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CONGRESS DOES IT TO US, AGAIN

July 14, 2015

inDisinformation and the healthcare system, Healthcare Insurance Industry, Medicare, Medicine: Healthcare System

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Stanley Feld M.D.,FACP,MACE

Americans have lived through scandal after scandal and lie after lie during the Obama administration.

None of the guilty parties have been penalized.

President Obama lied about Obamacare. “If you like your doctor you can keep your doctor.” “If you like your insurance plan you can keep your insurance plan.”

Yet Obamacare continues to destroy our healthcare system as well as our economy with unconstitutional changes in the law, lies, increased regulations and an expanded bureaucracy.

Notable scandals have included the Benghazi affair, clandestine weapons to Syria, red line foreign policy retreats, IRS scandals, the Clinton email scandal, and now the Iranian nontransparent nuclear agreement scandal. I can go on and on.

The traditional media does not report the details of the scandals. There is little complaining from the traditional media about these scandals that President Obama reports as insignificant.

The scandals last only a few news cycles. Most of the scandals are then ignored. There is hardly ever accountability from or punishment for the guilty parties.

Republicans just sit back and do nothing to expose the scandals.

The number of uninformed Americans amazes me. Government policies are mentioned but are deemed by progressives as being insignificant. There is hardly ever any correlation between the scandals and the effect on our budget deficit and our economy.

I think Americans are finally starting to get it. They are becoming fed up with the unbridled arrogance of President Obama and congress.

The government is shafting American taxpayers without anyone knowing it.

The most outrageous scandal in Washington has been kept under the radar and away from the press.

The House and Senate have both falsely certified themselves as small businesses in order to fund health insurance for themselves and their staff with taxpayer dollars, sidestepping provisions of Obamacare.

How did this happen? Why wasn’t this reported in the press?

When President Obama and the Democrats were rushing the health care law through Congress without even knowing what was in it, Chuck Grassley (R-IA) managed, with strong public support, to insert a provision in the law requiring members of Congress and their staff to purchase insurance through the new health care exchanges.

Senator Grassley’s goal was to have Congress and their congressional staffs have the same healthcare insurance experience that millions of Americans were going to have.

His hope was to create a strong incentive for Congress to make sure that President Obama’s new healthcare insurance system worked.

When congress and the congressional staff realized the cost of being in the healthcare exchanges and they needed to give up Medicare C, Congress’ special Medicare program, congressmen and their congressional staff bitterly complained to President Obama.

President Obama had the Office of Personnel Management (OPM) issue a rule in 2013 allowing Congress and congressional employees to once again have taxpayers continue pick up most of the cost of their premiums.

State and federal health insurance exchange rules do not permit employers of large organizations to pay the premiums for their employees.

“Like many Americans being dumped into Obamacare exchanges, members of Congress and their staff stood to lose their employer contributions – in this case, the generous financing of their health benefits by taxpayers that they had before the law passed and took it away.”

The OPM ‘s rule makes clear that congressional members and staff still can receive the contribution from the government even though they have purchased their insurance from their exchange.

Office of Personnel Management’s (OPM) changed the rule in 2013. The rule insulated these insiders from the premium increases of between $5,000 and $10,000 per person they would have otherwise faced if they were forced give up their taxpayer-subsidized policies and buy their insurance through the Obamacare exchanges.

This rule is illegal because it separates Congress and staff from the rest of the population. The only employers that can make contributions for their employees purchasing insurance through the exchanges are small businesses with less than 50 employees.

“There is no mechanism for employer contributions in the individual healthcare exchange market.”

Congress also filed false documents claiming the House and Senate each have less than 50 employees to qualify as “small businesses,” even though over 13,700 congressional employees have in fact signed up.”

“ That’s fraud.”

Judicial Watch obtained these false documents in Freedom of Information Act litigation.

However, the documents were heavily redacted including the names of Senators and Representatives who signed these false documents under penalty of perjury.

The blatantly false documents stated that the Representatives and Senators each have only 45 employees. The congressional staff is not an individual Representative or Senator’s employee. They are government employees.

The employer, the federal government, has more than 49 employees and is not a small business.

“The House and Senate have both falsely certified themselves as small businesses in order to fund health insurance for themselves and their staffs with taxpayer dollars, sidestepping provisions of Obamacare.”

An important question the public has to know the answer to is which Senators and Representatives signed the false declaration.

