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The Failure Of The British Electronic Medical Record

May 22, 2011

inEMR, Information Technology in Healthcare, Innovations in Healthcare

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Stanley Feld M.D.,FACP,MACE

The development and use of an electronic medical record is extremely important for communication, rapid diagnosis and clinical decision making, increasing efficiency in working up patients, decreasing the cost of duplication of testing and time delays in medical care and treatment.

There are many other advantages of using a functional electronic medical records. A person could be anywhere in the world and have his medical information immediately available. The results of all testing should immediately be communicated to the treating physician. All imaging studies should be digital.

Patients’ physicians could immediately read and use them for their clinical decision making.

These are only a few of the advantages of the electronic medical record. During an office visit the physicians’ cost of removing a chart from the shelf, dictating a notes and pasting lab results into the chart is $7.75. Instant automatic noes and laboratory testing delivered to the chart by electronic medical record cost nothing.

Dr. Don Berwick the head of CMS loves the English system. England has a a single party payer system of socialized medicine. The healthcare system is controlled by the taxpayer-funded National Health Service (NHS). The NHS committed itself to installing a fully functional electronic medical record in 2002 with the goal to have it completed by 2005.

“Not one of England’s 250 hospitals has a full electronic records system in 2011. A rollout promised for 2005 will not now be complete by 2015.”

It is easy for government to visualize the value of a fully functioning EMR. The execution of the EMR has proven to be nearly impossible even in Britain’s homogenized healthcare system.

“Of the original big four suppliers, only BT, which is responsible for London and a few hospitals in the south, would remain.”

“Richard Bacon, a Conservative member of the Commons public accounts committee, told Mr. Cameron that the programme, which is years behind schedule, would “never deliver its early promise” of a record for all 50m patients in England.”

Of the £11.4bn budget, some £4.7bn is still unspent, he said, and, rather than “squander” it, a better way had to be found to spend it.

Only 44 of 250 big hospitals have received a partially functioning new electronic medical record system after trying for 8 years. While the installed systems have contributed some functionality they are not fully functional. They cannot fully exchange information.

“The US-owned Computer Sciences Corporation – which is responsible for installing the system in two-thirds of the country but, by a mile, holds the programme’s record for missed deadlines.”

The installations of EMRs have frequently led to initial chaos in hospitals. There are reports of lost patients, lost records, an inability of hospitals to be paid for the care they provide.

The scope of the program for developing a functioning EMR has been decreased as a result of cost overruns and missed deadlines. New EMRs for ambulance services and doctors offices have been eliminated.

In April 2010, the minister then in charge – Labour’s Mike O’Brien – admitted that it would never now deliver the promised comprehensive solution

Nowhere in the world has found the creation of an electronic patient record easy. Denmark, which has a publicly funded health system, is reckoned by many to be as far ahead as anyone. But even that small country after 20 years still has hospitals that use paper records.

There have been many unintended consequences, too numerous to list, in trying to implement the NHS’s goal for a functional EMR. The NHS has accomplished a few of its goals.

The NHS was the first in the world to replace X-ray film with digital images for scans and X-rays.

2. Half the country’s general practitioners, or family doctors, can now transfer at least some of their records electronically to another practice when patients move.

3.Electronic transfer of prescriptions to pharmacies is finally proceeding at pace.

4. Six million out of 50 million patients now have a summary care record. It contains a limited list of allergies and current medications. It makes emergency room care significantly safer.

The NHS has a long way to go and lots more money to spend if they continue the present course.

What is the solution?

Create incentives for patients to obtain their clinical information. Scan the clinical information into a thumb flash drive and carry the data on a key chain.
Create incentives for hospitals and doctors to open the thumb flash drives and use the data.

This would be an instant solution to a difficult problem. The system would reduce the cost of retesting.

EMR are too expensive for U.S. physicians. Physicians are experiencing reimbursement cuts. A fully functioning system costs more than $60,000 per physician. There are additional costs such as service and upgrade fees.

If a satisfactory EMR was available the government should buy it. They should put it in the Internet cloud. Upgrades should be installed as necessary. A single integrated healthcare system wide EMR would result. Physicians should be given incentives to use the EMR. They would be charged by the click. The cloud EMR must be integrated into a physicians’ present non functional legacy systems.

This process was used while converting to electronic billing in the 1980’s. It should be done with the EMR now. It will save everyone time and money and increase the ability to diagnose and treat patients rapidly.

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

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Accountable Care Organizations Will Fail !

April 27, 2011

inMedicare, Medicine: Healthcare System, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

The more I study ACOs the worse they look. Dr. Berwick’s goal is redistribution of wealth. This is exactly what ACOs are going to do. Patients, taxpayers and physicians are going to get the short end of the distribution.

Hospital systems are spending a ton of money trying to form ACOs. They are going to lose big. I have concentrated on the obvious defects and difficulties in forming ACOs in the past. Here are some more traps.

I don’t think anyone has considered the following,

Which consumers will ACOs treat?

Only Medicare patients are included in the ACO program for now. Medicaid and private insurance patients are not included. Medicaid will have a severe physician shortage with increasing enrollees. The result will be greater cost shifting in the private sector. The private sector will disappear.

2. How many Medicare patients will be covered?

“ACOs will only care for 1.5-4 million beneficiaries” As of 2001 there were 35 million Medicare seniors and 5 million persons on Medicare disability. The number is estimated to grow the 72 million by 2030.

3. How will the government decide on reimbursement to the individual ACOs?

Unknown. There have already been indications that the government will individualize ACO reimbursement.

4. What are the criteria to determine under utilizing or over utilizing ACOs?

Unknown. Under utilizers are supposed to share the difference 50 /50 or 60/40 with the government and over utilizers will pay the government the difference.

