Stanley

Feld MD,FACP,MACE

I received the following email a few days ago.

Could you please provide a reference that supports the 80% statistic ("Fixing the complication absorbs 80% of the healthcare dollar")?  I am not questioning this number, but I would like to read more about it.  Thanks!

There are many articles in the literature to support the 80% rule. Our focus is on Diabetes Mellitus a disease that cost society about $150 billion dollars.

The best recent reference is published in a story in the LA Times on June 19, 2006 entitled “Medicare Looks to Boost Seniors’ Use of Preventive Care.”

Mark B. McClellan Medicare administrator said in an interview “If you take a big step back and look at Medicare spending, 90%-plus of what we are spending is going for the complications of chronic disease.” He goes on to say “We can get healthier beneficiaries and lot lower costs related to complications if we can get more prevention.”

Medicare’s budget is $336 billion dollars a year. In some diseases, you can reduce the complication rate by 50% or more as shown by the DCCT (Diabetes Control and Complications Trial) NEJM 1993.

If we spend 90% of the healthcare dollar on complications of disease for persons over 65, and we can reduce the complication rate by 30% rather than the 50% or the theoretical 100%, the cost saving would be $90 billion. If we could reduce the complication rate by 50%, the savings to the Medicare system would be $168 billion. Then Medicare would not have to solve their increasing cost of care problem by reducing payment to physicians yearly, and restricting patient access to care.

Since Medicare is the payer of last resort, physicians have finally gotten the governments attention about the “Power of Prevention”. The 2007 Medicare handbook will focus on preventive care. Medicare will finally start paying for preventive care.

Complications of chronic diseases take a long time to develop. It has been estimated that Diabetes mellitus takes 8 years to discover from the time of onset of disease and the onset of complications even longer. Many times a high blood sugar is discovered when the patient is in the Cardiac Intensive Care Unit after having a heart attack. Coronary artery disease is the most common complication of Type 2 Diabetes Mellitus. If the blood sugar was controlled by intensive self management this complication could have been reduced 30-100% depending on the control of the blood sugar. There are many other complications in other chronic diseases states that the “Power of Prevention” will stop.

The private insurance industry has been very slow to pay for prevention of chronic complications. I imagine the thinking is “we pay for some things that are broken”. If something becomes broken, we will pay but raise the insurance premium or not offer the employers insurance next year. If you are self employed, simply getting older and at greater risk for disease might make it impossible to buy insurance.

How do we motivate the private insurance industry to pay for a future event that will not happen on their watch? A clue is that every State has a State Insurance Board that licenses the insurance company to sell insurance in that State. We, the people, have to do is educate our politicans, policy makers and State Insurance Boards and demand coverage for chronic disease from the insurance company in order for them to sell health insurance in our state.

There are many other things we, the people, will have to demand. We will get to them in time.

The LA Times article goes on to state that “some of the results have been disappointing to Medicare officials. 2% of eligible seniors have taken advantage of the physical examinations that are paid for. “Only 54% of male beneficiaries get Prostate Specific Antigen, or PSA blood test- prostate cancer screenings that are free."

Why is that? The presentation of the information is confusing to the elderly. The patients are afraid to be checked for fear of discovering an unknown illness. Patients do not understand the Power of Prevention. Patients lack economic incentives to participate in prevention.  Chronic disease management is not a strong card in the Primary Care physicians’ deck as I have stated previously. However, we, the medical profession, are trying very hard to improve the Quality of Care for Chronic Disease.

I will cover my opinions for the reasons for all of the above and more in future blogs.

The article is worth reading completely.    

I
have described how most of the major programs initiated by Obamacare,

(such
as the Accountable Care Organizations, the Electronic Health Record
initiatives and the Health Insurance Exchanges development), are failing or off
to a slow start.

 A detailed critique of the Obama
administrations’ Obamacare can be found using the search engine in my blog.

If
you receive my blog by email (RSS) double click on the blog title or go to the
web site http//:stan.feld.com.

Search
for the topic in the search engine in the top right corner of the blog post.

The
shortcomings of Obamacare are becoming obvious to many citizens. Most physicians
and hospital systems are finding Obamacare’s new programs difficult to execute.