“Senator David Vitter (La.), chairman of the Senate Small Business Committee recently tried to subpoena the documents in which the false declarations were made, but he ran into strong bipartisan opposition.”

Senator Vitter wanted to know how the House and Senate, with thousands of government employees, came to be officially designated as small businesses. He wanted to know who signed the false documents and have his committee question these representatives.

Fourteen (14 of the 19) members of his committee objected to Senator Vitter proceeding with the subpoena of documents.

Democratic senators on Senator Vitter’s committee all voted in lockstep to keep the signed documents a secret from the American people.

They are: Jeanne Shaheen (N.H.), Maria Cantwell (Wash.), Ben Cardin (Md.), Heidi Heitkamp (N.D.), Ed Markey (Mass.), Cory Booker (N.J.), Chris Coons (Del.), Mazie Hirono (Hawaii), and Gary Peters (Mich.).

Republicans on the committee who voted to keep the documents secret from the people are Mike Enzi (Wyo.), Jim Risch (Idaho), Deb Fischer (Neb.), Kelly Ayotte (N.H.) and Rand Paul (Ky).

Republicans on the committee voted with Chairman Vitter to issue the subpoenas to those whose signed the false documents were Marco Rubio (Fla.), Tim Scott (S.C.), Cory Gardner (Colo.), Joni Ernst (Iowa).

These Republicans were the only ones that voted for the vested interest of the American people.

This is a very significant scandal.

The traditional mainstream media should be reporting this scandal. I think the Representatives and Senators who signed the false documents should be booted out of office.

It is a perfect example of Congress and the President making backroom deals for the benefit of Congressmen their congressional staff.

The congress is ripping off taxpayers while taxpayers not only are paying for their illegally subsidizing healthcare insurance.

Taxpayers have to pay the increased premiums for their own insurance while they are paying for congress’ healthcare insurance by on illegal congressional maneuver.

This corruption should make the American people madder than hell if they knew this was going on.

However the media is the message. The media is keeping us stupid. This scandal like others will fade away as being insignificant.

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How Should Healthcare Quality Be Measured?

April 26, 2015

inDisinformation and the healthcare system, Medicine: Healthcare System, Patients Problems, Physician's Problems, Quality medical care measures, Stakeholder Mistrust

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Stanley Feld M.D., FACP,MACE

The U.S. Preventive Services Task Force’s (USPSTF) grading system for measuring the quality of healthcare is an wrong. It results in a way to limit physicians’ judgment and treats medical care as a commodity. It enables a computer program to judge if physicians have followed an algorithm to treat patients.

“The U.S. Preventive Services Task Force (USPSTF).^[57]^[^{citation needed} has developed grading systems for assessing the quality of evidence for making judgments about treatments.

Level I: Evidence obtained from at least one properly designed randomized controlled trial.
Level II-1: Evidence obtained from well-designed controlled trials without randomization.
Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
Level II-3: Evidence obtained from multiple time series designs with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.
Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.”

The grading system is wrong. I will lead to shabby medical care. If quality of care should be measured, it should be measured by using Evidence-Based Behavioral Practice evaluations

“Evidence-based behavioral practice (EBBP) "entails making decisions about how to promote health or provide care by integrating the best available evidence with practitioner expertise and other resources, and with the characteristics, state, needs, values and preferences of those who will be affected.”

“Empirically supported treatments (ESTs) in some clinical settings are defined as "clearly specified psychological treatments shown to be efficacious in controlled research with a delineated population" ^[3]

Only when physicians’ clinical judgment and observations are included in the assessment of their quality of medical care should evaluation of that quality of care be measured.

The narrow criteria of the USPSTF will not define quality. It will only serve to restrict access to care and penalize physicians for using clinical judgment and consumers’ from receiving medical care.

Suddenly, it becomes easy to see how difficult it is to assess the quality medical care.

There is little question that an occasional physician practices terrible medicine. This is obvious to the medical community. The mechanism for improving a bad physicians quality of care is in place but not well executed.

Few, especially healthcare policy wonks, seem to understand the difficulty of assessment of medical care.

It should be easy for policy wonks to understand the limitations and criticisms of evidence based medicine.

Yet the Obama administration regards evidence-based medicine as measured presently as the gold standard of clinical practice,

Limitations and Criticisms of Evidence-Based Medicine (EBM)

EBM produces quantitative research, especially from randomized controlled trials (RCTs). Accordingly, results may not be relevant for all treatment situations.^[67]

This is obvious to most physicians.