Different ACOs approved can develop different models of organization and payment structures for care as long as it meets the budget and quality goals the government determines.

The government’s thinking is that decentralized accountability and leadership with (monetary) sticks and carrots are likely to produce better results for the whole country than central government rules without the ability to enforce the rules.

ACOs which incur too high a utilization or which do not meet the quality targets, may have to forgo reimbursements completely (see patients for nothing) or even pay CMS money back. CMS has placed its emphasis on ACOs beating the reimbursement goals. The government would then share the savings with the ACO. In either case the government wins.

A frightening thought is ACOs can become too big to fail. It would necessitate another government bailout. You can be sure within 456 pages of the rules there are many unintended consequences. There are also ways to beat the system that will be discovered in the future.

Once again, CMS, HHS and President Obama are trying to fool us with numbers.

“CMS hopes that ACOs could save it $170-960 million over three years.” The Medicare and Medicaid budget for three years is $1.8 trillion with Medicare consuming most of the money. The “cost savings” represent only 0.01%- 0.05% of the Medicare budget. This is a tiny savings.

Can anyone be impressed with the potential cost savings? One should be impressed with how the savings is presented by the administration and how much bureaucracy it will take to set up and implement the system.

The performance measurements (or standardized “metrics”) have not been defined for ACOs. Performance measurements discussed so far have been process measurements. Process measurements do not necessarily lead to better medical or financial outcomes. These process measurements are just a surrogate that assumes better outcomes.

The fact that if an ACO or its physicians do four HbA1c tests per year for the management of Diabetes Mellitus, it does not mean that the medical and financial outcomes will improve. This defect in process measurements applies to many chronic diseases. The management of chronic diseases and their complication account for 80% of the healthcare dollars spent.

“ACOs must have a minimum size of 5,000 “ Medicare ensured lives”. This is not possible with small practices. The net margin is too small for Medicare to overload a small group practice with 5,00 Medicare patients at present rates of reimbursement. Reimbursement is projected to become even smaller.

CMS has already picked the groups (identified by Dr. Don Berwick’s Institute for Healthcare Improvement) who will qualify for ACOs. They are supposedly low cost/high quality groups. The goal is to create ACOs with integrated healthcare systems who salary physicians. Physicians in those organizations are supposedly used to working closely together. There should be an emphasis on primary care physicians. The government will then let the hospital systems and physicians fight over dividing the government reimbursement.

ACOs are not for everyone. If the ACO is fragmented, with weak physician leadership and high usage of independent specialists, it will difficult to have a high-performing ACO. Even if an ACO is low cost and high quality it will be difficult to be profitable as reimbursement is decreased. If Medicaid is added to the scheme hospital systems will fail

The only advantage is that the ACO might be too big to fail. The government will be forced to bail them out.

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

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The Federal Government and Accountable Care Organizations (ACOs)

April 6, 2011

inDisinformation and the healthcare system, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

In 2009 President Obama stated that Accountable Care Organizations (ACOs) were going to be pilot programs in real world settings. The goal was to see if they effective in reducing costs and increasing “quality of care.” The results of the pilot programs have not been published.

Last week despite the lack of proof of concept HHS and CMS announced new proposed regulations for ACOs.

The new delivery and payment model the agency estimates could serve up to 5 million Medicare beneficiaries through participating providers, and also potentially save the Medicare program as much as $960 million over three years.

How were these estimates derived? It could be another accounting trick by President Obama’s administration.

The idea of coordinating care and developing systems of care is a great idea theoretically. From a practical standpoint, execution is very difficult.

I tried to execute something similar in 1996 with the American Association of Clinical Endocrinologists; a national Independent Practice Association. AACECare received little cooperation or interest from Clinical Endocrinologists.

The problem is coordinated medical care is dependent on physicians cooperating and not competing with each other. It also depends on hospital systems developing an equitable partnership with physicians.

The equitable partnerships between hospital systems and physicians are difficult to achieve if past results are any indication of future results.

An important element to the success of ACOs is patients’ use or abuse of the ACO. There are no incentives provided for patients to manage their chronic diseases and avoid complication of those diseases.

Some of the problems with Dr. Don Berwick’s rules and regulations for ACO’s are:

1.Patient compliance is not considered in the system. Positive outcomes and savings are mostly dependent on patient behaviors and compliance with treatment.

2. ACOs are dependent on hospital systems developing a network of physicians who cooperate to coordinate care.

3. Cooperation between physician and hospital systems depends on mutual trust. The hospital systems will receive and distribute the money received from the government. This is an area ripe for conflict and mistrust.

4. Dr. Berwick does not calculate the role of patients in risk management of their chronic disease. Patients are the drivers of their medical outcomes.

5. One Medicare and Medicaid check would go to the hospital system to be distributed to physicians. The administration of the ACOs would determine the distribution. This will result in great conflict. The trust issue must be resolved from the onset.

6. Physicians are uncomfortable working for organizations who determine the value of their intellectual property or surgical skills.

ACOs’ will have to develop systems to dictate care consistent with government determined evidence based medicine. The government will reward organizations that are successful. It will penalize organizations with poor outcomes. The hope is to increase quality of care and decrease the cost of care.

The execution will be difficult. In reality ACOs are HMOs on steroids.

The proposed payment formula is difficult to follow. It must be understood in order to appreciate the defects in the system.

1. Hospital systems will own and control physicians’ intellectual property.

2. Hospital systems’ political decision process will determine pay and distribution.

3. The federal government will determine what it will to pay the ACOs. This is a major defect given the federal government past behavior in judging the value of physicians intellectual property and surgical skills. As a reason of budget pressure the federal government will be forced to decrease reimbursement.

4. It will be the ACO’s responsibility to come in under budget. If the ACOs come in under budget the excess will be shared 50/50 between the government and the ACOs.

