Stanley Feld M.D.FACP,MACE

The intuitive meaning of Pay for Performance (P4P) is the better you perform the more you get paid. This is true in many industries. The concept is well advertised in the well publicized salaries of professional athletes. Recently we have heard of grotesques salaries of fired CEO that get hundreds of millions of dollars in termination salaries for doing a bad job. They are getting paid well for poor job performance.

The underlying assumption is that with P4P, physicians should be responsible and accountable for medical outcomes. The physicians will be reimbursed for medical outcomes. The reimbursements made to the physicians are under the control of the government or insurance industry. These entities are interpreting the criteria for the quality of medical outcomes.

We have seen what happened to Dr. Petak even though his treatment is correct and saves money for the health care system. Many physicians feel P4P is simply code for reducing physician reimbursement. In an environment of existing mistrust between all the stakeholders, the potential is great for generating more mistrust. The growth of the mistrust will result in more dysfunction in the healthcare system and increased cost.

The definition of quality medical care has not been made clear by the secondary facilitators while proposing the P4P rollout. Organized medicine has not been outraged by the proposal. No one has analyzed it with all the potential for unforeseen consequence. Can P4P prevent the onset of disease or decrease complication rate for chronic disease? Who are the responsible stakeholders for increasing quality? The stakeholders responsible for medical quality care are the physician and the patient. If the patients do not adhere to the medical regime prescribed, the quality of care will not improve. Many studies have shown that compliance rates are as low as 30% for certain treatments. Patients will not have improved medical outcomes if they do not follow a treatment plan. Why should the physician be penalized? Why doesn’t the government and the insurance industry declare that patients are equally responsible for both good and bad medical outcomes? The structures of bureaucratic systems would not permit it because not only would it be judged to be insensitive it would be socially incorrect and result in a public outrage.

Patients have to be educated and become professor of their disease, be responsible for their health behaviors such as filling their prescriptions, exercising , decreasing obesity, not smoking or drinking. All preventive measures must be promoted. Patient need to be responsible their behavior and adherence to therapy. The physicians should not experience all of the brunt of poor outcomes or the credit for good outcomes. The P4P movement is misguided.

They are misguided when they think this is the fix. P4P represents another false hope and complicated mistake that in my opinion will lead to great cost to the healthcare system without improvement in medical outcomes.

I have defined quality medical care in a measurable way. None of these criteria are individual indicators of quality medical care. The system of quality of care should be the quality measure of prevention of medical complications and not the measurement of the parts on the path toward quality medical care. The patients’ activity is at least half of the quality equation to reduce the complications of chronic disease.

However, the secondary stakeholders are making a mistake with P4P. They have developed artificial quality indicators that do not measure quality medical care accurately. They want to force physicians to follow their indicators rather than use their medical skill and medical judgment. The way to improve quality is not to be punitive to the physicians. They are only one half of the quality equation to reduce medical care cost. The way to do it is to set up a competitive environment.

Lasik surgery is a perfect example. It stated with all ophthalmologic doing Lasik for $3000 an eye. Insurance did not pay for Lasik surgery. Some ophthalmologists’ developed focus factories that did just Lasik surgery. They developed economies of scale and expertise that enabled them to reduce the price. Patients chose these focused factories on the bases of price, and outcomes rather than the local opthalmologists. The price in some cities is now $250 an eye. Remember patients are not stupid. However, they are the 50% of the quality care equation. They will spend their money wisely and drive quality, if they own their healthcare dollar. It is our job to teach patients how to make the correct decisions. It is not the insurance industry or the government to restrict access to care and judge what is best. I believe the market place can do it.

In diabetes the healthcare system sends 15% of the healthcare dollar on 5% of the population and rising. Ninety percent of those dollars is spent on the complications of diabetes. If patients with diabetes were given control of their healthcare dollar and were rewarded for avoiding complications of diabetes we would be on our way to a competitive environment for the treatment of diabetes. The patients would search for physicians that had economies of scale and expertise to help them improve their quality of medical care. They would drive the creation of focus factories in diabetes as well as any other chronic disease. The system would then be stimulating competition and improving quality medical care not punishing physicians and patients. A negative and faulty penalty system (P4P) will not solve any of our problems. I predict it will only make it worse for the patient and the physician and more profitable for the insurance industry and hospitals. The physician and patient community ought to be outraged. They are not because we are a sound byte society and do not pay attention to the details of issues.

