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Politicians Give Me A Headache. We Must Vote! But For Whom? For The Best Person.

September 8, 2008

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Stanley Feld M.D.,FACP,MACE

Both Presidential candidates have claimed they have specific proposals for change for many policies. If we decide on whom to vote for on the basis of healthcare policy we will be making a mistake. They both want to change the wrong things. They also have not given us an idea of how they are going to execute their promised changes.

Neither candidate is going to have a positive effect on Repairng the Healthcare system because they are focused on the wrong changes. If they can get congress to approve of any of their proposals, they will only make the healthcare system worse.

My last ten blog entries have reviewed both Barack Obama’s and John McCain’s healthcare proposals specifically. I am disappointed in each candidate. Neither is focused on the basic problems in the healthcare system

Both candidates advocate universal coverage. Barack Obama wants universal coverage with a single party payer.

The sound bytes Barack Obama uses suggests a competitive environment between the government and the healthcare insurance companies. If the government was serious, the healthcare insurance industry would not want to compete. The rules and regulation promised would be intolerable. They would rather run the single party payer system for the government.

John McCain is against entitlements. His goal is to shift the burden of acquiring healthcare insurance to the citizens. John McCain plans to provide tax credits to citizens. The tax credits are suppose to be used to purchase healthcare insurance. In affect, John McCain wants to relieve government and employers from providing healthcare insurance for their constituents and employees. The sound bytes John McCain uses suggest that all citizens will have the opportunity to buy healthcare insurance. This is not quite universal coverage. His tax credits are not large enough to buy the healthcare insurance even if consumers could afford it.

The basic problem is the healthcare insurance industry will set the price of the insurance premiums as it does in the present system using antiquated actuarial systems and bloated administration fees. This is a basic problem in the healthcare system. Neither candidate is focused on this problem. Neither candidate respects the consumer’s ability to manage his own healthcare dollar.

The cost of universal care in Massachusetts has doubled. Massachusetts outsources the universal healthcare insurance coverage to a couple of insurance companies. Government officials in Massachusetts claim the reason for the high premium costs is more people are obtaining subsidized insurance than anticipated. Economics 101 dictates that the more people are insured the less the premium should be. Unfortunately, the healthcare insurance company controls the money and the bids.

Consumers should own their healthcare dollar. They do not need first dollar insurance coverage. Consumers should manage their own first dollar coverage. The first dollar coverage should be funded by their employer or the government, tax free. This would eliminate the insurance companies’ administrative cost for the first $6,000 in healthcare coverage. If consumers do not spend the first $6,000 the remainder would be deposited in a tax free retirement trust fund. It would not be deposited in a health savings account to be paid back to the healthcare insurance industry for future co-payments and deductibles.

Consumers would then be motivated to use the first $6,000 wisely. They would be motivated to remain healthy. If a patient had a chronic disease that required medical care and spent $4,000 to avoid complications of their chronic disease, the employer or the government would provide a bonus for their retirement trust. If a patient developed a chronic disease and spent the first $6,000 then the high deductible insurance would provide first dollar coverage for the remaining expenses.

Consumers responsible for their own healthcare dollar would then shop for the best treatment at the best price. They would also be motivated to stay healthy and exercise regularly, The economic gain would motivate consumers not to smoke, drink or become obese. Consumers would also be motivated to demand environment clean-up in order to protect their health. Politicians might listen. There is no reason Dallas, Texas should be out of EPA compliance except for the polluting effects of coal plants. Soot and cigarette smoking cause chronic lung disease and asthma. Consumers would demand rapid change if they were denied being rewarded for staying healthy because of circumstance beyond their control, but in the hands of the politicians.

This innovative healthcare plan would eliminate the healthcare insurance industry’s excessive administrative costs for the first $6,000, provide incentive for healthcare insurance companies to compete for highly profitable high deductible insurance plans , and provide incentive for consumers to be responsible for keeping themselves healthy. It would also provide incentive for physicians and hospitals to become more efficient. Consumers would be shopping for the best care at the best price. The government would have to force and enforce real transparency. If stakeholders were not really transparent they would be denied a license to sell insurance, hospital services or physicians’ services in that state. The states, not the federal government must be in charge. Insurance premiums would have to be calculated on a community rating basis. Electronic medical records must be uniform and interchangeable. EMR software should be distributed via the web download. So should electronic prescriptions software. Physicians should pay for the software by the click. This would promote rapid adoption and avoid unaffordable capital expenditures. Compliance by physicians and patients should be rewarded, not like present proposals for punishing non compliance.

In my review of the Presidential candidates’ healthcare plans none of these solutions are mentioned. Instead, both candidates make proposals that are not well thought out. They do not offer basic solutions. They do not motivate or trust consumers to be responsible for their health.

The consumers’ healthcare dollar should be under consumer control. They have to be taught how to use their dollar wisely. The government should set and enforce rules to prevent abuse by the vendors. America’s healthcare crisis will not be solved until a leader listens to the primary stakeholders, the patients and the physicians.