5. Each ACO will have an individual budget based on patient demographics and risk weighting. Risk weight is an imperfect science.

6. ACOs must define the processes it uses to coordinate care. CMS rules outline a range of strategies for ACOs to accomplish this. The processes included must be;

a. Predictive modeling.

b. Use of case managers in primary-care offices.

c. Use of a specific transition-of-care program that includes clear guidance and instructions for patients, their families and their caregivers;

d. Remote monitoring.

e. Telehealth.

If any of these processes are lacking or defective in the government’s judgment the ACO will not be eligible to save in any savings.

The payment system is equally frightening under the proposed regulations:

1.ACOs would provide an organization with a separate tax identification number.

2. Payments would go directly to the ACO’s administration. The ACOs administration would decide on the distribution of those payments to its member providers.

3. The ACO rules would allow ACOs to receive shared savings if they meet both the quality performance standards established by the HHS secretary and their target spending goals.

4.The target spending goals would be set for each ACO by HHS.

5.HHS can also limit or adjust the total amount of shared savings paid to an ACO.

6. There will be no administrative or judicial review process for determining ACO's eligibility for shared savings. There is no review process for “termination of an ACO” for failing to meet quality performance standards.

7. ACOs can participate under either :

a. A model that shares both savings and losses from the beginning of a three-year period or

b. shares only savings in the first two years and shares both savings and losses in the last year.

8. ACOs will be required to demonstrate a partnership with Medicare fee-for-service beneficiaries by having a beneficiary represented in the ACO's governing body.

In order for ACOs to share in savings, ACOs would have to meet quality standards in five key areas determined by the government:

Patient/caregiver care experiences

Care coordination

Patient safety

Preventive health

At-risk population/frail elderly health.

None of these measures are clearly defined. It will become a bureaucratic mess. The results will compromise medical care. It will promote adversary relationships among and between stakeholders. It will promote dependence on the government’s bureaucratic discretion among stakeholders.

ACOs are much to complicated to work. The further along Dr. Berwick gets in constructing the infrastructure the harder it will be to dismantle it.

I believe this is the reason President Obama’s Justice Department is stalling the appeals process of the challenges to the constitutionality of President Obama’s Healthcare Reform Act.

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

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Barriers To Accountable Care Organizations (ACOs) Success

October 27, 2010

inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

In response to my last blog about the complexity of Accountable Care Organizations, a reader wrote, “Complexity breeds fraud, waste, abuse and inefficiency. By nature, huge Government programs are complex and breed all four of the problems mentioned.”

Many of President Obama’s well intended government control programs have experienced terrible outcomes because he followed theories of “experts” instead of using common sense.

President Obama’s theoretical Accountable Care Organizations will be a failure. The pity is ACOs will waste money and destroy medical resources. President Obama’s healthcare reform law is not going to solve the healthcare system’s basic problems.

There are three possible reasons:

1. President Obama does not know what he is doing. He doesn’t understand physicians mentality, the process of medical care or previous physicians’ experiences with government control.

2. President Obama refuses to learn from past history.

Government dictated planning and attempts at execution of social, economic and cultural change usually fails. The government should make the rules to level the playing field for all stakeholders and then get out of the way.

Government planning and controls are expensive to execute for all stakeholders. The planning usually restricts freedom of choice by imposing mandates.

3. President Obama knows exactly what he is doing. He wants the healthcare reform plan to fail.

Failure would lead the way for the government to impose a government controlled single party payer system.

There is no question America needs healthcare reform. Rules to create a more efficient system are essential.

Patients own their disease. They should be put in the power position. Patients should be responsible for their care. The government should set up the rules and protections for patients to be responsible for their care.

The secretary of health and human services is required to establish a program within Medicare in which savings from efficient, high-value care are shared using Accountable Care Organizations (ACOs).

The ACO program of payment is to be launched in January 2012. At this time, only two of the 10 demonstration projects have been partially successful in saving money. The demonstration projects were done in ten clinics that were supposed to theoretically succeed in saving money..

At the moment, there are no real world ACOs exist. The rules and regulations regarding qualification as an ACO have not yet been published. We are approaching 2012.

The barriers for the success of ACOs are overwhelming.

“In principle, ACOs will efficiently deliver the measurably high-quality care offered by integrated health maintenance organizations (HMOs) without the “lock-in” that many Medicare beneficiaries abhor.”

The author assumes that HMOs delivered high-quality medical care. ACOs payment will be the same as HMOs without the lock in patients abhor.

ACOs are really HMOs on steroids. Once patients and physicians understand this they will be hesitant to join.

“ ACOs begin not with insurance but with a collection of providers (physicians and facilities) who come together and accept internal payment arrangements that facilitate the provision of efficient, high-quality care. If the ACO does well, the savings it achieves can be shared among the providers or pumped back into the provision of high-value care.”

ACOs are a fixed payment system. The financial risk is shifted from the government to physicians. Why should physicians pick up the risk for irresponsible patients?

Patients are attributed to the ACO on the basis of their patterns of service use. That is, if a patient typically sees a primary care physician who belongs to an ACO, all of that patient’s care is attributed to that ACO. If the costs incurred by the ACO’s “attributees” are sufficiently below Medicare’s spending projections for that population, the ACO shares in the savings realized by Medicare; if the costs are too high, the ACO loses nothing.

Patients will not have a choice of physicians. The experts predict physicians’ incentives are changed from “over testing” to “under testing” patients. However, physicians will be forced to continue to over test for defensive medicine purposes and the threat of malpractice. I think over testing for defensive medicine will not be solved until effective malpractice reform is passed. President Obama has no interest in malpractice reform.