The theoretical ideal of EBM (that every narrow clinical question, of which hundreds of thousands can exist, would be answered by meta-analysis and systematic reviews of multiple RCTs) faces the limitation that research (especially the RCTs themselves) is expensive; thus, in reality, for the foreseeable future, there will always be much more demand for EBM than supply, and the best humanity can do is to triage the application of scarce resources.

The reasons for EMS shortcoming are listed below. The list is not complete.

Because RCTs are expensive, the priority assigned to research topics is inevitably influenced by the sponsors' interests.
There is a lag between when the RCT is conducted and when its results are published.^[68]

There is a lag between when results are published and when these are properly applied.^[69]
Certain population segments have been historically under-researched (racial minorities and people with co-morbid diseases), and thus the RCT restricts generalizing.^[70]
Not all evidence from an RCT is made accessible. Treatment effectiveness reported from RCTs may be different than that achieved in routine clinical practice.^[64]
Published studies may not be representative of all studies completed on a given topic (published and unpublished) or may be unreliable due to the different study conditions and variables.^[71]
Research tends to focus on populations, but individual persons can vary substantially from population norms, meaning that extrapolation of lessons learned may founder.
Thus EBM applies to groups of people, but this should not preclude clinicians from using their personal experience in deciding how to treat each patient. One author advises that "the knowledge gained from clinical research does not directly answer the primary clinical question of what is best for the patient at hand" and suggests that evidence-based medicine should not discount the value of clinical experience.^[56] Another author stated that "the practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."^[72]
Hypocognition (the absence of a simple, consolidated mental framework that new information can be placed into) can hinder the application of EBM.^[73]
Valid enthusiasm for science should not cross the line into scientism, losing critical perspective.
Although clinical experience and expert opinion are insufficient by themselves, neither are they valueless, as EBM fervor that approaches scientism sometimes tends to paint them.

This last point is repetition of a very important shortcoming.

An informed clinician can weigh confounding variables in a clinical case and decide that following a population-based guideline to the letter feels inadequate for the situation. Thus clinical backlash against "cookbook medicine" is not always misguided, and "guidelines are not gospel."^[74]
Conceptual models, by having fewer variables than always-multivariate reality, face limits of predictive accuracy, just as even the best supercomputer simulations cannot predict the weather with 100% accuracy, whether because of the butterfly effect or otherwise.
Thus, just as clinical judgment alone cannot give epistemological completeness, neither can RCTs and systematic reviews alone.”

The answer to the reader’s last comment and question, “I believe a carrot and stick approach may be necessary with more carrot and less stick. Your thoughts?” is

I believe that government must learn how to evaluate quality medical care accurately, if they want to base healthcare payments on the quality of medical care. Presently, the government is far from achieving that goal.

It could also be that measuring quality medical care is not President Obama’s goal.

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

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Is This A Lie?

December 4, 2013

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

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Stanley Feld M.D., FACP,MACE

In the last ten days before the November 30 deadline to fix healthcare.gov President Obama dialed down his definition of fixing www.healtcare.gov.

http://youtu.be/mr_bHZbqqhU

President Obama knew at that time that the back end of www.healthcare.gov was not completed. He knew a security was not built into the system. Yet he is telling the people it would not work perfectly.

At the same time he made this promise he was fighting the reality. It looked like the traditional media was finally presenting reality and not President Obama campaign hype.

Obamacare is directly affecting them. Over 5 million people, in the individual market have lost a healthcare insurance policy. They could not get on healthcare.gov to buy insurance from the health insurance exchange.

I would expect at least 5 million more to lose their individual insurance. It is predicted that at least 80 million more will lose their group policy under Obamacare.

The premiums for new policies are skyrocketing because of the required Obamacare coverage mandate.

On Sunday, as a Nov. 30 deadline set by the administration for improvements to the web site had passed.

CMS issued a report concluding: "We believe we have met the goal of having a system that will work smoothly for the vast majority of users."

On October 5, we were told that healthcare.gov would be completely operational by November 30^th. Would that statement be considered a lie given the result?

Federal officials have acknowledged they had only begun to make headway on the biggest underlying problems: the system's ability to verify users' identities and accurately transmit enrollment data to insurers.

Insurers have complained they have not gotten accurate data to do their due diligence. There is no mechanism for payment of premiums or subsidies. The insurance companies have not issued insurance policies.

Many people think they have signed up for insurance. They do not have an insurance policy that covers their healthcare.

They have not been issued insurance policies because of the lack of the health insurance exchange transfer of accurate verified data nor have they paid the premium.

