the educational races. The goal was networking the community electronically and providing instant information and education on the issue of the “Dirty Coal Plants” affect on our environment.

Citizens from all over the hillsides of North Central Texas started to participate in the news group. Many added information and insight for the education of all of us. The brain power was additive. Shortly after Dallas Mayor Laura Miller made presentations at the Bells and Savoy town hall meetings, Bells and Savoy joined the Coalitions of Texas Cities. Bells is a city of 1700 people and Savoy less than 800 people. TXU decided to build its coal plant in Savoy expecting little opposition. Bells and Savoy received special standing with the coalition because they were close to ground zero. Our lakes and soil were going to be contaminated with mercury and our air with particulate matter, sulfuric acid and nitric acid.

I was especially interested in the medical aspects of these contaminants. Mercury levels are related to the incidence of autism and attention deficit syndrome. The others are related to asthma and chronic obstructive lung disease. It has been calculated that lung disease from particulate matter, sulfuric and nitric acid represent an expenditure of $34 billion dollars per year to the healthcare system. This does not include the pain and suffering in the affected communities. The toll for autism and attention deficit syndrome to local school systems and families is unable to be estimated. A guess by an autism specialist at University of Texas, Southwestern Medical School was a cost nationally of $100 billion dollar in hard and soft costs.

Our governor, Rick Perry was not interested in listening to anyone, especially a few dozen country folks as he was fast tracking the TXU permits to build the “Dirty Coal Plants”. However, the movement (CORE) with the use of internet communications grew and grew as leadership of the Dallas Business Coalition for a Clean Environment joined in. Many small towns joined and we were finally got the Texas legislature aroused.

We all know the result. KKR bought TXU and promised the citizens of Texas they would not seek to build all the coal plants TXU wanted to build. They also promised to clean up the old “Dirty Coal Burning Plants in Texas. Texas is the most polluted state in the nation. KKR also promised to lower our electric bills by 15%. The question remaining is whether KKR/TXU will stand by their promises.

My main point is small groups of people can grow into large groups of people protecting their property, health, and childrens’ health from the dysfunction of the government and industry. We got the attention of old school institutions and positive change resulted.

While we rejoiced, I told everyone this might be a trick play on KKR/TXU’s part. We were relieved that this idyllic part of Texas would be spared deadly contamination. We were also very proud of the small role we played in making it happen.

Last weekend we had a party at Tom Wagemen’s Ranch to thank the three people who helped lead us in this truly citizen driven movement. It convinced me that people as consumers and as the electorate can have an impact on the system. If we understand the data and facts we have phenomenal power and potential. Most importantly, the exercise created a sense of community and friendships among neighbors that did not exist before the group was formed. One person told me that he knew none of these people before CORE. Everyone should know that medically participation in community activities is good for your health and well being.

In the hyper speed technological society the people can impact societies’ slow paced, malfunctioning, obsolete institutions and overcome the inertia of the institutional structures of the old society.

In the United States our culture smiles at innovators, supports positive change makers, and roots for the underdog. People are all feeling a sense of frustration. They are the underdogs to our bureaucracies, clogged courts, legislative myopia, pathological incrementalism and power of vested interest lobbyists. However, with ‘People Power’ we have the brain power and the purchasing power to change our disadvantaged position. Our small group (CORE) was able to demonstrate “People Power” and ignite the interest and support of others feeling the same frustration.
I applaud the CORE group’s leadership.

I also believe with the appropriate understanding of the data, the information and the knowledge that can be derived about the healthcare system, Americans can create the solutions to the healthcare systems problems. Americans want the enormous benefits of the greatest medical care on the planet. They will root out, replace, or radically restructure the legacy institutions which stand in the way. The knowledge about the healthcare system will be communication by physician blogs on the internet. Some innovator working in a large company will come along, produce a medical insurance program, the ideal Medical Savings Account, and the healthcare system will be restructured overnight. The employees want it. The employer wants it. The government wants its. The physicians want it. We need stronger leadership that want to really understand the problem and not leadership that is seeking the best sound bite to win votes.