George Thomas, a New York physician, has posted a blog describing to non-doctors and non-sued doctors what is wrong with the malpractice system and its economic effect on healthcare cost. It is written from the point of view of a physician who has been sued five times and won each suit.

“First, being sued does not make a doctor a better doctor. We improve through experience and studying, and not making the same mistake twice.”

I hope President Obama will read this article. Everyone should read this article. The ACO payment system is destined to fail.

Elliot Fisher M.D. of the Dartmouth group is one of the masterminds of the ACOs.

Dr. Fischer has little real world experience. He has described an attribution rule whereby Medicare beneficiaries are assigned to their primary care provider and then to unique physician–hospital networks. Please note the lack of patient choice.

1.“ ACOs must be able to collect information on the quality of care, create new incentives, and accept and distribute bonus payments. Building these capabilities will entail substantial up-front costs for new legal entities, information systems, and other infrastructure. Large multispecialty groups are well positioned to take on these responsibilities”

Most primary care physicians are not in that position and are unwilling to hand their intellectual property over to a hospital system.

All primary care practitioners will not likely to be invited into or want to participate in an ACO.

The ACO concept will generate severe shortages of primary care physicians. There are important legal antitrust concerns about the corporate ownership of physicians in some areas of the country. The Medical Home concept designed to enable primary care to survive will quicken the specialty’s demise.

3.” The ACO concept calls for each primary care practitioner to be part of only one ACO.”

The practice of medicine will be under the dictates of the federal government.

A excellent panel discussion was presented by the online New England Journal of Medicine. Thomas H. Lee, M.D., Lawrence P. Casalino, M.D., Ph.D., Elliott S. Fisher, M.D., M.P.H., and Gail R. Wilensky, Ph.D. presented the virtues and defects in ACOs. Gail Wilensky and Lawrence Casalino point out the impractical ideals of ACOs.

In spite of this, President Obama has declared the ACO payment system a done deal.

He is misguided.

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

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Finland’s Government Collapses Over Universal Healthcare Costs. March 2019 :Part 2

January 16, 2020

inDisinformation and the healthcare system, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Repairing the Healthcare System

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Part 2

Stanley Feld MD,FACP,MACE

https://blogs.scientificamerican.com/observations/finland-is-the-happiest-country-in-the-world-and-finns-arent-happy-about-it/

Bernie Sanders (I-VT) has been hanging his socialistic rhetoric on the success of Finland’s socialist society and especially Finland’s healthcare system which is supposed to be a free healthcare system for all.

The New York Times published the article “Finland is a Capitalist Paradise” on December 2, 2019.

On March 3,2019, Finland’s government collapsed because the universal healthcare costs were unsustainable.

President Donald Trump was correct when he said,

“Finland, of course, is one of those Nordic countries that we hear some Americans, including President Trump, describe as unsustainable and oppressive — “socialist nanny states.”

The New York Times ridiculed President Trump in December 2, 2019 for saying that Finland is a socialist nanny state.

https://legalinsurrection.com/2019/03/finland-government-collapses-over-universal-health-care-costs-bernie2020-hardest-hit/

https://freebeacon.com/politics/finnish-government-collapses-due-to-rising-cost-of-universal-health-care/

“Similar problems are bedeviling Sweden and Denmark, two other countries frequently held up as models to follow on health care. Finland’s crisis in particular comes as calls for universal health care have grown louder among Democrats in the United States.”

Americans have heard from few in the mainstream media about the collapse of Finland’s government or the reasons for that collapse.

Norway is excused from this discussion because Norway has become a very rich country from its North Sea oil income and its restrictive immigration policies. It is the citizen’s sugar daddy along with a 50% tax rate.

KFF Health Tracking Poll – January 2019: The Public On Next Steps For The ACA And Proposals To Expand Coverage

The Kaiser Family Foundation found that 58 percent of Americans oppose “Medicare for all” if told it would eliminate private health insurance plans, and 60 percent oppose it if it requires higher taxes.

Reuters reported that soaring treatment costs and longer life spans have particularly affected the Nordic countries financial problems.

“Nordic countries, where comprehensive welfare is the cornerstone of the social model, have been among the most affected,” according to Reuters. “But reform has been controversial and, in Finland, plans to cut costs and boost efficiency have stalled for years.”

Just a few days before Finland’s government collapsed over its inability to foot the bill for its expansive socialist experiment, Sanders took to Twitter in an attempt to shame America.

https://pbs.twimg.com/profile_images/1097820307388334080/9ddg5F6v_bigger.png

Bernie Sanders‏Verified account @BernieSanders

FollowFollow @BernieSanders

“In the United States it costs, on average, $12,000 to have a baby. In Finland it costs $60. We’ve got to end the disgrace of our profit-driven health care system and pass Medicare for all.”

Bernie Sanders is not being honest with the American people.

“With the collapse of Finland’s government over its inability to financially support its massive socialist agenda, Bernie will undoubtedly do the same thing he always does when socialism (or communism) fails: ignore, obfuscate, and deflect.”

We only have to remember Vermont’s “Medicare for All” failure.

Why the Failure of Vermont’s Single-Payer Plan Is the Best Argument Against Medicare for All

Bernie Sanders and AOC should read Finland and Sweden’s newspapers to understand that the people are unhappy with free but unavailable medical care. The unhappiness of the citizens historically happens in every socialist state run healthcare system..

If Democrats are successful in getting “Medicare for All” into law, America will face the same dilemma in the future

“The social welfare and health care reform was one of our government’s most important objectives,” Sipilä said at a press briefing. “The snapshot of the situation that I got from the parliament obliged me to examine if there was a possibility of continuing the reform process. There wasn’t.”