Once a person applies for insurance, income must be verified, subsidy calculated and a premium must be paid before insurance is in effect.

Much of this data collection and transfer has not been built into the healthcare.gov system.

Many software programmers claim the software used by CGI makes the integration impossible to do effectively.

Insurers do not want to take the risk without verification of the criteria for qualifications or premium collection.

Insurers and some states are continuing to look for ways to bypass the balky technology underpinning the health-care law despite the Obama administration's claim Sunday that it had made "dramatic progress" in fixing the federal insurance website.

The Obama administration has not released the number of people who have applied, been approved and have paid their premiums.

Only 26,000 people signed up and think they “got” insurance coverage by November 2 according to data released November 15^th.

The November 30^th numbers have not been officially released.

I do not blame the healthcare insurance industry for doing business in a business like way.

Obamacare is facing these and other giant issues.

Another big issue is the security of personal information issue an applicant enters on the web site. The security of information has not been addressed. In fact, hidden code in the web sites code releases www.healthcare.gov from responsibility for maintaining privacy.

The application process is still complex. This is a glimpse of the steps necessary to complete the application. Double click on the image to enlarge the image.

http://online.wsj.com/news/articles/SB10001424052702304355104579231870862102710

As far as President Obama is concerned he has delivered on his promise to make www.healthcare.gov functional by November 30 even if he modified his promise along the way.

The traditional media is cheering for him on his delivery of his promise.

Can anyone believe this?

After spending two months of defending www.healthcare.gov and his ill advised promises about “keeping your healthcare insurance and doctor period”, President Obama figured it is time to change the subject and go on the offensive since he has delivered as promised on the web site.

President Obama, starting Tuesday, will hold an event a day that will emphasize a different benefit of the law and try to remind Americans why Democrats pushed the law through Congress in the first place, according a White House official.

The plan is to have an event-a-day push to extoll the virtues of Obamacare. It will continue through much of the holiday season until the Dec. 23 enrollment deadline for January coverage.

The Obama administration coordinated the promotional blitz with Democratic allies on Capitol Hill and the party's campaign committees, all of which will be involved in pitching the daily message through press events and social media.

The idea of this campaign is to refocus the media and citizens away from the upcoming problems with www.healthcare.gov and emphasize the core principles of Obamacare.

President Obama has used the same strategy many times with healthcare, and his other scandals as he pursues his transformational agenda. It is called a diversion.

He plans to make clear the direct benefits Obamacare has provided to millions of Americans already.

Americans are starting realize Obamacare has meant more taxes,( to everyone including the poor, middleclass and wealthy), tremendous increases in healthcare insurance premiums, less full time jobs, less access to care and glimpses of the upcoming torrent of rationing of medical care.

Democrats and consumers are realizing the sham of this promotional campaign.

Many congressmen are running for the exits because they are up for reelection in 2014. They are trying to avoid the folly of President Obama’s promotional blitz.

The public relations ploy will further decrease President Obama’s credibility.

How can we trust the government with our healthcare decisions when it is having so much difficulty constructing a web site?

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

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A Special Message from the Dallas County Medical Society President

June 4, 2013

inDisinformation and the healthcare system, Medicine: Healthcare System, Patients Problems, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

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Stanley Feld M.D.,FACP,MACE

The following is a special message to members of the Dallas
County Medical Society (DCMS) from Dr. Cindy Sherry. Dr. Sherry is a very smart
woman and an excellent physician.

She is also extremely tactful. If you read between the lines of
her message, you will sense the difficulty and mistrust physicians have for
hospital systems. You will also
understand the government’s lack of interest in physician innovation.

If physicians threaten hospital system’s vested interest even if
it is to improve patient care in a community the hospital system is against it.

There is no need to ask why physicians should mistrust the
promises of hospital systems. Hospital systems must prove their sincerity to
the physicians in the community and not the other way around.

Dr. Sherry describes the way Centers for Medicare and Medicaid
Services (CMS) received the Dallas County Medical Society (DCMS)
representatives. The DCMS has a plan that can help the indigent patients in our
community.

I think the plan will work.

The message I got from Dr. Sherry’s special message is CMS is too
busy to listen to physicians.

They simply do not have the time or the bench strength to work
on something that might capture the imagination of medical communities in other
cities and other states. The physicians’ ideas might lead to additional
innovative ideas that could markedly decrease the cost of delivering medical
care in America.