One problem is that politicians, policy wonks, and government do not understand the patient-physician relationship and its importance to clinical and financial outcomes. They do not understand the patients’ responsibility for their care nor the physicians’ responsibilities in the medical care system. They focus their efforts on commoditizing healthcare and imposing formulas on the healthcare system for physicians and patients to follow. Eighty percent of the population does not use the medical care system because at any one time only 20% of the people are sick. They have no idea of the need for a positive patient physician relationship as a therapeutic tool.
Shel Israel, coauthor of Naked Conversations wrote to my blog this winter, “repairing the medical system in America is a lofty goal and about 98 percent of the American people see the need. The rest work for insurance companies.”

To me those odds seem pretty good. All we have to do is educate Americans and free them from the political spinning of disinformation. I believe this blog and other blogs written by physicians will help Americans understand what is happening to them and the healthcare system. People power will then force legacy institutions to respond, thereby changing the healthcare system to the advantage of the patient.

Stanley Feld M.D.,FACP,MACE

The problem is the government can not do it. It is up to us the consumers and electorate to force the legacy systems to change. Alvin and Heidi Toffler’s book Revolutionary Wealth sums it.

In the section on Inertia vs. Hyper speed they say, “As we look at our institutions and how they interact it becomes clear that what America confronts today is not simply a runaway acceleration of change but a significant mismatch between the demands of a fast growing new economy and the inertia of the institutional structures of the old society.”

I think of the government, the insurance industry, the hospitals, big Parma, all facilitator stakeholders as the old society and physicians and medical researchers as the new society.

“Can a hyper speed 21st century information/biological economy continue to advance or will societies slow paced malfunctioning obsolete institutions grind its progress to a halt. Bureaucracy, clogged courts, legislative myopia, pathological incrementalism can not but take their toll.
Something, it would appear would have to give. Few problems will prove more challenging than the growing systemic dysfunction of so many related but desynchronized institutions.”

Why doesn’t the healthcare system do something about the obvious things? They do not do anything about the obvious because the obvious is counter to ossified dysfunctional facilitator stakeholders’ vested interests. The complications of chronic disease are the biggest cost to the healthcare system. Why doesn’t the government mandate payment for systems of care for the complications of chronic disease and the prevention of the onset of chronic disease.

Rather than do something to prevent the complications of chronic disease, these institutions block the innovative progress of the advances in the use of informational and biological technologies. In fact, they punish medical innovation with non payment.

The following are two of hundreds of simple examples to illustrate the point.

Osteoporosis is a chronic, silent debilitating disease that severely reduces quality of life after osteoporotic fractures occur. Only 30% of people eligible for Bone Mineral Density testing presently receive Bone Density testing. We have to do better. Medicare does not pay for Bone Density testing of men. Just as many men have osteoporosis after age 70 as women. Our system waits around until they have a hip fracture. Prevention is cure in osteoporosis. The complications of osteoporosis cost the healthcare system $20 billion dollars per year. Early detection is essential. The mismatch between legacy institutions and science is clear. The government and private insurance institutions are discouraging systems of care for osteoporosis by decreasing the compensation for bone density testing by 75% in the next three years. As soon as these plans were announced the sale of Bone Density machines fell dramatically. The government even found an expert witness to say that Americans’ do not live any longer than people in other country even with our technology. A generalization out of context and unrelated to osteoporosis. The implication is technological advances do not help us save or live better lives.This is disinformation at its best. Apparently, the legacy institutions do not realize that consumers are smarter than they think. With the help of the internet consumers will be able to cut through this disinformation.
Important advances have been developed that have been under utilized or over penalized. The old institutions have not caught up with the speed of info-biological advances.