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

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Is Barack Obama Any Different Than Other Politicians? Part 6

August 26, 2008

inMedicine: Healthcare System, Patients Problems, Politicians,Healthcare and Vested Interests

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Stanley Feld M.D.,FACP, MACE

Some of the ideas in Barack Obama’s healthcare plan are good. However, some of the ideas have defects. The defects will render execution of his healthcare plan impossible. The complexity of his bureaucratic machinery will make his plan inefficient and costly.

Quality and efficiency are important bullet points in Barack Obama’s healthcare plan

· Quality and Efficiency.

“ Participating insurance companies in the new public program will be required to report data to ensure that standards for quality, health information technology and administration are being met.”

I have stated that measuring quality medical care has not been accurately defined. Quality medical care should be measured by positive medical outcomes at the least cost. Successful medical outcomes have to be linked to successful financial outcomes.

Inaccurate quality measurements are presently being used to judge physician performance. The system is called Pay for Performance (P4P).

Hemoglobin A1c testing is an example of a presently used quality measure. Does the physician do four hemoglobin A1c’s per year in treating his diabetics? HbA1c is a measurement of glucose control over a 3 month period of time. The result is a valid measurement of glucose control.

The four measurements of HbA1c are in itself meaningless. The importance of the measurement is to track patients’ HbA1c improvement over the year? How much of the improvement was due to the physician’s treatment? How much of it was due to the patient’s effort to improve his HbA1c? Did the improvement in HbA1c prevent the patient from developing a complication of Diabetes Mellitus?

Did the improvement keep the patient out of the hospital? The results and cost savings from these results are the parameters that should be measured to make the judgment of the quality of care and not the measurement of HbA1c itself. The dual fulfillment of the responsibility of the physician and patient should be measured. None of these goals are included in the definition of quality measurements at this time. Until they are we do not have an accurate measurement of quality medical care.

Before the government can demand that participating insurance companies in the new public program can ensure that standards of quality are met quality has to be defined. If the healthcare insurance companies are determining quality the government is essentially putting the fox in the hen house to have a feast.

Lowering costs by modernizing the healthcare system is an essential idea. The responsibility for the cost of care should not be a burden of the government. It should not be a burden on the employer who is providing the benefit. It should be a burden of the consumer (patient). It should be the consumer’s responsibility to take care of him. The employer and government should aid the consumer in his ability to fulfill his responsibility for his wellness and effective and efficient care if he is sick.

Lower Costs by Modernizing The U.S. Health Care System

Reducing Costs of Catastrophic Illnesses for Employers and Their Employees:

Catastrophic health expenditures account for a high percentage of medical expenses for private insurers. The Obama plan would reimburse employer health plans for a portion of the catastrophic costs they incur above a threshold if they guarantee such savings are used to reduce the cost of workers’ premiums.

Many of the chronic diseases are the result of our social behavior and environment. Obesity, pollution, drug addiction, smoking, and public hygiene generate many chronic diseases. Who should be responsible for our social behavior and environment? Should it be the government, our employer, the state, or our neighbors?

I believe the government should be responsible for developing programs to eliminate pollution as it did in the past with smoking. Our government has dropped the ball with its public service campaign against smoking. It can be done if Congress and the President had the courage to do it.

The government could also do much to reduce obesity and drug addiction. However, it must be up to the consumer to be responsible for himself. Obesity and drug addiction are tinder box problems for our healthcare system. Coal burning electricity plants are another problem. It increases our carbon footprint but this impact is not even a required measurement for license. The indiscriminate use of antibiotics in cattle feed lots is another tinder box problem. The problem could be a mutation of an antibiotic resistant infectious disease epidemic. Barack Obama should be talking about solving these problems and not providing a rebate for employers who have employees with catastrophic illness.

Helping Patients:
1. Support disease management programs. Seventy five percent of total health care dollars are spent on patients with one or more chronic conditions, such as diabetes, heart disease and high blood pressure. Obama will require that providers that participate in the new public plan, Medicare or the Federal Employee Health Benefits Program (FEHBP) utilize proven disease management programs. This will improve quality of care, give doctors better information and lower costs.

This is a great idea. Presently these programs are not supported by the government or healthcare insurance companies.

Traditionally the government sets up pilot programs to test every concept. However, when the pilot study for the effect of managing chronic disease failed, it failed not because the concept of chronic disease management was wrong but because the design of the pilot was defective.

· Coordinate and Integrate care.

Over 133 million Americans have at least one chronic disease and these chronic conditions cost a staggering $1.7 trillion yearly. Obama will support implementation of programs and encourage team care that will improve coordination and integration of care of those with chronic conditions.

This is another great idea. The emphasis for reimbursement has to shift from procedural medicine to cognitive medicine. Since cognitive medicine has not been well supported with reimbursement, physician care has migrated to procedural medicine. Diabetes education is an essential element in teaching the patient how to become a “professor of their disease”. It is essential that patients know how to self manage their diabetes. Diabetes education program must be supported so that physicians can afford to develop diabetes education centers in their office. The diabetes education must be an extension of the physicians care. It does not work in a free standing clinic that is uncoordinated with the physician. It has to be a team management effort with the patient in the center of the team and the physician the captain of the team. It must be a team effort so the patient feels connected and cared for.