However, the government has its mind made up and is not
interested.

“DCMS News: Special
Message from the Dallas County Medical Society President

Dear
Fellow Members of DCMS:

As your
president, I would like to tell you about your DCMS executive committee’s May
visit to the national headquarters of CMS (Centers for Medicare and Medicaid
Services) in Baltimore. Joining me were Immediate Past President Rick Snyder
III, MD; President-elect Jeff Janis, MD; Secretary-treasurer Jim Walton, DO,
and CEO Michael Darrouzet.

To begin
with, getting into CMS was more complicated than getting through security at
DFW airport. At the gate, our car was thoroughly checked, including under the
hood, in the trunk and inside all suitcases, and all passenger IDs were
examined. IDs were rechecked at the building entrance, plus we and all our
belongings passed through metal detectors, overseen by armed guards and guard
dogs.

In
preparation for the trip, we acknowledged that the Medicaid 1115 Waiver
opportunity had passed to transition Project Access Dallas to a physician-led
ACO (accountable care organization) called My Medical Home. Therefore, the
intent of our meeting with CMS was not to create a last-minute effort to revive
the program, but rather to keep our concerns about the Waiver alive, and to
express these concerns to the people in charge. We wanted to inform the CMS
policymakers about how their plans and goals for the underserved population of
our region are being interpreted and implemented in the offices of physicians
and in the halls of hospitals. Furthermore, although we remain sorely
disappointed in our Big 5 Dallas-area hospital systems for their role in
thwarting the transition of Project Access Dallas to My Medical Home, we did
not make this trip to air dirty laundry or to ask CMS to intervene in a
hospital-physician dispute.

Our
concerns are centered on the reality that health care is in transformation
across this country, including Dallas. Now is the time for DCMS physicians to
assert our leadership and to work to ensure that the transformation occurs
according to guiding principles — principles that will lead to programs that
provide quality care to all of our citizens; principles that will ensure that
resources are deployed across the healthcare continuum, not only for
hospitalizations and ER visits. We had embraced the principles and goals
espoused in the Waiver, including collaboration, accountability, transparency,
and a focus on access, wellness and quality.

While in
Baltimore, we spent about 90 minutes voicing our concerns with CMS representatives,
including Steven Cha, MD, chief medical officer; Rob Nelb, Texas 1115 Waiver
project officer; Therese DeCaro, senior adviser to Cindy Mann, deputy
administrator, responsible for development and implementation of national
policies governing Medicaid; and Julia Hinckley, acting deputy director of the
Children and Adults Health Program Group. We realized that they are
office-based, policy personnel who have no interaction with patients or
physicians that would enable them to fully grasp how their plans play out
across communities. We also recognized that a resolution to our immediate
problem would not be forthcoming, so we remained focused on constructively
sharing concerns that have the potential to impact future programs and
decisions.

We
emphasized our belief that a truly transformative plan would create a new
financing and delivery model that would include outpatient clinics, specialty
and primary care physicians, community care transitions, community health and
pharmacy navigation and transportation, referral management and case
management, and preventive and wellness services.

We further
stressed the need for more balance in the use of funds. With current funding
focused on hospitals, how could one realistically expect the transition to more
affordable and more coordinated outpatient care? The current focus on hospital
funding disregards the recent results of the needs assessment completed as part
of the Waiver process, which largely is outpatient-focused. This funding
imbalance omits ambulatory care clinics, care coordinators and physician
compensation from the equation.

How did
the CMS staffers respond to us? They pointed out the depth of the problem they
face — each state is submitting numerous proposals, adding up to innumerable
programs from across the country. They simply don’t have the bench strength or
depth to adequately oversee the programs in the detail we described. They used
glorified terms of transformation such as “collaboration,” “innovation” and
“transparency” in the Waiver, but also acknowledged that these are long-term
goals, and that they do not expect their immediate fulfillment. They have no
plan or capability to police the programs, instead relying on state and local
administrators. They acknowledged that the letter from county medical societies
represented a desirable component of a region’s proposal, but the medical
society did not possess veto power, and that the letter would be considered as
one piece of information among many in the proposals. In point of fact, the
medical society letter was a requirement added at the state level; it did not
originate at the federal level.

CMS officials also acknowledged that the dispersal of funds should be more
balanced. However, they said there is no mechanism or pathway for the funds to
flow differently, and integration of outpatient care truly is a big challenge.