Another stunning example is that companies have created devices to monitor patients’ vital signs, function and movements at home that can be transmitted electronically to the doctors office in real time. This is a very exciting concept. Not only can people live in their homes longer as they get older, they can be monitored and treated either on the phone or on the internet by their physician in real time. The physician could use his medical judgment to alter medication to avoid congestive heart failure or impending complications of lung disease. This simple act could avoid many emergency room visits and hospitalizations as well as increase the quality of life of the patients suffering from these chronic diseases.

The government and the insurance industry pay home healthcare agencies to collect this data but do not pay the physicians for interpreting the data. As a result this innovative approach to disease management has been underutilized.

In 2001 The American Medical Association (AMA)/ Specialty Society RVS Update Committee (RUC) commented to CMS. CMS had specified that it would consider comments on the Clinical Practice Expert Panel data, the physician self-referral designated health services, and the interim RVUs for selected procedure codes identified in Addendum C. namely payment code (CPT) 99091, a code for reimbursement for physician interpretation of patients collected data. Medicare considered these extra telephone or email interpretations (consultations) as being part of the previous office visit and did not publish the code or reimbursement schedule for non face to face consultation. Finally, in 2007 they published the code but not a payment schedule. Therefore, each consultation for the physician’s opinion requires an office visit. Lawyers and other consultants charge for telephone advise routinely.

The antiquated mentality of the government and the insurance industry is not only costly to the healthcare system, it has discouraged the development of innovative telemedicine. Telemedicine is a valuable technological tool that is slowly appearing in the healthcare system. It can dramatically improve the quality of care and decrease the cost to the healthcare system. What more could a person with head trauma in a distant place want than an expert reading his MRI at 3 a.m. and recommending immediate action.

“Something, it would appear will have to give. Few problems will prove more challenging than the growing systemic, desynchronized institutions. If Americans want the enormous benefits of a worlds’ leading economy the United States will have to root out, replace, or radically restructure its legacy institutions which stand in the way. As change accelerates further institutional crisis will not be limited to the United States.
Some countries my find the threat more difficult than the United States whose culture at least smiles on change makers.”

Consumers are not only smiling on the need for a change in the culture in medicine and the healthcare system. They are fed up with the facilitator stakeholders’ holding them and their healthcare dollar hostage. They are demanding change. All they need is a Pied Piper. Well, the leaders are in your midst, all they need is a posse. You can sign up for my posse at stanfeld@feld.com. You will receive your official membership card like a Captain Midnight ring.

Stanley Feld M.D. FACP,MACE

In my opinion Pay for Performance (P4P) is code for decreased physician reimbursement. It also represents an attempt by healthcare policy makers to standardize the standards. We can remember Dr Petak’s experience with Blue Cross/Blue Shield of Texas. He was penalized for doing the right thing. He was using a benign medication works for infertile couples. The medication’s was not in the insurance industries algorithm. He saved the patient lots of procedures and the healthcare system thousands of dollars per patient. In thinking about it, quantification of the standards has little to do with the actual medical outcome.

Paying for Performance implies you are willing to pay more for quality medical care than you are for medical care that lacks quality. However, quality medical care has been defined artificially. There are many components to quality medical care. The first is the physicians’ performance and the second and most important is the patients’ performance. If the patient does not do what the physician recommends, the ultimate outcome, the patients avoiding the complications of chronic disease, will not occur. Presently, patient compliance with medication and treatment advice is 45%. None of the healthcare policy wonks thought of this when P4P was invented. Their goal was to impose measurable standards to measure physician performance. They have not developed standards that measure clinical outcomes. The actual clinical outcomes must also be link to social, psychological and financial outcomes. An excellent performance is helping the patients help themselves stay healthy and avoid the complications of chronic disease.

On May 27, 2007 the New York Times Magazine section Ann Hulbert published an
article criticizing the No Child Left Behind Program of President Bush. The title of the
article was THE WAY WE LIVE NOW: Standardizing The Standards It made me think about what is going on in the P4P experiment. It also brought to mind the Pete Seeger song whose chorus is “When Will They Ever Learn.”