“My conclusion was that my government had to hand in our note of resignation,” he added. “I take my responsibility.”

https://www.politico.eu/article/finlands-government-collapses-over-failed-health-care-reform/

Finland has a decentralized system of health and social welfare programs, where much of the administration is left to local municipalities. This arrangement has led to widespread geographic variation when it comes to quality and access to health care services.

The reform was meant to address these inequalities and reduce the growing cost of the country’s health care system, which has come under increasing stress from an ageing population. It included centralization of the administration at a regional level.”

Finland has been held up as a model welfare state. The distribution of the resulting high taxes is spent on the social issues the politicians think are most important and not what the citizens think are most important.

The government should not be telling the people what they need if a healthcare system is to succeed. The people should decide on what they need and be responsible for their own care. The government should protect the people from both government and corporate abuse in a free enterprise system.

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

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The Concept of “Medicare for All” is Misguided

April 5, 2019

inUncategorized

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The Concept of “Medicare for All” is Misguided

Stanley Feld M.D.FACP,MACE

Bernie Sanders (I-VT), has long been touting Finland, Sweden, Denmark and Norway as the shining examples of socialism and socialized medicine.

The New York Times reported on a UN study proving Finland is the happiest country in the world. The problem is the Finns do not think the study is accurate.

The New York Times has once again printed fake news to influence readers to believe in the wisdom of “Medicare for All.”

Carl Sandberg said in “The Prairie Years”, “If you tell a lie enough times it becomes the truth.”

https://blogs.scientificamerican.com/observations/finland-is-the-happiest-country-in-the-world-and-finns-arent-happy-about-it/

Bernie Sanders (I-VT) has been hanging his socialistic rhetoric on the success of Finland’s socialist society and especially Finland’s healthcare system which is free healthcare for all.

Last week Finland’s government collapsed over universal healthcare costs.

Americans have not heard from the mainstream media about the collapse of Finland’s government or the reasons for that collapse.

Reuters reported that soaring treatment costs and longer life spans have particularly affected the Nordic countries financial problems.

..Just a few days before Finland’s government collapsed over its inability to foot the bill for its expansive socialist experiment, Sanders took to Twitter in an attempt to shame America.

Bernie Sanders‏Verified account@BernieSanders

FollowFollow @BernieSanders

More

“In the United States it costs, on average, $12,000 to have a baby. In Finland it costs $60. We’ve got to end the disgrace of our profit-driven health care system and pass Medicare for all.”

We only have to remember Vermont’s “Medicare for All” failure.

If Democrats are successful in getting “Medicare for All” into law, we will face the same dilemma in America’s future.

The experience of a patient in Finland is very educational. This article appeared in Britain’s Guardian newspaper as Britain struggles with its National Health Services system.

“Why is Finland’s healthcare system failing my family?”

This reporter moved to Finland from the U.K. to experience this highly rated welfare state. Finland receives an extremely positive press in Britain. The British welfare state systems are failing.

“I have moved to from Britain to Finland because it is lauded as the shining example of a successful welfare state.”

https://www.theguardian.com/society/2016/feb/23/finland-health-system-failing-welfare-state-high-taxes

“Imagine going to your nearest doctors’ surgery at 9am on a weekday with your sick six-year-old daughter because you cannot make an appointment over the phone. After your drive to another part of the city, you can’t simply book a time with the receptionist.”

There is no receptionist. You have to swipe your daughter’s national insurance card through a machine, which gives you a number.

“Then you and your feverish child simply sit and wait. Or rather, you stand, because the room is so crowded that people are sitting on the floor, on steps, or leaning against walls. The numbers come up on a screen every 10 minutes or so, in no particular order so you’ve no idea how long your wait will be as your daughter complains of feeling cold then hot and then cold again.”

Patients get sicker and frustrated waiting for care.

“By 10.45, another patient’s dad exclaims he’s been there since 8.15, he’s had enough, and he’s going to go to a private GP. “You used to just be able to make an appointment with a doctor!” he says angrily.”

You are not waiting to see a physician you are waiting to see a nurse that will determine whether you see a physician assistant or General Practitioner.

“At 11.30, you give up and take your daughter to see a private doctor as well, forking out £50 for the privilege.”

Finland’s schools always have the best ranked international student assessment results in the western world; there’s high social equality; all its teachers have master’s degrees.

But unknown to Bernie Sanders, Finland has one of the worst health services records in Europe.

According to an OECD report published in 2013, the Finnish health system is chronically underfunded. The Nordic nation of five million people spent only 7% of GDP on its public health system in 2012, compared with 8% in the UK. In 2012, the report found, 80% of the Finnish population had to wait more than two weeks to see a GP.

America’s healthcare system is becoming unaffordable. When politicians like Bernie Sanders, AOC, and all the announced Democrat candidates for president support “Medicare for All” it sounds easy and appealing. The fact is socialized medicine doesn’t work.

The only system that can work is a system that creates incentives for consumers to be financially and medically responsible for themselves and the creation of rules by the government forcing insurance companies and hospital systems to become competitive in favor of consumers.

Donald Trump knows this. If only our elected officials in Washington wanted to act for the benefit of the citizens who elected them.

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

Copywrite 2006-2019

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The Mainstream Media Refuses to Understand the Meaning of President Trump’s Healthcare Insurance Associations

November 5, 2018

inDisinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

The Mainstream media refuses to acknowledge the advantage of the Presidential order to allow Associations to participate in available health insurance plans.

Democrats do not want the public to understand the advantages President Trump’s healthcare insurance associations will provide to consumers. It is an important step in Repairing the Healthcare System. Obamacare was advertised only to fix the individual insurance market.

Pre- Obamacare there were 14 million people who had individual healthcare insurance plans. Most were unaffordable. Now, there are only 12 million in the individual market on Obamacare. Most are unaffordable.