A
reader wrote

"Dear Dr. Feld,

Once it becomes so painful for the
average voter, Obama will simply say, “a single payer system is the only way to
fix this insurance company mess.”  He’s doing exactly what he planned to
do, he’s just not telling the truth about it.

X"

It
is becoming more apparent that President Obama’s goal has been to destroy the public
and private sector healthcare systems. In reality the money in both the public and
private healthcare system has been controlled by the healthcare insurance
industry and not by the government.

The
Obama administration is building the infrastructure to easily convert the
healthcare system to a single party payer system. The majority of Americans are
opposed to a single party payer system. It eliminates choice.

The
expense of Obamacare has been and will be enormous to all stakeholders with 300
new agencies and 20,000 new regulations.

The
new healthcare taxes are scheduled to take effect almost monthly.

At
present at least 40% of the healthcare system is a single party payer system
when considering the government healthcare plans in place.

The
Obama administration will have two major problems converting America totally to
a single party payer.

The
public will be outraged when it becomes aware of that the direct costs to them,
the lack of availability of medical care and restriction to access to care
caused by Obamacare.

There
are two possible solutions. Either repeal Obamacare and start from square one
or let the government control the entire system.  

The
government will not be able to afford a single party payer system. It will have
no choice but to increase taxes further to support the healthcare system.

The
other major problem Obamacare will have with a universal single party payer system is the
healthcare insurance industry will continue to control the money in the system.

The
government does not have the infrastructure to provide the administrative
services and to adjudication claims. There are many hidden cost in the movement
of money that most are unaware of.

The entire situation reminds
me of Ray Charles’ song “I’m busted.”

http://youtu.be/D_Ew-768xmk

In 2008, after President
Obama was elected I wrote him six letters explaining how he could reduce the
costs of medical care in America by introducing cost savings initiatives.

Dear President Obama Part 1

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/11/dear-president-elect-obama.html

Dear President Obama Part 2

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/11/dear-president-elect-obama-part-2.html

Dear President Obama Part 3

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/11/dear-president-elect-obama-part-3.html

Dear President Obama Part 4

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/12/dear-president-elect-obama-part-4.html

Dear President Obama Part 5

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/12/dear-president–elect-barack-obama-part-5.html

Dear President Obama Part 6

http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2008/12/dear-president-elect-obama-part-6-why-dont-you-listen-to-practicing-physicians.html

I took a Willie Sutton
approach. “ Go where the money is.” 

If the government provided incentives to decrease
wasteful spending, the healthcare system would self correct without the myriad rules
and regulations    that
will not work and cannot be enforce.

Simple things such as:

1. Incentivize individual responsibility with Medical
   Savings Accounts,
2. Encourage the use of a Universal Electron Health
   Record with a fully functional EHR in the cloud. Physicians and hospitals would
   pay for its use inexpensively by the click. It would be sort of like a toll way
   fee without capital expense. The EHR could be upgraded and serviced at no
   expense.
3. Create a healthcare system that is consumer driven
   with consumer owning their healthcare dollars and being responsible for their
   healthcare choices.
4. A Tort Reform System that eliminates the need for
   defensive medicine that over tests patients to avoid law suits.
5. Chronic Disease Management Systems to teach patients
   to be the professor of their disease in order to avoid costly complications of
   their disease.
6. Develop patient educational systems available on the
   Internet 24/7 as an extension of their physicians’ care.
7. Help develop disease specific Social Networks. The development
   of a disease specific community can serve to solve some problems patients have.
8. Eliminate secondary stakeholder waste, fraud and
   abuse.
9. Eliminate the purchase of first dollar healthcare coverage
   from the healthcare insurance industry  

I believe if all of the
above was done correctly it would save $750 billion to $1 trillion dollars a
year for the healthcare system.

President Obama has ignored
every point I have tried to make. Obamacare has not included any of the real
cost drivers in a non-punitive way.

He has simply added a huge
bureaucracy with rules and regulations that are expensive, difficult to execute
and more difficult to enforce.

If my recommendations were initiated
and executed properly America would have a sustainable healthcare system.