“The president’s signature domestic initiative, now due for its five-year reauthorization, was supposed to be a model of the hardheaded rigor it aims to instill in America’s schools. ”No ‘accountability proposals’ without accountability,” a Bush education adviser declared early on. So one of the most glaring legacies of No Child Left Behind is surprising: it has made a muddle of meaningful assessment. Testing has never been more important; inadequate annual progress toward ”proficiency” triggers sanctions on schools. Yet testing has never been more suspect, either. The very zeal for accountability is confusing the quest for consistent academic expectations across the country.”

There are endless problems reported in the article about standardizing the testing standards for children so that no child is left behind. There is a social science principle called Campbell’s law. ”The more any quantitative social indicator is used for social decision making,” the social psychologist Donald Campbell concluded in 1975, ”the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor.” The article was referring to measuring the performance of public school on the basis of test scores. “With ”high stakes” testing, N.C.L.B. introduces an incentive not to cheat, necessarily, but to manipulate. Signs are that states define proficiency down while schools ramp up narrow test prep. ”Score pollution” — results that reflect intensive coaching — becomes a risk”.

I thought the purpose of education was to teach children reading, writing, and arithmetic. Learning the basics should teach children to think, and solve problems. The goal should not be to get high scores on standardized tests for the maintenance of school funding by the federal government. It represents a pay for performance model for education. In my view, it represents fuzzy thinking.

The author says, “The National Assessment of Educational Progress could serve as a model for a test that judges students’ ability to apply their knowledge and thus discourages rote coaching.” Learning by rote is an invention of policy wonks. In my view, it is not education.

“But recent experience — and Campbell’s law — argues against making test results the sole trigger of federal sanctions. Instead, the data would give states and school districts reliable information on where progress is, and isn’t, happening across the country, to catalyze their own strategies to boost achievement. Rather than cramming to reach an unrealistic target by 2014, states could be more like the laboratories of curricular improvement the country needs”.

The policy wonks ignored Campbell’s Law. They are repeating the same error in medicine with P4P. America sent Dr. Deming to Japan after World War II. He taught the Japanese the concept of continuing quality improvement. Why can’t we do this in education and medicine as well.

“Agreeing on common goals for what kids should be learning can free up teachers to focus more productively on how they could be learning better.”

Education, like medicine, also has two stakeholders. They are the student and the teacher. We have to create an environment of incentives to have both the teachers and the students responsible for their actions and excited about their goals. The methods in NCLB dumb down the system of education and have not produced results. In two words “it failed.”

I predict the same thing will happen in P4P in medicine. The clinical outcomes will be worse. Medical care will be worse. The healthcare system will be dumbed down. The patients will suffer. The healthcare system can not stand another disaster. The healthcare system has to focus on improving clinical outcomes for chronic diseases to avoid their complications. The system should not be imposing requirements on physicians to do certain measurements to get paid. This standardization is foolish. It will turn out to be counterproductive. The two main stakeholders are the patients and the physicians. They are both responsible for the patients’ care. The patients are most responsible and must drive the system. This is one of the arguments for consumer driven healthcare. Consumers are not as stupid as policy wonks think they are. Formulas such as P4P have to be taken out of the hands of the policy wonks and put in the hands of the patients. We must give patients the incentive to do it right by giving them control of their healthcare dollar.

In the treatment of chronic disease it is essential that patients become the professor of the disease with the physicians and their health care teams becoming the coaches that help the patients’ problem solve.
Since 90% of the healthcare dollar is spent on the complications of chronic disease we should be concentrating on developing systems of care (focused factories) that concentrate on the treatment of chronic diseases. The measurement of testing done has little importance. The interpretation of the test results is important. The clinical step taken will influence the clinical outcomes. Pay for Performance represents as perfect opportunity to once again demonstrate that Campbell’s law is true.