None of the infrastructure for chronic disease management is in place presently. I am happy that in Barack Obam
a’s healthcare plan there is awareness of this essential element to repair the healthcare system. However legislative regulation must occur for this to become a reality.

· Require full transparency about quality and costs.

“Obama will require hospitals and providers to collect and publicly report measures of health care costs and quality, including data on preventable medical errors, nurse staffing ratios, hospital-acquired infections, and disparities in care. Health plans will also be required to disclose the percentage of premiums that go to patient care as opposed to administrative costs.”

Real price transparency is another big idea.

It must occur if there is going to be any improvement in the costs of the healthcare system. However, if all we have is a single party payer (the government) with the administrative services outsourced to the healthcare insurance industry price transparency will not occur. There will be no competition for healthcare insurance coverage. The lack of competition means the lack of innovation.

Barack Obama has some good ideas.The ideas will fail because big government is king. It is big government’s role to control the lives of the people rather than creating programs which promote people to control their own lives? Most people can be trusted. If they can not control their own lives under proper incentives and supervision they should be penalized. The government should not try to control the lives of the people.

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

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Is Barack Obama Any Different Than Other Politicians? Part 5

August 24, 2008

inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests

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Stanley Feld M.D.,FACP, MACE

From a distance everything Barack Obama says sounds great. The events of the last eight years have created cynicism and despair. We are a nation thirsty for hope to solve our many problems.

In healthcare the basic problem is not how we are going to pay for healthcare for all of our citizens but how to change the healthcare delivery system to create a healthier society and less chronic disease. Eighty percent of our healthcare dollars are spent on the treatment of chronic disease.

Barack Obama’s National Health Insurance Exchange does not address the basic problem in a meaningful way. It creates another bureaucracy that will drive competition out of the market place. It will result in socialized medicine with all of its bureaucratic and monetary problems.

“National Health Insurance Exchange:

The Obama plan will create a National Health Insurance Exchange to help individuals who wish to purchase a private insurance plan. The Exchange will act as a watchdog group and help reform the private insurance market by creating rules and standards for participating insurance plans to ensure fairness and to make individual coverage more affordable and accessible.

I believe his National Health Insurance Exchange will drive the private insurance companies out of the healthcare insurance business. This might not be a half bad idea since the healthcare insurance industry controls healthcare cost and earns a grotesque amount of money. Also the government outsources and will continue to outsource its Medicare administrative services to the healthcare insurance industry at an equally large profit.

“ Insurers would have to issue every applicant a policy, and charge fair and stable premiums that will not depend upon health status. The Exchange will require that all the plans offered are at least as generous as the new public plan and have the same standards for quality and efficiency. The Exchange would evaluate plans and make the differences among the plans, including cost of services, public.”

The only option remaining would be the new public plan similar to Medicare Part C the coverage that Senator Kennedy has. In recent years Medicare Part B has experienced increasing deficits. The increasing deficits have resulted in increasing costs to seniors and decreasing healthcare benefits. Increasing costs and deficits are inevitable in a single party payer system if the basic problems in the healthcare system are not addressed.

I believe the goal of the Democratic Party is to convert our healthcare system to a system of universal care with a single party payer. Hillary Clinton tried it in 1993 and Barack Obama will try in 2009 if elected.

It has been said that democratic countries in the west with single party payers do just fine. Canada and England have healthcare systems with universal care with a single party payer. All one has to do is look online at newspapers in Canada (National Post) and London ( Evening Star) to see how well these systems are really doing for their citizen. The following articles appeared in the National Post in Canada

1. Millions of Canadians lack family doctor

MD uses lottery to cull patients Not first such case as lack of doctors causes huge caseloads. In the latest jarring illustration of the country’s doctor shortage, a family physician in Northern Ontario has used a lottery to determine which patients would be ejected from his overloaded practice.

2. Let private sector into health care: CMA president Day

“We must not deny any patient access to essential health care based on ability to pay; nor should we deny access based on a shortage of doctors, hospital beds or operating time.

“Competition, consumer choice and market principles barely exist in our health system. The CMA President is asking for the basic principles that stimulate organizations to work properly

“Let’s note that three of the main Olympic values — excellence, universality, sustainability — are similar to our values and aspirations for a truly great health system. “And, of course, an integral part of the Olympics is competition. Without competition we cannot expect improvement, let alone excellence. “I believe that if we are to preserve universal health care for the next generation, we need to embrace similar principles.”

He clearly pointed out the problems with the Canadian system.

“And he bemoaned the fact that more than one million Canadians were on waiting lists for health care and that five million people did not have access to a family doctor. Yet neither the governing Conservatives nor the Liberal opposition seemed to care, he charged.”

This is what I worry about with Barack Obama’s healthcare plan.