The P4P fad is simply another reason why patients need to be in control of their healthcare dollar. They should be rewarded if they avoid complications and improve their health. Physicians should compete to develop focus factories in order to generate economies of scale and improved medical outcomes. All of this has to be done in a price transparent environment.

Stanley Feld M.D.,FACP,MACE

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

Only 20% of the people are sick at any one time. Therefore only 20% of the people think about the healthcare system and their healthcare insurance policy at any one time. The uninsured think about the potential cost of getting sick and fear not having health insurance.

When insured people get sick and navigate through the healthcare system is a nightmare for only about 40% of them. At any one point in time only 8 out of 100 people who have health insurance are having difficulty with the healthcare system. When all the people with healthcare insurance are forced to think about the healthcare system only 40% have experienced a horror of the situation. The other 60% that did not have a problem think the problems with the healthcare system are over exaggerated.

In August 2006 I received this comment from Cleve:

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

Last week I spoke to a friend who had neck surgery two years ago. He was hospitalized for 2 days. He had the opposite comment. He has health insurance with UnitedHealthcare. He thought my comments about UnitedHealthcare were exaggerated. His hospital bill was $17,500. The surgeon charged him $17,000. I remember his complaining about how atrocious these two bills were. I assured him the adjudication of the bill would look nothing like the retail charges. UnitedHealthcare paid both the hospital and the surgeon $3,500 each. He was responsible for nothing. He was relieved and pleased with the system. He said the hospital and surgeon seemed satisfied.

What about Denise? Remember her. She did not have health insurance. She was self employed with a preexisting condition. She did not qualify for health insurance. If she needed emergency neck surgery she would have been responsible for the entire $34,500. Both the hospital and doctor would have been unrelenting in the pursuit of payment. If the hospital and doctor would settle for $3,500 with the insurance company they should settle for the same with Denise. However, she would probably go to the collection agency and if she did not pay, her credit would be destroyed.
Denise could not get information for the price of a simple x-ray from the hospital. This precipitated her frustration and letter to then gubernatorial candidate Kinky Friedman the comedian cowboy running for governor.

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

Matthew Huebert wrote:

“There is something meaningful about blogs and RSS that I’ve only begun to understand recently, and this post describes and exemplifies it well: you are a thinking person, putting yourself ‘out there’, introducing outsiders into your own world and adding depth to a discussion that matters to you and matters to society. For me, it is writing like this that is an antidote to the superficial sound bytes that obscure possibilities for change by avoiding the “Why?” questions. I think what’s finally hitting me is the fact that these conversations simply wouldn’t be happening if RSS did not exist! What you’re doing is inspiring. Thanks for the great post.
Matthew Huebert”

A huge barrier to real repair is the lack of awareness of 60% of the insured population. The 46.7 million uninsured are a mere abstraction to these people. The horror of the 40% insured is also an abstraction. If the trend continues the system will cave in all at once and everyone will be affected. People have to be stimulated to action now and demand the solutions I outlined in the last three blogs.
We are approaching a Presidential election year. We will hear all sorts of noise from “leaders” who in my opinion have little serious knowledge of the problem or the solution as seen in recent initiatives in California and Massachusetts. Our leaders are not stupid. The problem is the input of information is coming from the facilitator vested interest groups and not the people in the street.

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

Stanley Feld M.D.,FACP, MACE

The following are additional solutions necessary for the Repair of the Healthcare System

• Develop Centers of Excellence and Focused Factories in both hospital based clinics and physician outpatient clinics to treat chronic diseases by a team of multi disciplinary experts using systems of care based on evidenced based medicine. Disease management systems can be developed in primary care physicians’ offices because there are not enough specialists to take care of all the patients with chronic disease. Treating chronic diseases this way should lower the complication rate for chronic diseases. The result should be a reduction in the cost of healthcare by at least 45%.

• Emphasis should be place on teaching the patient how to be the “professor of his disease”. Payment should be available to the Center of Excellence for this education.

• Promotion of and payment for early evaluation and recognition of chronic disease. It is essential to detect and prevent these chronic diseases early to prevent costly complications of these diseases.

• A sophisticated information system connecting medical care with financial outcomes. An ideal EHR should be made available to physicians on a per use basis so that the investment cost is not a burden to the physician. The information technology should be used as a learning tool for the physician to continually improve the quality of care and not as a weapon to penalize the physician. .