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

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Stanley Feld M.D., FACP, MACE

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The value of social networking has been partially understood by society. To me social networking’s potential for improving the quality of medical care has been poorly understood. Social networking can be a valuable educational tool in medical care.

I have always believed that if patients have a better understanding of their disease, they can better understand the reasons for their treatment. The result will be a better treatment outcome. This understanding will increase adherence to treatment. Adherence to recommended treatment nationally is about 50% for most chronic diseases. 

One of the spokes in the business model wheel for the ideal future healthcare system state emphasizes development of social networks within medical practices.

Social networks can act as physician extenders to increase physicians’ ability to teach patients to be a “Professor of Their Disease.” Physicians can increase the quality of care they deliver by creating social networks within their practice. Patients can create a nickname so as to be anonymous to the social network. The physicians would be aware of the nickname.

Social networking is another name for participating in a community. Most people participate in multiple communities. Some join communities for social reasons, others for educational reasons, and still others for economic reasons.

Human are social beings. They enjoy interrelating with others.  

There are hundreds of communities on-line. These communities encompass many of the subcultures in our society.

For example, I have joined the on-line TED, Sermo, and Medscape communities to name a few to satisfy my need for continuing life long learning.

Some patients go on-line to find out about their disease. They either did not hear or did not understand their physician’s explanation of their disease.

Some explanations are very complicated. Some are not in agreement with the physician’s explanation. Some physicians do not explain diseases well.

The lack of understanding about their disease could have been because patients were too anxious about their disease to hear or understand the explanation for a particular treatment. A patient could believe the explanation was gibberish.

A great illustration of gibberish is the following explanation of the Turbo Encabulator. Try to understand the following explanation of the Turbo Encabulator.

http://youtu.be/MXW0bx_Ooq4

This is pure gibberish. A person can understand all the words if he concentrated but the string of words has no meaning.   Patients need to be able to hear explanations that answer their specific questions over and over again. Disease processes and the effects of treatment can be complicated.

All complicated issues can be explained simply. Complexity is the result of combining multiple simple effects.  The complicated issues can be explained by dissecting these effects to their core.

The trick is to develop the right teaching materials. The following is an example of what I mean by developing the right teaching material.

The main stream media and many people have interpreted Paul Ryan’s claim that President Obama has double counted the $500 billion dollar saving by which the President claims he is reducing the deficit with his healthcare reform act.

Everyone has heard the Carl Sandberg’s statement, “If you tell a lie enough times it becomes the truth.”

If Representative Ryan demonstrated the double counting in plain English as the following animated cartoon does, 100% of people would understand why Paul Ryan is correct in making that claim. It is arithmetic explained simply.

http://youtu.be/q8x20P4RpgQ

A more complicated subject can be made simple as the following animation, “Changing Education Paradigms” shows

The animation technique is entertaining. It holds the viewer’s attention. It is a powerful teaching tool. This tool can be developed for all chronic and acute diseases. It could be used as a teaching tool in social networks within a physician’s practice. It would be available 24/7.

http://youtu.be/zDZFcDGpL4U

 It the government wanted to create an efficient healthcare system it should help physicians set up social networks and develop animated cartoons for chronic disease management.

Physicians could choose web sites of their choice to educate their patients. These social networks could be set up so patients could interact with other patients in their physicians’ practices.

Patients could learn from each other about their treatment successes and failures. The social networks could be broken into subgroups such as diabetes, asthma, heart disease and others.

The social network could be an effective extension of the physician’s care with interactions supervised by the patient’s own physician. A modest reimbursement for the physician’s time should be provided.

Physicians should set up social networks with other physicians in their community to discuss interesting cases. This was the original purpose of hospital grand rounds and other teaching rounds.  This community activity is disappearing as physicians are seeing more patients and cannot break away to get to the conferences. The national online communities are good but a local online community is better.

All medicine is local and medical education should be local to have its greatest impact.

Social networking in medicine is all about educating patients in the care of their disease. Patients are the only ones who can control the course of their disease and its outcome. Physicians have to provide patients with the learning platform and supervise the treatment.

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

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