Medicaid has expanded from 2 million to 10 million under Obamacare. The total on healthcare insurance provide by Obamacare is 22 million. Medicaid is a failed healthcare insurance plan. It is a socialized medical insurance plan the has failed.

The mainstream media has forgotten that Obamacare was originally sold by President Obama to cover the individual insurance market. The individual healthcare insurance market was unaffordable. Obamacare was supposed to make it affordable. It turns out that 85% of Obamacare recipients are subsidized by the federal government. President Obama has expanded socialized medicine and a single party payer (the government) with Obamacare. Even with government subsidies the insurance is unaffordable because of the high deductibles.

It is difficult for me to understand how President Obama says he always tells the truth. He said he was going to make the healthcare individual market more affordable. He has not.

I remember he also said; “If you like your doctor you can keep your doctor” and “if you like your healthcare plan you can keep your healthcare plan.” Nothing could be further from the truth.

When Obamacare was passed there were requirements in the bill that outlined coverage the healthcare insurance industry must provide for everyone who has any kind of healthcare insurance. These requirements included levels of coverage that many people did not need. This excess coverage raised the cost of healthcare insurance in both the individual healthcare insurance market and the group healthcare insurance market. Both types of insurance became unaffordable.

This, combined with the inefficiency of a bureaucratic government raised prices of healthcare insurance even further. Remember the government outsources all of the administrative services to the healthcare insurance industry.

Now, the Democrats want the government to run the entire healthcare delivery system with “Medicare for All.” The unsustainability of “Medicare for All” is estimated at 32 TRILLION dollars over the next ten years!

Associations will not solve all the problems in the healthcare system. However, they will start solving a good many of them. The Democrats are scared to death that the public will start to understand the advantages of associations. Consumers will have a choice of healthcare insurance plans. Consumers will be in a position to start controlling their healthcare dollars.

The pundits in the mainstream media seem to have no interest in understanding this dynamic. Their only interest is to despise President Trump and regurgitate the Democrats’ easy to understand talking points.

Trump’s associations will:

allow the healthcare industry to sell healthcare plans without the rigid requirements imposed on them by Obamacare.

make individual healthcare plans tax deductible. The large corporations’ group healthcare insurance plans are tax deductible. The individual healthcare insurance plans presently are not tax deductible.

allow members to buy healthcare insurance across state lines. This will create price competition that will lower premiums.

let small companies and the self-employed band together and buy health insurance outside of Obamacare’s strict rules.

offer a way for people to take advantage of the group insurance market, even if they are self-employed or work for a business too small to provide insurance.

“will “level the playing field” by giving small businesses bargaining power.” This statement was made by Labor Secretary Alexander Acosta.

Mr. Acosta said “As the cost of insurance for small businesses has been increasing, the percentage of small business offering health coverage has been dropping substantially,”. “This expansion will offer millions of Americans more affordable health care options.”

The U.S. Chamber of Commerce said the change, “will give employers the relief and flexibility they need to cover more employees at a lower cost with more choices for quality care.”

The Congressional Budget Office estimates that 4 million people, including 400,000 who otherwise would go without insurance, are expected to join association health care plans by 2023.

The introduction of associations is going to disrupt the Democrats plans to take total control of the delivery of healthcare. It is going to start to put healthcare delivery back in the hands of the consumer!

Mr. Trump said at the National Federation of Independent Business’ 75th anniversary celebration in his usual hyperbolic style;

“You’re going to save a fortune,”

I believe he is closer to being right than he is being wrong.

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

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Hospital Mergers Don’t Work

September 11, 2018

inMedicine: Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

This article appeared in Kevin M.D. several weeks ago. The article has some valid points. However, it misses the vital reasons hospital mergers are not working.

“In 2010, there were 66 hospital mergers in this country. Since the Affordable Care Act went into effect, the rate of hospital consolidation has increased by 70 percent.

By creating incentives for physicians and health providers to coordinate under accountable care organizations (ACOs), the ACA hindered the ability of regulators to block hospital mergers while incentivizing hospital consolidation.”

The government published reason for encouraging hospital mergers was to increase hospital efficiency and decrease healthcare costs.

I have said over and over again that the real goal of Obamacare was to have total control over the healthcare system. This control could be accomplished by controlling all the providers.

Hospitals realized that physicians controlled the utilization of hospital facilities. As knowledge and technology improved more and more diagnosis and treatment could be performed on an outpatient basis.

All the hospitals had to offer was a brick and mortar facility. Hospitals tried to stop physicians, before Obamacare, from developing their own outpatient facilities. The hospitals lobbied the government to require certificate of need for advanced outpatient technology (MRI, CAT scans, Outpatient Surgical facilities, and laboratories).

It did not work.

Obamacare provided incentives for hospitals to merge and consolidate into hospital systems.

Obamacare also provided incentives for hospital systems to create Accountable Care Organizations (ACOs). I have written about ACOs destiny to fail ad nauseum.

The government’s pretext was that hospital consolidation into hospital systems would increase efficiency with resultant decreases in hospital care costs.

The real reason was to get hospitals to hire physicians. At that point they would lower reimbursement on both. Hospitals and physicians would be totally dependent on the government.

“There is a growing body of evidence that hospital mergers lead to higher prices for consumers, employers, insurance and the government.”

The result is opposite the stated goal and was totally predictable.

“It is imperative to educate patients and lawmakers as to how the consolidation of hospitals and medical practices raise costs, decrease access, eliminate jobs and, ultimately, reduce care quality as a result.”

The development of hospital systems led to the expansion of administrative personnel which in turn led to increased administrative salaries and costs. Administrative costs are not government controlled. They are part of the overinflated hospital overhead.

In some cases, the government increased hospital systems’ subsidies because of increased administrative costs.

It did not lead to greater compensation to physicians they hired. Yet the hospital system was totally dependent on staff physicians for revenue production.