• Quality of care should be defined as whom to evaluate, how to evaluate, whom to treat, how to treat, how long to treat, how often the patient should be seen, how often the patient should be retested, and the measurement of adherence to medication. Measurement of quality should be all of the above. However, the key measurement of quality is the medical outcome as it relates to the financial outcome. If you prevent a $50,000 complication utilizing $1,000 of treatment you have a leveraged financial outcome as well as an excellent medical outcome. The main question is, “was the complication of the chronic disease avoided?” We are misguided when we start believing that measuring the percentage of our patients we measure cholesterol on, or the percentage of patients on whom we do colonoscopies or bone densities is a measure of quality of care. It is simply one element of quality medical care and it should not be rewarded as the Pay 4 Performance advocates are suggesting. This thinking makes us vulnerable to another false hope of reducing complications of chronic diseases.

• Increasing obesity in our population is a huge health risk. The government should declare war on obesity. It should strive to eliminate the many stimuli we are exposed to. It should institute a gigantic public media campaign to explain the health risks and the stimuli to overeat.

The most important need is to put the patient in charge of his disease management. The patient must be responsible for his care and in control of his health care dollar. We do not need more schemes destined to fail such as the California and Massachusetts mandates. We do not need the Pay 4 Performance scheme that will distort the healthcare system even further. We need some common sense infused into the development of a system that is driven by the patients and not the facilitator stakeholder for the purpose of the facilitator stakeholders’ bottom line.

If patients do not want to take care of themselves they will suffer medically and financially.
These are some of the solutions I have proposed. We need the political will and leadership to institute and execute these solutions. Responsibility for follow up care and compliance must be the patient. The physicians are the teachers educating patients to be experts in their disease self- management. In the present system the penalty to the patient is bad health. The new system should have a clear message of good health and financial reward. It is much cheaper for all the stakeholders in the long run.

The patient has to;
• Be responsible for the purchase of care.
• Have ready access to care.
• Be responsible for the appropriate adherence to care and medication regime given by the physicians.
• Be rewarded for excellent lifestyle changes and avoidance of complications of disease.

If this is accomplished, and it can be with appropriate leadership and the demand by the consumer, we can repair the healthcare system.

Stanley Feld M.D.,FACP,MACE

The solutions I have proposed are all directed to a patient centered, patient driven, and patient advantaged system. I will review the proposed solutions in the next two blogs.

• Price transparency is an essential beginning. No only must the retail price be published but all of the discounted prices must be transparent as well. Somehow, the government has to enact legislation so that the providers and the insurance companies post their range of prices. The government has to empower the patient with negotiating power to get the best price. There are many different prices paid for a service depending on the negotiating power of the purchaser. The net effect of this total price transparency will be lower the prices and decrease cost of health insurance. The consumer must demand real price transparency. Aetna’s declaration of price transparency last year was a rouse. The hospital associations of Wisconsin and now Texas have developed web sites to provide hospital retail prices. We have little idea how much the government or insurance companies pay for these services. I assure you the discount is very deep and the hospitals are satisfied with the payments. The automobile industry has figured out how to deal with total price transparency and the internet publication of the MSRP, the invoice prices and the average prices paid for an individual automobile. We should demand that the healthcare system does the same. The system should be set up where the patient can negotiate price pre or post treatment. Sometimes the patients need a care emergently and are not in a position to negotiate in an emergency room.

• Elimination of a two tier payment system with hospital clinics receiving more money for procedures than outpatient physician clinics for the same procedures. Eliminate the restricting of payment to the physicians’ office clinics as long as there is proof of equal quality and qualifications to do the procedures in the physicians’ office. This can serve to increase price competition for services. Price competition is a vital element on the repair of the healthcare system.

•Expand consumer driven healthcare using the ideal Medical Savings Accounts and not the present Health Savings Accounts. I have made clear the difference between the two. The ideal Medical Savings Account would be to the patients’ advantage and not the insurance industries advantage. The ideal MSA would serve to motivate the patient to shop price and quality because they are spending their own money. It would also encourage adherence to treatment for the same reason.

• Create a level tax exempt playing field for the self employed and uninsured
so they can buy insurance with pretax dollars. Provide those who qualify for subsidy with a subsidy to pay for their Medical Saving Account. If they use the healthcare system appropriately or they do not have to use the system they should be rewarded with a lifetime tax exempt saving account. Incentives on all levels drive our system of free enterprise.