“Individually, most [politicians] have a deep understanding of the plight of our health-care system.”Collectively, especially at the federal level, they are reluctant — even afraid — of engaging in a meaningful public policy discussion on health.

Claude Castonguay, a former health minister in Quebec summarized the findings of a report he submitted to the provincial government. He said that public health care system, as it now stood, was not financially sustainable.

The following articles appeared in the London Evening Star

1. Doctors call for ‘rationing’ of NHS services

“Rationing of services in the NHS is a ‘fact of life’, doctors insisted. The British Medical Association said a postcode lottery operates nationwide with some treatments denied to patients simply because of where they live.

It called for a charter that would tell patients exactly what ‘core’ services they are entitled to receive in England.

But in order to make the NHS work successfully, the BMA says the day-to-day running of the service must be wrested from politicians.

James Johnson, chairman of the BMA’s council, said there had to be an end to the ‘constant political dabbling’ and ‘micro-management’. “

2. London’s healthcare is lagging

3. Third of broken hip victims have to wait two days for surgery

“Thousands of elderly people with broken bones caused by falls are being betrayed by a postcode lottery in NHS care. A report says around one in three broken hip victims had to wait more than 48 hours for surgery – a delay that could have put their lives in danger. “

Enough said about the glories of socialized medicine in Canada or England. Is this what the American people want? Some say most people are satisfied with the healthcare service they receive in Canada and England. Only 20% of the population is sick at any one time. Therefore (most) have no idea what is going on in the healthcare system. It is easy to say they are satisfied with the system when they are not sick.

Rather than our next President creating another ineffective bureaucracy and costly entitlement program all he would have to do is

level the tax playing field for the self employed to be able buy insurance with pre tax dollars
permit the purchase of insurance across state lines
produce purchasing power and negotiating power for consumers with hospitals and physicians and insurance companies in a real price transparent environment
impose community rating with universal coverage regardless of pre-existing illness
provide ownership of the first $6000 to the consumer

I would bet consumers would use their healthcare dollar wisely.

Barack Obama’s National Health Insurance Exchange is a bad idea. It will not work if passed. The fact is the plan is not hopeful. It is the opposite of Barack Obama’s message of hope. A message America dearly needs.

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

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Is Barack Obama Any Different Than Other Politicians? Part 4

August 22, 2008

inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests

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Stanley Feld M.D.,FACP,MACE

I continue to look at Barack Obama’s statement puny statement on subsidies.

Subsidies.

“Individuals and families who do not qualify for Medicaid or SCHIP but still need financial assistance will receive an income-related federal subsidy to buy into the new public plan or purchase a private health care plan.”

Is this a false hope? Another example of a deficient subsidy is Medicare Part D. Again, the intention was good but the construction of the subsidy resulted in subsidizing the healthcare insurance industry.

UnitedHealthcare paid AARP $4 billion dollars to be the only provider of AARP’s Medicare Part D plan. Would UnitedHealthcare do this if they thought they would lose money? No! Part D is supposed to be a plan subsiding drug benefits for seniors. The government is supposed to fix the premium for all seniors regardless of health risk.

Last year UnitedHealthcare’s net income from Medicare Part D was over $1 billion dollars. UnitedHealthcare expects this net income to increase in the future as more baby boomers qualify for coverage. Despite all the profit from Medicare Part D next year the premium for seniors is going to increase from $25 to $28 per month per senior in post tax dollars.

The government does not negotiate directly with the pharmaceutical companies for drug prices as it does in the VA and Military healthcare systems. The healthcare insurance industry does the negotiating. The prices set are non transparent.

If the government wanted to be effective it would do its own negotiating. However, this does not seem to be the bureaucracy’s way. This is one of the reasons the government should not be a single party payer.

“Medicare’s drug plans will cost beneficiaries an average of $28 a month in 2009, about $3 more monthly than this year, according to the U.S. health-care program for the elderly.”

This increase represents an 11.5% increase from the previous year monthly cost of $25. It brings up the question again as to whether we can trust our politicians to look after our welfare and not the welfare of a secondary stakeholder?

“Premiums paid by beneficiaries for basic prescription plans cover about one-fourth of the program’s cost, with the government paying the remainder, according to Medicare. Medicare will spend about $36 billion this year to subsidize drug coverage.”

This is ridiculous. A generic drug estradiol cost $4 a month in Wal-Mart outside the Medicare Part D system. Inside the Medicare Part D system the patients benefit (“Doughnut”) is charged $20. The patient’s co-pay is $4 for the generic estradiol. Does anyone think Wal-Mart charged the healthcare insurance company $18 for this prescription? Does anyone think the Healthcare insurance company didn’t charge CMS (Medicare) $18 plus an additional administrative fee for this prescription? All we are told is Medicare will spend about $36 million this year to subsidize drug coverage.

Who is benefiting from all this money? In reality the government is subsidizing the healthcare insurance industry at a sizable profit. One can blame it on the Republicans. However it was a bipartisan bill with politicians being influenced by the vested interests of the healthcare insurance industry.