Unfortunately, it looks like P4P is a concept developed by technocrats to maintain their importance and value promoting another flawed methodology. It will create more dysfunction in the healthcare system. It is also an excuse for the government and the insurance industry to decrease payment and increase their control over the healthcare system. I predict P4P will increase cost of medical care and decrease the real goal which should be decreasing the complications of chronic disease.

We should be spending money on reimbursed the institution of systems of care that decease the complications of chronic diseases. This is not happening. Physicians must drive these systems of care for it to work. When patients control the healthcare dollar they will pay physicians to develop systems of chronic disease management.

Perhaps hospitals like to treat the complications of chronic disease. It helps their bottom line. Maybe the insurance industry wants an excuse to increase the price of insurance. Once again the goal of medical care system should be to keep people healthy. The emphasis of the facilitator stakeholders is to fix people when they are sick. This must change if we are going to fix the healthcare system.

Stanley Feld M.D.,FACP,MACE

Our healthcare system is broken. It is not getting better. The dysfunction in the healthcare system increases as time goes by and nothing is happening to fix the system.

I have introduced some “big ideas” in the past year.

The goal is to increase understanding of how the system became broken and what we have to do it. If the ideas necessary to repair the healthcare system are going to work the ideas have to be enacted as a comprehensive package. Unfortunately, this is not the way politicians work unless we are in a meltdown situation. For example, real price transparency of negotiated prices has to be linked to an accurate assessment of quality which has to be linked to patients owning their healthcare dollar and having the ability to chose and evaluate their care. The patients have to be given the ability to negotiate the price with hospitals and physicians or chose an insurance company that will fight to protect expenditure of their healthcare dollars. Patients must be given the incentive to be an informed consumer and educated to spend their healthcare dollar wisely and be penalized if they do not.

Medical practices have to be given the incentives to develop their practices that are dedicated to chronic care of particular diseases (focused factories). The incentives for these focused care clinics must be adequate compensation for their care to make patients professors of their disease. These focused factories will help prevent the complications of chronic diseases. The complications of chronic diseases absorb 90% of the healthcare dollar. There has to be monetary incentives for medical practices to emphasis preventive medicine in order to avoid the onset of chronic disease.

The patients must be responsible for their care and their healthcare dollar. Access to care must not be restricted. Patients are capable of being responsible consumers of healthcare given the appropriate incentives.

Systems of care have already been developed to achieve these goals. I have explained how the Ideal Medical Savings Account as an insurance vehicle can achieve the goal. I do not believe the presently available Health Savings Accounts is a step in the right direction. Health Savings Accounts (HSA) will fail because they lack patient motivation and physician incentives. The failure of HSA’s will move us closer to a single party payer system as a proposed solution. In my view a single party payer system will be a terrible solution for the patients and the physicians.

We will need strong leadership. We need a leader who really understands the problems in the dysfunctional healthcare system. A leader who is not afraid to act contrary to the pressure of facilitator stakeholder vested interests There does not seem to be one around. We will need groups of citizens who are angry enough at the present system who will be willing to demand a consumer driven healthcare system. People power can demand that leadership. First they have to understand the problem and solutions.

Some of the comments I have received in the last few weeks express our generalized cynicism, pessimism and depression about the healthcare system from both patients and physicians.

Paula Hartzell, MD’s sad story in Medical Economics tells it all. It is truly a worthwhile read. I was directed to Dr. Hartzell’s story by KevinMD .Dr. Kevin Pho, a primarycare physician and internal medicine specialist who operates one the top 10 medical blogs in the country. He has a wonderful blog and is providing a great service for both the general population and physicians. If you want to know what is going on in healthcare and medicine read KevinMD. Kevin’s blog provides the information that exposes the ills of the healthcare system and will help stimulate the demand for change.