Physicians tended to work hard when they owned their own practice. Now that their salary was guaranteed they tended not to work 12-hour days.

Initially, hospital systems paid physicians on the basis of physicians’ previous productivity in their private practice. Additionally, physicians were given a payout for their practice. The payout was never the real value of their practice.

Hospital systems calculated the physicians’ productivity because the hospital system hired all the full-time employees. The hospital systems’ computer systems were also used in the calculation of productivity and overhead.

Hospital systems controlled the overhead and the books. A lot of the time the calculation was inaccurate. This was the result of two fees collected from the government and the insurance companies. One was a technical fee that belonged to the hospital system. The other was a professional fee for the physician.

At times, the professional fees were not collected and the physician groups could not figure out the discrepancy.

There had been a long-standing mistrust by physicians toward hospitals prior to Obamacare. The errors in calculations resulted in greater mistrust by physicians toward hospitals.

If a physician was not producing according to the hospital system’s calculation the physician, at the end of a usual two-year contract, was let go. This created more mistrust and suspicion among physicians toward hospital systems.

It has also caused physicians who anticipated this stranglehold by hospital systems to become concierge physicians or open outpatient clinics of their own.

This has caused hospital systems to provide concierge physicians of their own as well as hospital outpatient ambulatory surgical care clinics. The problem is that the free-standing physician owned ambulatory surgical care clinics (ASC) are more efficient and cheaper than the inpatient hospital care and the hospital’s own outpatient ambulatory surgical care clinics (HOPD). Some privately own ASC are cheaper than the increasing deductibles patients with private insurance have to pay using their insurance.

Below are some examples of Ambulatory Care Surgical Center fees as opposed to Hospital Owned Outpatient Surgical fees.

“ASC – $1250 ($500 out of pocket)

HOPD: $4250 ($1000 out of pocket)

Echocardiogram:

ASC $500 ($200 out of pocket)

HOPD: $4250 ($1250 out of pocket)

Arthroscopy of Knee:

ASC – $3600 ($1070 out of pocket)

HOPD: $13,000 ($3900 out of pocket)

Hernia Repair:

ASC – $2500 ($750 out of pocket)

HOPD: $19,000 ($5700 out of pocket)”

There has been a dramatic increase in hospitals gobbling up independent providers and becoming powerful regional monopolies. These monopolies raise prices not decrease prices.

“According to a 2012 study by the Robert Wood Johnson Foundation, “the magnitude of price increases when hospitals merge in concentrated markets is typically quite large, most exceeding 20 percent.”

Forbes’ Avvik Roy of Forbes said, a presentation in 2012.

“You have to get at the errors in public policies which drive the hospitals to merge.” He concluded that government must do more to fight consolidation among hospitals.”

The underlying theme is that President Obama wanted Obamacare to fail so it can be replaced by a single party payer system that has been pushed by progressives since 1935. Obamacare is moribund despite claims by Democrats. They refuse to face the fact that socialism does not work even thought it is a feel-good concept.

“A recent paper authored by Northwestern’s Leemore Dafny, Columbia’s Kate Ho, and Harvard’s Robin Lee provides some definitive proof that when hospitals consolidate, prices increase substantially. The effect is made worse directly in proportion to proximity of the merging hospitals. “If you are doing it because you think in the long run it will serve your community well, you should think twice,” Dafny said.”

Hospital systems are consolidating because they think it is in their vested interests to consolidate. They are falling right into President Obama’s trap. Hospital systems do not control productivity. Physicians control productivity.

A study published by the National Bureau of Economic Research, conducted by Zack Cooper of Yale University, Stuart Craig of the University of Pennsylvania, Martin Gaynor of Carnegie Mellon and John Van Reenen of the London School of Economics, sheds light on the real cost of reduced competition among hospitals: hospital prices are 15.3 % higher when a hospital had no competition compared in markets with four or more hospitals, amounting to a cost difference of up to $2000 per admission. Hospital prices are 6.4% higher in markets with two hospitals and those with three are 4.8 % more expensive when compared to markets with four hospitals.”

The American Hospital Association has been aggressive in criticizing those reports. It has funded a couple of critical reports defending mergers and consolidations. The American Hospital Association doesn’t understand the progressives’ trap either.

It is backfiring already as hospital systems are saying they are losing money. The government is cutting reimbursement, the insurance companies are raising insurance rates and increased deductibles are unaffordable. Consumers are experiencing a decreased access to care.

None of the policy makers are focused on the right problems because they want a single party payer system in order to gain total control over the healthcare system. Progressive have no interests in the cost of care, the need to raise taxes or the delivery of efficient care.

America is going to experience an economic disaster as it has been experienced in Canada, England and many other countries in the world.

Consumers are continuing to take it on the chin in other countries because 80% are not sick at any one time. Consumers in other countries feel secure with the guaranteed coverage even if it increases their taxes and decreases access to care.

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

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Listen Up: It Is All About Personal Responsibility

February 17, 2017

inChronic Disese Management, Consumer Driven Health Care, Health Savings Accounts vs Medical Savings Accounts, Medicine: Healthcare System

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Stanley Feld M.D.,FACP,MACE

In my last blog I continued my War on Obesity. I started this war in 2007.

There has been little progress in this war because of cultural conditioning and a lack of emphasis on personal responsibility.

Every New Year’s Day millions of Americans make New Year resolutions to lose weight. They are initially successful. They then regain the weight they have lost.

If America is going to solve the healthcare systems unsustainable cost, it is going to have to solve the increasing Obesity problem.

The National Institute of Diabetes (niddk.nih} recently published Overweight and Obesity statistics:

“More than two-thirds (68.8 percent) of adults are considered to be overweight or obese.”

“ More than one-third (35.7 percent) of adults are considered to be obese.”