I have received many complaints about Medicare Part D. An outstanding complaint of a patient reaching the $2500 drug subsidy limit was a patient with glaucoma. The drops the patient was prescribed was not generic. The patient had a $65 co-pay. She paid this amount without noting the amount charged to her. After she paid $65 a month for 5 months she was out of drug coverage and into her Medicare Part D doughnut hole. She was charged $500 for her sixth month prescription. This was an out of pocket expense.

She complained to her ophthalmologist. Her ophthalmologist discovered that the retail price on the glucoma eyes drops was $90 for a one month supply bottle rather than $500 charged Medicare by the pharmacy. Her Medicare Part D account was charged $500 each month. She tried to complain but got nowhere. She did not receive a response from the healthcare insurance carrier or the government. The pharmacy said this was the price. They could not tell her how much the healthcare insurance company paid the pharmacy.

“The new estimates for Medicare Part D were based on bids submitted by companies that receive government subsidies to offer the plans.” “About 25.4 million Americans have drug coverage through Medicare, 17.7 million of them in standalone plans and 7.7 million in Medicare Advantage plans that provide health care through private insurers.”

My guess is the healthcare insurance companies make a greater net profit from Medicare Advantage than Medicare Part D because the subsidy is greater.

The point of these examples is the government will overpay the healthcare insurance companies and undercover patients for care. It continuously cuts the reimbursement to physicians while a facilitator stakeholder increases its profit.

George Bush recently proposed consumers pay for Medicare Part D on a means tested bases. He did not demand price transparency or cut the profit from the subsidy to the healthcare insurance industry.

“Republican President George W. Bush proposed raising the premiums paid by individuals earning more than $82,000 a year and married couples making more than $164,000. Democrats in Congress have said the government should have to power to negotiate directly with drug makers to hold down prices.”

Barack Obama plan will simply extend the charade. The only way to fix it is to have the consumer control their healthcare dollar and motivate him to use is healthcare dollar wisely.

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

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Is Barack Obama Any Different Than Other Politicians? Part 2

August 19, 2008

inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests

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Stanley Feld M.D.,FACP,MACE

Every week the words used to describe Barack Obama’s healthcare policy change. I am going to review his healthcare platform as described during the week of August 5-11^th. Each platform revision has the same bottom line. The bottom line is universal coverage with the government being the single party payer.(socialized medicine with all its regulations and inefficiencies).

However, each week his words are refined to made them more palatable. It gets to the point where one could believe the words are something more significant than they are. Clearly Barack Obama’s platform is not a solution to our dysfunctional healthcare system. I will evaluate each of his heading separately.

Comprehensive benefits. “The benefit package will be similar to that offered through Federal Employees Health Benefits Program (FEHBP), the plan members of Congress have. The plan will cover all essential medical services, including preventive, maternity and mental health care.”

This sounds perfect because 90% of the healthcare dollars is spent on the complications of chronic diseases. However, the restrictions to access to care and the availability of care have to be analyzed to be understood. Does anyone think Senator Kennedy suffered any of these restrictions for the treatment of his brain tumor?

When Senator Edward M. Kennedy disclosed on May 20 that he had brain cancer, three days after suffering a seizure, doctors did not list surgery as a possibility. A news release from Massachusetts General Hospital in Boston left the impression that radiation and chemotherapy were the main options for his pernicious type of cancer.

Precisely why Mr. Kennedy’s treatment course changed is not known; he and his doctors are not talking to reporters.

What is known is that a few days after Mr. Kennedy learned he had a malignant brain tumor in the left parietal lobe, he invited a group of national experts to discuss his case.

The meeting on May 30 was extraordinary in at least two ways.

One was the ability of a powerful patient — in this case, a scion of a legendary political family and the chairman of the Senate’s health committee — to summon noted consultants to learn about the latest therapy and research findings.

The second was his efficiency in quickly convening more than a dozen experts from at least six academic centers. Some flew to Boston. Others participated by telephone after receiving pertinent test results and other medical records.

Is this what Senator Obama means by The benefit package will be similar to that offered through Federal Employees Health Benefits Program (FEHBP), the plan members of Congress have.” Does anyone believe this policy would produce the care Senator Kennedy received? If it were true it would be great. However, this is an expansion of an entitlement America can not afford without improving the many inefficiencies and loopholes in the present healthcare system.

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Politicians Are Hard To Trust: Part 3

July 20, 2008

inMedicare, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests

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Stanley Feld M.D.,FACP, MACE

Why would the Senate initially vote against S. 3101 and H 6331? Why would President Bush threaten to veto it?

“ Nine Republicans who had voted against cloture last week pivoted to produce a potentially veto-proof 69-30 vote in favor of linking another temporary physician-pay fix to Medicare Advantage (MA) modifications already passed in the House by a 355-59 margin.”