To the CMS
officials, our visit was a reality check for them to hone in on questions such
as, “How is the process working? Can it be improved?” Our visit served as the
launching pad for them to begin a conversation for future policies. Based on
our initial conversation, they have bolstered some of their regulations for
interim follow-up reports and they have incorporated requirements for learning
collaboration plans. These midcourse corrections now allow for future 2-year
funding windows rather than 5-year approvals.

Probably
their best take-home message for us was that we (physicians, in general, and
DCMS, specifically) need to strengthen our voice and increase our clout through
our political connections, and that we should have been able to recruit
political allies locally and statewide to help us be more effective and support
our position.

In
conclusion, the visit with CMS strengthened the DCMS executive committee’s
resolve that the Blue Ribbon Task Force for the Underserved is heading in the
right direction. We remain committed to moving forward and creating an
innovative plan through activating leaders — including physicians, hospitals,
outpatient facilities and services, midlevel providers, and business leaders—
from all corners of the community to work together to blaze a trail for a more
cohesive plan to provide health care for the underserved citizens of Dallas. It
was an honor to represent the 6,500 members of DCMS in Baltimore.

Sincerely,
Cynthia Sherry, MD
President, Dallas County Medical Society”

Many physicians
throughout the country have said, “Why bother?” The answer is because you cannot give up. Some how Americans will wake up.

Our government is by the people for the people. We are the people.

Not government bureaucrats!

There you have it. Leonard
Cohen is right. “The Dice are Loaded.”

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

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Obama Administration Continuously Declines To Renew Indiana’s Medicaid Waiver

May 19, 2013

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

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Stanley Feld M.D.,FACP,MACE

In light of the recent alleged IRS
scandel targeting certain groups, I am reminded of the Medicaid incident in
Indiana. I believe the incident is resolved now with the Obama administration
granting a waiver to Indiana after two years of bureaucratic haggling.

In 2007 Governor Mitch Daniels (R.) was
successful in getting the Indiana state legislature to pass a Medicaid reform
plan called the Healthy Indiana Plan. It is an expansion of Medicaid. It uses a consumer-driven
health plan to encourage low-income beneficiaries to take control of their
health and healthcare dollars.

This healthcare plan is a variant of my
ideal medical saving account.

The Healthy Indiana Plan has been very successful.

Healthy Indiana Plan has been the most
innovative and successful reform of Medicaid in the history of the Medicaid
program.

The federal government’s waiver for the
plan was given in 2007 and set to expire on December 31, 2012. Indiana applied
for an extension of the Medicaid wavier in early 2011. In November 2011 the
Obama Administration rejected the state’s request to extend its federal waiver.

Over 45,000 poor Hoosiers on Medicaid
were scheduled to lose this innovative Medicaid coverage in 2013.

Medicaid is theoretically run by the
states in cooperation with the federal government. In reality, any time a state wants to make
the tiniest changes in its
Medicaid program, it has to go hat-in-hand to the U.S. Department of Health and
Human Services with a formal request for a waiver and these waivers are usually
denied.

This federal control has been part of the
disagreement states have with the federal government over health insurance
exchanges. The central government wants to shift the financial burden on the
states while controlling the states’ decisions.

Indiana succeeded in gaining a waiver in 2007
because it was seeking to expand Medicaid to
a group of people who weren’t then eligible for the program and because the
state’s effort required no additional outlays from the federal government. Governor
Mitch Daniels paid for the
Medicaid expansion by increasing the state’s cigarette tax by 44 cents. It made
sense to everyone except the people that smoked.

Patients had skin in the game because
they had to pay 2 -5% of their income for their insurance coverage. The plan
provided financial as well as wellness incentives.

“We did a lot of reading on
criticism of health savings accounts,” says Seema Verma, who was the architect of the Indiana
program. “One of the criticisms was that people didn’t have enough money to pay
for preventive care. So we took preventive care out, made that first-dollar
coverage.

“ Also, people said that people didn’t have enough for the
deductible, so we fully funded it. Then, you have to make your contribution
every month, with a 60-day grace period. If you don’t make the contribution,
you’re out of the program for 12 months. It’s a strong personal responsibility
mechanism.”

I described the Healthy Indiana plan in
detail in January 2008 pre President Obama.

Medicaid patients get a specified amount
of preventive care for free. Included
are free annual physical exams, pap smears and mammograms for women,
cholesterol tests, flu shots, blood glucose screenings, and tetanus-diphtheria
screenings.

Medicaid beneficiaries have no
cost-sharing requirements (co-pays, deductibles, etc.) except for non-urgent
use of emergency rooms.