“ More than 1 in 20 (6.3 percent) have extreme obesity.”

“ Almost 3 in 4 men (74 percent) are considered to be overweight or obese.”

Each year the obesity problem gets worse. Companies have sprung up selling weight loss formulas. These companies advertise their great success.

However, most of the iconic personalities used in their advertising have regained their weight after experiencing mild or significant weight loss.

This study was conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention.

NHANES III was designed to provide nationally representative data to estimate the prevalence of major diseases, nutritional disorders, and potential risk factors.

Sixty-three percent of men and 55% of women had a body mass index of 25 kg/m² or greater.

A graded increase in the prevalence ratio (PR) was observed with increasing severity of overweight and obesity for all of the health outcomes except for coronary heart disease in men and high blood cholesterol level in both men and women.

With normal-weight individuals as the reference, for individuals with BMIs of at least 40 kg/m² and who were younger than 55 years, PRs were highest for type 2 diabetes for men (PR, 18.1; 95% confidence interval [CI], 6.7-46.8)

Women (PR, 12.9; 95% CI, 5.7-28.1]

Gallbladder disease for men (PR, 21.1; 95% CI, 4.1-84.2) and women (PR, 5.2; 95% CI, 2.9-8.9).

Prevalence ratios generally were greater in younger than in older adults.

The prevalence of having 2 or more health conditions increased with weight status category across all racial and ethnic subgroups.

The Prevalence Ratio of Obesity and Type 2 Diabetes is 18.1 for men and 12.9 for women.

Therefore Type 2 Diabetes is very prevalent in both Obese and Overweight men and women.

Up to 75% of adults with diabetes also have hypertension, and patients with hypertension alone often show evidence of insulin resistance.
Hypertension and diabetes are common, intertwined conditions that share a significant overlap in underlying risk factors (including ethnicity, familial, dyslipidemia, and lifestyle determinants) and complications.
These complications include microvascular and macrovascular disorders. The macrovascular complications, which are well recognized in patients with longstanding diabetes or hypertension, include coronary artery disease, myocardial infarction, stroke, congestive heart failure, and peripheral vascular disease.
Although microvascular complications (retinopathy, nephropathy, and neuropathy) are conventionally linked to hyperglycemia, studies have shown that hypertension constitutes an important risk factor, especially for nephropathy.

Eighty percent of the treatment costs for diabetes and hypertension to the healthcare system is the result of the treatment of the complications of hypertension and diabetes.

In order for a healthcare system to be sustainable diabetes and hypertension must be cured. It is essential that each must be recognized early and treated aggressively.

Patients must be taught to be “the professor of their disease” so they can self-manage the control of their disease. Blood pressures and blood sugar are changing continuously. Patients live with their disease 24/7.

This takes a lot of personal responsibility and personal discipline.

Equally important is the morbidity resulting from the complications of diabetes and hypertension, two diseases that result from obesity.

Complications from the onset of both hypertension and diabetes take about eight years to develop. This is the reason to diagnose and discover Pre-Diabetes at the onset.

The shared lifestyle factors in the etiology of hypertension and diabetes provide ample opportunity for non-pharmacological intervention.
Thus, the initial approach to the management of both diabetes and hypertension must emphasize weight control, physical activity, and dietary modification.

Lifestyle intervention is remarkably effective in the primary prevention of diabetes and hypertension. These principles also are pertinent to the prevention of downstream macrovascular complications of the two disorders.

This is the where my story of the importance of personal responsibility comes in.

A restaurateur, in his early 50’s, who runs a large restaurant in Dallas, that I frequent, was slowly gaining weight. At 269 lbs. he had difficulty standing on his feet all day long. He was being treated for hypertension and hyperlipidemia (high cholesterol).

His physician told him he must lose weight. He informed him of his risk factors for the complications of these diseases.

This was all he needed hear. The thought of having to quit the job he loved and the possibility of dying from the complications of his diseases was enough to make him decide to loss the weight.

He was told he would be fine if he lost the weight.

He has lost 70 lbs.so far without assistence. He has decided to be personally responsible for his weight loss.

He now gets up at 5 am each morning and exercises for one hour each day before work.

He has stopped eating his wonderful pasta dishes. He eats nothing that is white.

Every time I meet a friend at the restaurant, the restaurateur sits down at our table for a chat. We usually talk about how great he is doing in the weight loss department.

I had initiated an obesity program at Endocrine Associates of Dallas P.A. in the mid 1980s. A California clinical endocrinologist, with whom I did my endocrine fellowship with, had a very successful obesity program. He convinced me to start one at EAD.

Patients on large doses of insulin were totally off insulin after two weeks. It was successful until the patients graduated from the program.

Unfortunately the recidivism rate (regaining weight) was around 80%. This rate was not dissimilar to the national overage at the time.

EAD stopped the program.

In my view there were not enough patients who turned the corner and stuck to the program.

I believe the restaurateur has turned the corner. This fellow has turned the personal responsibility corner to control his food intake and exercise output. I do not believe he will regain his weight.

He has exhibited personal responsibility for his health and well-being.

If only physicians could solve the obesity problem so easily, the cost of healthcare would plummet to sustainable levels.

The development of Type 2 Diabetes Mellitus would also plummet and the cost of the treatment of its complications would vanish.

Social change is necessary in restaurants and fast food chains.

People have to be taught to eat wisely in restaurants and at home.

People have to be provided with education about the perils of obesity.

People have to understand the natural history of obesity.

People have to be motivated to not only maintain their health. They have to be given financial incentives to control their health.

This can only be achieved with a consumer driven healthcare system in which people are provided with incentives to control their healthcare dollars.

My ideal medical savings account will provide all the appropriate incentives for all people of all economic levels.

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

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