The answer is President Bush is committed to the transfer of Medicare to the healthcare insurance industry (privatization of Medicare). He is subsidizing the healthcare insurance industry through the Medicare Advantage program at the expense of physicians’ reimbursement and to the disadvantage of seniors. The reimbursement reductions are below cost. Seniors are one of the primary stakeholders in the healthcare system.

President Bush’s advisers have convinced him that he has to get rid of the Medicare entitlement program. Medicare was invented by the Democratic Party and initiated in 1965 by President Johnson. It has been pretty clear for a while that Medicare’s business model was faulty. It is predicted to result in a 100 trillion dollar deficit by the time today’s young children become eligible for Medicare at the present level of spending.Source: Social Security/Medicare Trustees Reports 2008. The Medicare payment structure is seriously flawed. The two biggest flaws are the DRG system and the payments to the healthcare insurance industry.

Rather than being innovative and repairing the healthcare system by, eliminating waste, inefficiencies, and adverse incentives in order to protect future seniors with guaranteed, effective healthcare coverage, President Bush and his administration have opted to subsidize the healthcare insurance industry, a very powerful secondary stakeholder in the healthcare system.

Unfortunately, Senator McCain is thinking like President Bush. He has pledged to eliminate entitlements. Senator Obama is focused on universal healthcare and a single party payer.Obama’s plan will simply expand the Medicare deficit and yield more profit for the healthcare industry. I have discussed constructive policies that are needed to change the paradigm of the healthcare system. Neither candidate has uttered a word about innovative solutions that provide hope for the healthcare system and the citizens using it.

President Bush is handing our healthcare system over the healthcare insurance industry. He is providing subsidies equal to at least three times the present cost of Medicare to the healthcare insurance industry to take the healthcare system off his hands.

“With the White House ideologically committed to protecting MA, the outcome of a veto struggle remains uncertain. Republican senators who changed their votes will be under heavy pressure from the administration to support a veto.”

President Bush’s veto was overridden on July 12, 2008 simply by constituent outcry once they understood the consequences of his actions. Much of the healthcare insurance companys’ profits come from Medicare Advantage (≈10 billion dollars per year).

“As the juggernaut for Medicare privatization, the PFFS plans have been staunchly supported by the Bush administration despite per beneficiary costs that are an estimated 17 percent higher than those of traditional Medicare.

Does anyone think this helps anyone except the healthcare insurance industry? The budgeted money is shifted from physicians’ reimbursement to a healthcare insurance industry subsidy. When President Bush’s veto is rejected he will be decreasing the healthcare insurance industrys’ profit from the Medicare Advantage program. I think he is afraid the healthcare insurance industry will be upset and not want to take over Medicare.

Before Medicare bankrupts the country, it must be reformed. However, this is not the way to do it. By putting the healthcare insurance companies in charge will lead to disaster. The way to do it is to provide incentives to the primary stakeholders, not punish them to the advantage of the secondary stakeholders.

President Bush has not even mentioned medical care outcomes and impacts (i.e., is the nation getting what you pay for?). This is the point when it comes to evaluating whether a program that transfers money from the public sector to the private sector will accomplish a public mission.

“All of the research says “NO.” Both types of MA plans provide no more care nor any better care than traditional Medicare does, in terms of health outcomes of seniors. There is no justification to continue this Medicare Advantage program, by any definition of “efficiency” or “effectiveness” that the “market-based” conservatives may use. The Congressional Budget Office points out; the current IME adjustment represents a double payment to MA plans, because Medicare’s fee-for-service hospital rates, on which MA benchmarks are partially based, already include an IME add-on.

President Bush has called himself a “compassionate conservative”. I think he is being an unthinking conservative bent on protecting the vested interests of secondary stakeholders and ignoring the perverse consequences to primary stakeholders…

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Disinformation and Media Spin: Part 2

June 23, 2008

inDisinformation and the healthcare system, Medicine: Healthcare System

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Stanley Feld M.D., FACP, MACE

Dr. Aaron Carroll and Dr. Ronald Ackerman, the principal authors of the 2003 survey and 2008 letter in the Annals of Internal Medicine, states very clearly that physicians support a national health insurance plan. They does not state whether physician support a government run single party payer plan.

"Many claim to speak for physicians and reflect their views. We asked doctors directly and found that, contrary to conventional wisdom, most doctors support the government creating national health insurance," study author Dr. Aaron E. Carroll, director of Indiana University's Center for Health Policy and Professionalism Research, said in a prepared statement.”

However they seem to be saying that physicians want the government to take over.

"Across the board, more physicians feel that our fragmented and for-profit insurance system is obstructing good patient care, and a majority now support national insurance as the remedy," Ackermann said in a prepared statement.”

The source data is not available in their 2008 letter published in the Annals of Internal Medicine. I have evaluated the source data in their 2003 survey. The survey consists of two questions. The questions have misleading implications. Both questions start by asking one “to assume the principal goal of any national health insurance proposal is to arrange health care financing for all U.S. citizens”. In 2008 I believe most physicians would agree there should be universal healthcare coverage. The real question is do physicians want the government as the single party payer?