The money remaining in the Medicaid
patients’ POWER accounts at the end of the year can be applied to the following
year’s contribution only if they obtain the required free preventive disease
services.

“The program has been, by many measures, a smashing success. “What
we’re finding out is that, first of all, low-income people are just as capable
as anybody else of making wise decisions when it’s their own money that they’re
spending,” Mitch Daniels explains in a Heritage Foundation video.”

“And they’re also acting more like good consumers. They’re
visiting emergency rooms less, they’re using more generic drugs, they’re asking
for second opinions. And some real money is starting to accumulate in their
[health savings] accounts.”

The program has been
very popular. Ninety (90) percent of enrollees are
making their required monthly contributions. Employers didn’t dump their
workers onto the program, crowding others out, because you needed to be
uninsured for six months in order to be eligible for it.

“The program’s level of
satisfaction is at an unheard-of 98 percent approval rating,” Verma told Kenneth Artz.

Lower income families are not too stupid
to be wise healthcare consumers despite popular belief.

A 2010 study by
Mathematica Policy Research found that in the program

71 percent met the preventive care
requirement and were able to roll the balances over to the following year. Only 39% obtained preventive care in the
first six months. It proves financial incentives work.

The lack of physician access is the
biggest reason why health outcomes for Medicaid patients lag far behind those
of individuals with private insurance.

Healthy Indiana pays better than
traditional Medicaid. The physician access trend has been reversed. Preventive
care participation rates are higher than the
privately-insured population.

Why would the Obama administration, which
controls the states’ Medicaid programs, refuse to grant a waiver for Indiana’s successful
program?

The first excuse HHS used was “ HSS hadn’t written the regulations for Obamacare
yet.”

According to Seema Verma “the state will now have to file a much more
complex “State Plan Amendment” that may not get approved before the Healthy
Indiana program is set to expire.”

Before his term expired Gov. Daniels
had written to HHS Secretary
Kathleen Sebelius asking her for permission to use the Healthy Indiana Plan to
handle Obamacare’s mandatory expansion of Medicaid. He had not heard back.

The Obama Administration claims to be on
the side of the poor. Why would it not
approve a waiver of a popular program for the poor that provides the poor with
superior health care?

Whatever the reason, tens of thousands of people will be
needlessly harmed.

Regulatory
burdens and “poison pills” have been thrown at the Indiana health plan. One
such poison pill is not allowing the state to include the $1100 Power account given to Medicaid patients to make
wise medical care choices.

Yet
the government pays the healthcare insurance industry for help desks and rent
for buildings where there are help desks as direct patient care instead of
expenses.

It is
not only bewildering, it is obscene.

The
controversy continued throughout 2012 past the expiration date of the 2007
waiver into 2013.

Mike
Pence, the new governor, kept fighting off bureaucratic rules but got nowhere
through March of 2013.

The subtext of all of this is the
Obama administration wants a top down centrally controlled Medicaid system with
the financial burden on the states and Indiana wants to control its own destiny
with its successful plan.

Stuff
like the following has been going on. Diane Gerrits, CMS' director of state
demonstrations and waivers, wrote in a Feb. 25 letter that the state will have
to resubmit its application because it had not yet held two public hearings
required by law.

CMS said as a result of the failure to comply with the transparency portion of
the proposal, the state must begin a 30-day state public comment and notice
period. The state must follow with an additional 30-day federal public comment.

This
has been going on since 2011

Governor
Mike Pence fired back,

"The Feb. 25, 2013, letter from HHS does not
indicate in any way that the waiver application process has been
jeopardized," he wrote Thursday. "It does, however, speak to the
flawed bureaucratic process that has impeded progress on our successful Healthy
Indiana Plan."

The
Obama administration is trying to destroy all health savings accounts both
public and private. This is probably the reason for these artificial delays.

Suddenly,
in mid April, under public pressure and possibly the impending IRS scandal Indiana’s
waiver request was approved.

This
is a happy ending to the Indiana saga and perhaps a model to get all the
Medicaid programs out of the deep ditch they are in.

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

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The Chautaugua: The Feld Men’s Trip

August 29, 2012

inLife's Experiences

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Stanley
Feld M.D, FACP,

Two weeks ago
after I wrote “A Tribute To Jack Feld”, I received a bunch of requests to write
about the upcoming Chautaugua we had scheduled at the Aspen Institute for this
year’s Feld Men’s Trip.