Richard H. Rowe M.D. is another Family Practitioner who confirms Dr. Hartzell’s story.
“Family practitioner Paula J. Hartzell’s “Medicine is a blame game” [“The Way I See It,” Apr. 20] is sobering. I agree with her commentary entirely.

After 32 years, I am totally disillusioned with medical practice and all the hassles associated with trying to care for patients. Let’s go down the list:
• The government and health insurers blame doctors for overcharging patients.
• The legal profession blames doctors for practicing poor-quality medicine—while these same lawyers are getting rich off the system.
• Regulatory agencies blame us for not doing enough or spending more time in the office.
• Liability insurers blame us for the ever-increasing number of lawsuits.
Meanwhile, organized medicine appears powerless, sitting on the sidelines. If the current trend persists, I am afraid we are heading for a medical meltdown. Perhaps future topics in Medical Economics will be: Where are all the doctors?”
Richard H. Rowe, MD
Mesa, AZ

Richard Rowe M.D. confirms the story as many others have. People must remember when they are sick they want a well trained physician who understands disease processes.

I received some comments as a result of my post” We Are Not Healthcare Providers, We Are Medical Care Providers” saying “you doctors are only trying to protect your guild.” It sounds to me that healthcare providers think physicians are in a turf war with them. As I stated previously the healthcare providers should be called physician extenders. They should be joining the medical care team to provide a team approach to medical care through focused factories rather than trying to compete with physicians and devalue treatment.

I received this comment from a famous oncologist.
“Having worked for several years in a community in which nurse practitioners, physician assistants and oriental medicine physicians (“DOM”) are accorded primary care status by regulatory and insurance entities, I can tell you that they have no clue about disease process. This leads to an enormous number of esoteric laboratory studies and imaging studies in the search of some or ANY diagnosis to explain symptoms. Eventually the patients are referred to a medical specialist and with them come myriads of pieces of unfocused medical data. “..just what is the significance of the elevated serum zinc in the patient with chronic weakness and fatigue who has negative imaging studies?” Nada! Excess healthcare costs and healthcare providers, as opposed to medical care providers, always go together!”

Physicians are calling for leadership to save a broken healthcare system. However, the Democrats think physicians are all crooks. The Republicans seem to make healthcare more profitable for the secondary stakeholders, namely the hospital systems, the insurance industry and big Parma. No leader seems to realize that the patient is the most important stakeholder.

The perception of the people is physicians are making a fortune overcharging us, over testing us, and over treating us with medication that hurt us. They use treatments I can not afford or insurance company will not pay for. Unfortunately, this is the perception generated by all the stakeholders and encouraged by the medias need at sensationalism.

A person who is uninsured wrote; “ I am frightened that I will get sick. I will be stuck with an outrageous hospital bill that will bankrupt me. I am a hard working person who lost my job and can not buy affordable individual health insurance.” This needs to be fixed immediately.

My view is that the consumer of healthcare and the giver of medical care have to unite and force our politicians to do something logical and constructive to change all of this.
Pessimism never got anyone anywhere.

Harry Truman said.” A pessimist is one who makes difficulties of his opportunities. An optimist is one who makes opportunities of his difficulties.”

To the pessimists out there I say read my blog. To the optimist out there I say read my blog. With things as bad as they are, the opportunities for improvement and innovations are limitless and awesomely rewarding both emotionally and financially.

Winston Churchill said,” I am an optimist. It does not seem too much use to be anything else.

Franklin Roosevelt said, “The only limit to our realizations of tomorrow will be our doubts of today.”

Ronald Reagan said “There are no great limits to growth because there are no limits of human intelligence, imagination, and wonder.”

Finally, Dwight D. Eisenhower said “Pessimism never won any battle.”

Our most valuable possession is our health. We must be optimistic in the battle to save the medical care system by reformatting the healthcare system. A system needs to be developed that protects patients, the most important stakeholder in the medical care system, not a system that protects the vested interests of the facilitator stakeholders in the healthcare system. The facilitator stakeholders add little value to our medical care system.