• Administrative waste in hospitals should be penalized and not rewarded. The system of payment presently is very opaque. For example payment for some chemotherapy is 10 time the cost of the drug. Yet the oncologist is not permitted to administer the drug in his office for one and one half times the cost. It is estimated that $150 billion dollar are wasted on administrative costs in the hospital and in the insurance industry. These costs add not value to the treatment of patients. The administrative waste is absorbed by increased executive salaries and increasing construction of enlarging hospital facilities. The brick and motor expansion of hospitals should be over since much can be done on an outpatient basis.

These are some of the solutions necessary to repair the healthcare system. The solutions have to be instituted as a total plan and not introduced piecemeal. Each of the pieces of the solution is dependent on each other in order to have a positive effect on repairing the healthcare system. Next time I will review the other elements of a plan I have proposed that will solve the dilemma expressed by the questions that need to be addressed to Repair the Healthcare System.

Stanley Feld M.D.,FACP,MACE

In August 2006 I summarized my blog to that point. I outlined some important solutions necessary for the repair of the healthcare system. Since then I have covered many of the solutions to the key questions I raised. Not one of these questions has been addressed effectively by our leadership or people in control of making policy. One must ask: Do they really want to solve the problems in healthcare delivery in this country or are they focused on preserving their own vested interest to the exclusion of a breakthrough that might benefit not only their vested interests but the vested interest of all the stakeholders.

The questions were:

• How do we reduce the cost of medical care?
• How do we provide affordable insurance for the 45 million people uninsured?
• How to we provide affordable medical care coverage so that all the patients can have access to medical care?
• How do we align all stakeholder incentives?
• How do we construct a system so that all the stakeholders make a reasonable return on investment?
• How do we close the holes in the system to eliminate abuse by stakeholders?
• How do we restore trust between stakeholders?
• How do we restore trust between the patient and physician?
• How do we stop secondary facilitator stakeholders from continuously destroying the patient physician relationship?

In reality, developing solutions to these questions are in themselves business opportunities for facilitator stakeholders that can help Repair the Healthcare System. However, neither the insurance industry, hospital systems, nor the government see the long term advantage and economic opportunity. In a comment to my blog Shel Isreal said “

The insurance industry has the money and the power.”

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2007/01/the_ideal_elect.html. However, we have demonstrated the abuse and misuse of the power of information technology by the insurance industry. The misuse and abuse has lead to further dysfunction in the healthcare system and mistrust by the hospitals and physicians. The insurance industry and the government have used information technology to penalize both physicians and patients using the wrong data to draw their conclusions. Insurance companies do not have the information technology resources to measure the correct parameters to measure quality care. I do not see an attempt on their part to correct this deficiency. I only see a movement to make the healthcare system worse with a Pay for Performance (P4P) reimbursement system that is not well thought out. .

It is essential that the solutions I have proposed be coordinated and introduced simultaneously as a single plan rather than introducing elements of the solution separately.

Unfortunately, the government with the pressures of its present political vested interest influences finds it difficult to present the components of repair as a single plan. The solutions will have to be driven by the consumer (the patient) and not the government. The patients have the power to drive the solutions because they are the users of the healthcare system. If they were the purchases of healthcare, some clever entrepreneur could provide the option for a compelling insurance product that could reward the patient for being responsible for their own care and well being. The insurance produce could be built to fix the healthcare system.

Stanley Feld M.D.,FACP,MACE

In response to my last blog,” Can You Believe This? UnitedHealthcare Is Committed To Improving the Healthcare System”. I receive this comment: “Believe it or not UnitedHealthcare is trying to repair the healthcare system and becoming user friendly?”

Just after I received that comment four articles appeared in press this week demonstrating that UnitedHealthcare is becoming less user friendly and continues to march forward to try to shut out the competitive environment necessary for constructive reform of the healthcare system.

This sort of information is immediately available through the broad reach of the internet and blogosphere. Ordinary citizens can now monitor events and actions occuriing throughout the country. We can instantly see the inconsistencies.

The major stakeholders in the healthcare system are the patients and the physicians. All actions taken by facilitator stakeholders should be for the improvement of the delivery of care by the physician to the patient. Judgments about patient care should not be directed by the facilitator stakeholder. It should be directed by the patient. Patient choice should not be limited by the facilitator stakeholder. The key to repair of the healthcare system is a competitive environment for the delivery of care and care driven by the patient.

Apparently this is not UnitedHealthcare’s goal.