Question 1 asks “ do you support or oppose government legislation to establish National Health Insurance?”

Does that mean the government creates a plan that should cover everyone or does that question mean the government establishes a National Health Insurance that it administers as a single party payer?

Question 2 implies the former. “Do you support or oppose a National Health Insurance plan where the entire healthcare is paid for by the government?”

The survey design is flawed. Therefore it cannot yield valid conclusions. However, let us assume we could draw conclusions from the data in the survey.

Figure 2 describes the characteristics of the respondents in the survey.1650 physicians completed the survey sent to 3250 physicians. Only 1263 physicians had their characteristics compared to the AMA Physician Master file of 733,183 U.S. Physicians. What happened to the characteristics of the other 387 included in the survey? Does this 30% drop in number of physicians invalidate any power to arrive at conclusions for the data? Does the number of physicians in the survey represent a large enough number of physicians to represent the 733,180 physicians in the U.S.?

None of the mean insurance types, primary practice settings and primary practice locations was available in the AMA Physician Master file. This is one of several flaws in the study
The most important characteristics of the 1263 physician respondents was missing. How many physicians were in private practice? How many physicians in the survey group were employed and salaried by a university or hospital? What is the percentage of survey group physicians in private practice who received an institutional salary? These characteristics would have a effect on the physician response to the questions.

Additionally, any study whose published results present percentages without actual numbers or statistics has conclusions that are suspect.

Physician attitudes about National Health Insurance Financing are the most important table in the article.(Figure 3). The results are presented in the most misleading way. If a physician assumed that a national health insurance plan was universal coverage without a single party payer they might choose one answer to a quick survey. They might have thought the question meant the government would be the single party payer. 19% generally oppose, 21% strongly oppose and11% were neutral. The 11% neutral respondents might have been uncertain of the meaning of the question. If opposed to a single party payer they might have chosen to remain neutral. Therefore 51% of physicians might have opposed a national health plan as opposed to the 40% in the survey.

The answer to question 2 was important. It nullifies the principle authors’ message. 33% of physician strongly opposed, 27% generally opposed while 14% were neutral to a government paid for National Health Insurance plan. A neutral answer to this question could mean to some that the government would give me less grief than the healthcare industry has in recent years. Only 9% of physicians strongly supported the government as a single party payer. Again, we do not know the actual number of these physicians in private practice with monthly overhead. We do not know if the sample is valid or the results statistically significant. The number of physicians opposed to a single party payer was not discussed in either the 2003 or 2008 press release.

Only three predictors of physician support for governmental legislation to establish national health insurance plan were statistically significant. (Figure 4) The statistically significant predictors of support for national health insurance plan in reality support opposition to a single party payer according to the data presented. The statically positive predictors were inner city physicians vs. non inner city physicians, Medicaid vs. non Medicaid providers, and primary care vs. specialists. The predictor chart did not separate out the demographics of the physicians in each category.

In the last table the percentages of physicians in favor of the federal government as the sole payer was soundly defeated by all specialties. All of the specialties represented voted below 50% for the government to be the single party payer.

Here we see the data telling us one thing and the authors, through the use of the media providing a sensational but false conclusion from the data. The survey was poorly designed with little statistical significance.

Quoting Dr. Carroll, a primary author "Many claim to speak for physicians and reflect their views. We asked doctors directly and found that, contrary to conventional wisdom, most doctors support the government creating national health insurance,"

The moral of my story is to not believe anything until you see the data, the source of the data, and the methods used to evaluate its validity. Unfortunately, this is very hard to do. Refereed journals have been delegated as our surrogate evaluators. To my disappointment it seems the American College of Physicians has not fulfilled its obligation to practicing physicians of internal medicine.

It looks like the few governing physicians of the American College of Physicians and the Annals of Internal Medicine have chosen instead to pursue their own agenda and not the agenda of science at the expense of their member physicians and their patients.

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

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Medicare “Drifting Towards Disaster”: Says U.S. Sec. HHS

June 18, 2008

inMedicare, Medicine: Healthcare System

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Stanley Feld M.D.,FACP,MACE

US Secretary of Health and Human Services Michael Levitt said Medicare is lurching toward disaster. Secretary Levitt has studied the problem for eight years. He has tried to introduce some innovative policies along with some poor policies. It seems as if only the poor policies survive.

“ Medicare is lurching toward disaster and it is too late for the Bush Administration and Congress to do anything about it, U.S. Health and Human Services Secretary Michael Leavitt said on Tuesday.”

He said the next administration will have to act to stop rising costs and get control of the $400 billion federal health insurance plan for the elderly, which now covers 44 million people.

$400 billion dollars is twice the cost of the war in Iraq. This amount only partially covers 44 million senior citizens. There are deductibles and co-pays. The insurance premium for Medicare is almost as expensive as private insurance for persons collecting retirement plan money. Medicare is an entitlement that should not be expanded to 300 million people. Do the math. The cost would be $2,727,272,727,273 dollars a year and rising, in addition to the premiums and co- pay citizens would be paying.