The St. Petersburg Times published the difficulty physicians and patients are having with UnitedHealthcare about laboratory work. The most convenient place to have laboratory work done is in the physician’s office. One stop service is a great convenience to the patient in an over stressed medical encounter. This is not permitted by UnitedHealthcare even if the physician office is less expensive that one of their designated laboratories.

“The Connecticut State Medical Society has written to the state attorney general about United’s exclusive contract with LabCorp, saying the company has a limited number of facilities in its area.”
“If I give a patient a script for LabCorp, but they go to the Quest Lab in my building because it’s convenient, do I get fined?” Wasylik asked. “The insurer allows a patient to have out-of-network benefits. But if they use them, they punish the docs. That doesn’t make sense.”

It certainly does not make sense. Worse, it is a direct contradiction to developing a more user friendly healthcare system UnitedHealthcare professes in its advertisement in the Wall Street Journal March 19,2007. It simply forces the patients and physician to be more captive to its controlling tactics.

The AMA provided another contradiction to UnitedHealthcare’s advertisement.
“In a press release, the AMA said it sent a letter in strong opposition to the merger to U.S. Attorney General Alberto Gonzales. The AMA said that it has “deep reservations about United’s goal of dominating the Nevada health insurance market, and in particular the Las Vegas market, by purchasing the state’s largest insurer.”
AMA Board Member James Rohack, M.D. said in the letter, “Federal authorities must not allow United’s blatant grab for dominant market power. The proposed merger would have negative long-term consequences for patients, physicians, hospitals and employers.”

“If the proposed merger is allowed, the AMA estimates that United would control 78 percent of the HMO market in Nevada, and 95 percent of the HMO market in the Las Vegas-Paradise metropolitan area.
It looks like UnitedHealthcare’s plan is to limit the competitive environment.

Then another inconsistency appeared in San Francisco. “United Healthcare under fire over pay” was the headline of a San Francisco Biz Journal article
California Medical Association wants state investigationThe CMA, which represents 35,000 doctors statewide, wants the state Department of Managed Health Care and the Department of Insurance to see if reports of widespread delays, underpayments and other errors on doctors’ contracts by the giant Minnesota-based health plan are the result, as the doctors’ group says it suspects, “of a significant lack of administrative capacity.”

A lame excuse when UnitedHealthcare’s profits and executive salaries are so high.

These are just a few of the examples I picked up on the internet this week. They are a total contradiction of UnitedHealthcare’s advertisement of March 19,2007 in the Wall Street Journal.

Before we can believe UnitedHealthcare really means what it says, it must show us it is ready to repair the healthcare system rather than continue to destroy it.

Stanley Feld M.D.,FACP,MACE

UnitedHealthcare had a full page ad in the Wall Street Journal Monday, March 19.2007. There is a temperature thermometer in the top left hand corner on a red page implying something has a fever.

They have to be joking. Doesn’t UnitedHealthcare understand it is a major contributor to making the healthcare system sick?

UnitedHealthcare has a terrific tag line “UnitedHealthcare Healing Healthcare. Together.” It is a great grabber but has little meaning.

The advertisement defines the healthcare system’s illness.” They say the healthcare system isn’t healthy. There is no denying it. A system that was designed to make you feel better often just makes things worse. Costs are out of control, access is inconsistent, quality is too variable and the entire process has become unwieldy.”

UnitedHealthcare claims that costs are out of control. Why? Who paid their CEO 1.8 billion dollar over 8 years? The amount equals 300 million dollar a year in salary and benefits to one person. UnitedHealthcare. What are the other top executives at UnitedHealthcare receiving in salary and benefits? Do you think these salaries affect the cost of insurance?

UnitedHealthcare has made access to care inconsistent. Ask any physician caring for its members. Is its pre-certification system and the restriction of access to care dangerous to its members’ health. Ask its members. The key question is “am I covered?”.

I am convinced UnitedHealthcare can not define quality properly. In my experience insurance companies define quality to their economic benefit and not the patients or physicians. Remember Dr. Petak’s example with Blue Cross/ Blue Shield of Texas. UnitedHealthcare can not possibly define real quality medical care with the claims data it has available.

Is the process unwieldy? You bet it is. Who creates all the paperwork for physicians so they have less time to spend with their patients? United Healthcare! Who rejects or modifies claims payment resulting in physicians and hospitals appeals leading to more paper work and more cost? United Healthcare! Does this increase premium cost. Most certainly.

The advertisement goes on to say “Every day, more Americans are added to the rolls of the uninsured.”

Who wants only to insure non sick or at risk people? UnitedHealthcare! A fifty year old Type 2 diabetic with hypertension and elevated cholesterol lost his job. He is now self-employed. He can not quality for an individual health insurance policy for him and his family from UnitedHealthcare because he is a high risk patient. UnitedHealthcare is required by law to insure him in a group policy if he was employed by a company that qualified for UnitedHealthcare’s group insurance. UnitedHealthcare has simply raised the premium on the group health insurance to his employer because they have high risk employee’s until the employer could not afford to provide insurance for the group. This patient profile makes up the profiles of two thirds of the uninsured in America today.

“There is an epidemic and it’s time we found a cure.” No kidding.

They go on to say; “At UnitedHealthcare, we are committed to improving the health care system. We aim to take what’s wrong and make it right. “

A welcome change of heart, but what is their plan?

“Simplifying everything and eliminating red tape.
Ensuring access to the right care anywhere in the U.S.
Empowering you to make better decision about your health 24/7
Providing information to doctors to better support people
Rewarding first-rate physicians for first-rate medicine.

All while making your health care more affordable.”

UnitedHealthcare figures we are a “Sound Bite Society” and in my opinion they decided to feed us a couple of sound bites to make us happy. TXU tried to do the same thing in Texas while destroying our health by wanting to build 11 dirty coal plants.

To my surprise, Texans came through. We did not buy the sound bite. We are smarter than they think we are. It is painful to understand the details of most issues but somehow we Texans rallied round and did let them sneak their sound bite through. Enough is enough. We need leadership and action, not words. We are smarter than they think.

I hope the country is ready to reject empty promises from UnitedHealthcare. Let them show us that they are going to reform their ways with deeds and not throw disinformation our way.

In conclusion the UnitedHealthcare”s adververtisement states;

“ Will all this be simple? No Simple doesn’t mean simple-minded. Sometimes simple means ingenious. Sometimes it means revolutionary. And no one is better prepared to lead this revolution with you that the strongest, most committed health care company in the nation. Simpler process, smarter solution, better results for you.
UnitedHealthcare Healing Health care. Together.

The UnitedHealthcare advertisement compelled me to look of the definition of disinformation in Wikepedia.

Disinformation is the deliberate dissemination of false information. It may include the distribution of forged documents, manuscripts, and photographs, or propagation of malicious rumors and fabricated intelligence. In the context of espionage or military intelligence, it is the spreading of deliberately false information to mislead an enemy as to one’s position or course of action. It also includes the distortion of true information in such a way as to render it useless.
Disinformation techniques may also be found in commerce and government, used by one group to try to undermine the position of a competitor.
Disinformation differs from propaganda in that its true source is concealed, and it usually involves some clandestine action. Unlike propaganda and Big Lie techniques designed to engage emotional support, disinformation is designed to manipulate the audience at the rational level by either discrediting conflicting information or supporting false conclusions. Another technique of concealing facts, or censorship is also used if the group can affect such control. When channels of information cannot be completely closed, they can be rendered useless by filling them with disinformation, effectively lowering their signal-to-noise ratio.

Is this advertisement disinformation or propaganda or both? Does UnitedHealthcare think we are stupid?

UnitedHealthcare has to show us what they are going to do and do it. Not throw sound bites at us.

Stanley Feld M.D.,FACP,MACE

Readers of my blog Repairing the Healthcare System have realized that I am developing a story of why the healthcare system is dysfunctional and the steps necessary to repair it. I have described some of reasons for the increasing costs; the 46.7 million uninsured and the restriction to the access to care.

I am also developing a story on how to repair the healthcare system. All of the entries are interconnected. They all should be linked. I have linked some of the posts. The links can be reached by clicking on the words that are in maroon and underlined.

When my son Brad Feld and I spent our weekend in Las Vegas, he said, “ Dad, you need Ligit. I will send you the link and put it on your blog.” Ligit is one of Brad’s portfolio companies. It is wonderful.

According to Ligit, “Lijit allows you to create your own search engine (in a very slick and pretty automated way), which searches your blog, blogroll, bookmarks, photos, etc. By placing the Lijit search Wijit on your blog, readers can search your collective goodness and receive amazing results. In turn, Lijit gives you information about the searches performed, such that you can get a better understanding of your reader community”.