"Higher and higher costs are being borne by fewer and fewer people. Sooner or later, this formula implodes,"
Leavitt said in a speech to the right-leaning Heritage Foundation and American Enterprise Institute think-tanks.

It doesn’t matter if he was talking to a right or left leaning organization. It takes a blind man to see the wheels are coming off and no one is doing anything about it. All it takes is a little common sense to know something creative has to be done.

There are many innovative changes that can be made easily. One would be an emphasis on effective chronic disease management. Another would be effective malpractice reform in each state to decrease the need for physicians to practice costly defensive medicine.

A national health plan run by the government would do is stifle innovation and run up the cost. If we compound the healthcare problem by adding all U.S. citizens to a government paid for and directed single party payer system we will accelerate disaster.

“There is serious danger here," he added. "Medicare is drifting towards disaster."
"It troubles me that this matter is not receiving more attention in the presidential candidates' discussions. The next president will have to deal with this in significant part," he said.

Doesn’t Secretary Levitt know the presidential candidates do not understand the issues, the problems, the potential solutions? He should speak out. The solutions are easy if all the stakeholders’ incentives are aligned. The recognition of patients as the primary stakeholder is critical. The needs of the physicians as medical care providers have to be understood. The needs of secondary stakeholders have to be modified and adjusted.

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Disinformation and Media Spin: Part 1

June 11, 2008

inDisinformation and the healthcare system, Medicine: Healthcare System

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Stanley Feld M.D., FACP, MACE

A recent headline in the Washington Post declared that “Majority of U.S. Doctors Back National Insurance Plan”. It should be noted that the original article was published in the Annals of Internal Medicine, the official journal of the American College of Physicians, in 2003. A 5 year follow-up letter was published with incomplete data on April 1, 2008 reevaluating physician attitudes. The Washington Post article quoting a press release stated that the 124,000member American College of Physicians, the nation's largest medical specialty group, endorsed a single-payer national health insurance program.

In 1993 the American College of Physicians generated significant backlash from member physicians all over the country. Many physicians quit the American College of Physicians. I recall the CEO, at that time, was forced to resign over the issue of calling for a single party payer.

I can’t believe that the executive committee of the American College of Physicians has once again tried to manipulate public opinion through the media by originally publishing the 2003 article and updating it with a letter from the same authors in 2008.

In my opinion, the original survey was a poor study. The original study and follow-up letter further contaminates the Annals of Internal Medicine and American College of Physicians’ credibility as spokesmen for practicing primary care internists.

Our sound bite society would believe the media headlines “Majority of U.S. doctors back national insurance plan”. The message is clear: The majority of U.S. physicians advocate a single party payer system.

Neither government nor the healthcare insurance industry has appreciated the value of primary care physicians or the importance of the patient physician relationship. Both reimburse inadequately for cognitive therapy. They have not wanted to reward the therapeutic value of the problem solving ability of primary care physicians.

Primary care physicians who have had any practice experience know the difficulties in collecting for services rendered from the government. They have also experienced an endless string of price reductions. Primary care physicians have faced the same problems with the private healthcare insurance industry.

I appreciate that the price of health care is sky rocketing. However physicians” fees are falling and not sky rocketing. I have pointed out that facilitator stakeholders are benefiting more than the primary stakeholders (patients and physicians).

It is hard to believe the majority of physicians in this country want the government (Medicare) as the single party payer for medical care.

The Washington Post article states “A majority of American doctors now support the concept of national health insurance, which represents a shift in thinking over the past five years, a new survey finds."
“Typically, national health insurance plans involve a single, federally administered social insurance fund that guarantees health coverage for everyone. In most cases, these plans eliminate or substantially reduce the role of private insurance companies.”

Unfortunately the media report what the press release tells them has been found in the study.

“Physicians For A National Health Program” published this press release. The Washington Post copied the press release.

This is disinformation with media spin at its height. The public usually accepts the data as valid findings when presented by the media.

The study had 2,193 physicians. The physicians responding to the survey are supposed to represent 733,183 physicians in America.

"A survey conducted last year of 2,193 physicians across the United States found that 59 percent support "government legislation to establish national health insurance," while 32 percent oppose it, and 9 percent are neutral. In 2002, a similar survey found that 49 percent of physicians supported the concept, while 40 percent opposed it."

A larger sample size with a better survey questionnaire might have come to a different conclusion. If one accepts the survey sample and sample size as valid the study shows the percentage of physicians who want universal healthcare coverage but not universal coverage under a government run single party payer system. The press release leads us to the single party payer preference.

“Typically, national health insurance plans involve a single, federally administered social insurance fund that guarantees health coverage for everyone.”

The AMA has recommended universal coverage, as do most physicians. The problem of the uninsured is large. However, neither the AMA nor most physicians in private practice recommend the government as a single party payer. Private practitioners understand the problems inherent in government run organizations as do most consumers
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In the next blog I will publish the original data and my commentary on the survey results. It will be clear how the data is manipulated to reach conclusions that should not be reached.

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

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