I used to go crazy, wasting a lot of time finding related links in my blog to refer readers to. I now simply search through Lijit.

You can find Ligit at the bottom of my blog on the right hand side of the page. All you do in put in a topic you want to search for. Ligit will bring up all the blogs that mention that topic or keyword.

Readers could start using Ligit to dig deeper into the connections on my blog. Ligit is powered by Google. It presents the search information that same way Google presents information.

For all those out there with their own Blogs I suggest you install Ligit.

Stanley Feld M.D.,FACP,MACE

I have mentioned mistrust by physicians of the insurance industry, the government and hospitals. I have also pointed out the invaluable potential of the Ideal EHR in helping physicians increase the quality of care delivered without being penalized by the insurance companies and government. This mistrust is part of the reason for delayed adoption of information technology by physicians.

Steven Petak M.D., J.D.,FACE, FCLM, current AACE(American Association of Clinical Endocrinologists) President wrote an important editorial in First Messenger (the Newsletter for the AACE) illustrating the danger Information Technology presents as a tool against doctors by Blue Cross/Blue Shield of Texas.

BC/BS of Texas data collection resulted in a defective value judgment of Dr. Petak’s quality of care. BC/BS information technology system made that judgment measuring the wrong thing. BC/BS clearly did not understand the use of a specific drug. Dr. Petak is an excellent doctor as are others in his group. Blue Cross/Blue Shield of Texas did not bother to ask Dr. Petak why he did not practice evidence-based medicine while using the drug metformin.

BC/BS of Texas simply awarded Dr. Petak with a gray ribbon (which is bad) for the whole world, his patients, and potential patients who have insurance with BC/BS of Texas, to see. A dark blue ribbon in the Texas Blue Compare program of Texas Blue Cross/Blue Shield stands for excellent. A light blue ribbon is defined as good or average. How would you, as a patient, like to be going to a bad or average doctor? You wouldn’t!

The ribbon classification is available for all the BC/BS of Texas insured patients. It is an attempt at quality transparency for the benefit of their insured members. The coveted dark blue ribbon would indicate to the world that physicians have mastered applying evidence-based medicine and cost efficiency to their patients. Dr. Peak states “ The dreaded gray ribbon would only communicate my shame and wanting to the world. Although a gray ribbon is defined as not being able to provide a measure because of insufficient data for the physician or specialty or their threshold was not met, I knew my hard won reputation for excellence would now be lost”.

What did Dr. Petak do wrong? He failed to meet the evidence-based requirements concerning diabetes care. He did not do enough eye exams, HbA1c, and urine microalbumin assessments. Metformin is used to treat diabetes. Dr. Petak does not treat Diabetes Mellitus and had so informed BC/BS. He did not submit the claim form with a diagnosis of Diabetes Mellitus. He sees many patients with Insulin Resistance Syndrome (Metabolic Syndrome). Metformin is used in the treatment of Metabolic Syndrome by many specialists. Many female patients with Metabolic Syndrome do not ovulate. When the insulin resistance is treated they can ovulate and become pregnant.

Patients can buy metformin for $4 per month at Wal-Mart. If they had a successful ovulatory cycle and became pregnant, the patient has avoided the multiple tests and procedures of in-vitro fertilization. The saving to the patient in stress, anxiety and money is enormous. The savings to the entire cost to the healthcare system is great.

What was BC/BS of Texas’ problem? The problem was a lack of understanding of medical care. They did not evaluate Dr. Petak with accurate or useful information. Their computer system did not search for the diagnosis of Diabetes Mellitus. They assumed he was treating Diabetes Mellitus. They did not ask Dr. Petak why he used metformin. They simply penalized him. They only evaluated him with one of the elements of quality care. They simply used the tests that should be performed at a given interval in treating a diabetic. BC/BS was only interested in showing the world they are a great company protecting their patients from bad doctors. They had no concern for the physicians’ reputation or the physician-patient relationship.

There are other of examples of insurance companies evaluating quality care with the wrong criteria and presenting physicians with report cards that seem meaningless to me. This is part of the reason there seems to be such resistance to the Pay for Performance. It is simply mistrust by the patients of the insurance companies and the government. Both have declared they want to gain our trust. However, they continually act in a way that creates an environment of mistrust.

Bravo, Dr. Petak for publishing this example. The ideal EHR must be set up so it is physician friendly and a physician extender. It should not be a weapon to be used against the physician.