Left to Right: Daniel, Stan, Kenny,
Jon, Brad in front and Charlie. There was no room on the rock for Brad so he
was pushed off.

Our private
Chitaugua took place August 23rd-26^th. Each of the 6 of us had 2-3
hours to talk about anything we wanted. During that time there would be
discussions and reactions to the ideas each of us presented.

My brother,
Charlie Feld, requested that he go first and that I be the cleanup presenter.

I figured
that was good because I would try to pull everyone’s ideas together.

Charlie
distributed statistics about the United States for the last 70 years. There are many categories that can be compared
such as population, the unemployment rate, the national debt and the baseball
standings.

http://www.infoplease.com/year/1942.html

http://www.infoplease.com/year/1952.html

http://www.infoplease.com/year/1962.html

http://www.infoplease.com/year/1972.html

http://www.infoplease.com/year/1982.html

http://www.infoplease.com/year/1992.html

http://www.infoplease.com/year/2002.html

The only
thing that remained stable was that on August 23 of each decade the New York
Yankees were in first place in their league or division.

The major
point that was made was there has always been uncertainty and change in the
world.

Technological
change has accelerated social, political and economic change.

PC’s are 30
years old. Smart phones are 12 years old. Our son’s kids don’t know what a
typewriter is. Imagine the rate of change in the next ten years.

We did a
lot of imagining.

We
concluded that change is not random. Technological change has stimulated innovation,
which in turn stimulated more innovation.

Leadership
evolves, and initiatives are started. The ability to change and progress lies
with Americans’ individual freedom.

The U.S.
constitution gives Americans these freedoms. We must protect these freedoms.

My son,
Brad Feld, was next. Brad is in the midst of creating a “Start Up
Revolution.”

He just
finished a book called” Start Up Communities, Building an Entrepreneurial
Ecosystem in Your City.”

Brad spoke
about the value of entrepreneurial ecosystems. He outlined how networking can increase
the efficiency of all organizations.

He stated
that society is in the process of changing from a hierarchical society to a
networked society. Hierarchical society was an invention of the industrial
revolution. The networked society is an outgrowth of the Digital society as we
progress through the Electronic
Revolution.

He also
spoke about the importance of social networking to communities and the vital
need for mentees to become mentors in their community.

The
community should become a non-zero sum community to enhance innovation in the
community. Community meet-ups are vital to enhancing entrepreneurial
ecosystems.

For more
details, buy his book. I think it is great even if I am his father.

The level
of the discussion of the first two sessions overwhelmed me. In fact the
discussions spilled over well into dinner.

Jon Feld
was up next. Jon talked about the mechanism for being great at something. First
you have to have a passion for the activity. Then it takes 20,000 hours of
intense practice. Sometimes putting in your 20,000 hours does not result in
greatness.

Daniel Feld
is missing because he is taking the picture. Jon is speaking and Charlie, Brad, Kenny and Stan are listening.

He gave us
examples. The discussion then went to kids and their inability to be exposed to
multiple activities because of the intensity of competition.

The lack of
concentration on one activity puts them too far behind children who have perfect
one activity.

The
examples given were basketball, baseball, piano, orchestra playing, dancing, singing
or acting.

The
children of today must concentrate on becoming expert in one activity and make
the grade in middle school or high school.

I remember
being perfect in nothing but exposed to everything. I wanted my boys to have
the same exposure. It worked.

In my view
a one- dimensional exposure to activities can be stifling when a child reaches
adulthood.

The
combination of a one-dimensional child exposed to fierce competitive stress can
burn out a child rapidly. If the parent is living through the child’s success
is can affect the parent/child relationship.

“Kids are
people too.”

I reminded
the guys that my father said to me “I could do anything I wanted as long as I
became a doctor.”

Brad
reminded us all that I said to him, “he could do anything he wanted.” I ended the sentence there and he appreciated
it.

The
discussion lasted a long while with lots of great ideas and opinions.

Kenny was
terrific. He analyzed the way he problem solves. He is very perceptive and very
optimistic. We discussed decision making in the context of reality vs. fantasy.

The
discussion became deeper and deeper as we progressed. This enhanced our bonding
with each other. Jon brought up the concept of the six of us being a tribe and
something special was happening here.

Daniel
asked us to define the meaning of charitable giving. Of the six of us Brad’s
concepts and methodology wins the prize. He and Amy have done a lot of thinking
about the concept. They have developed a well-designed plan for giving.

There were
many meaningful ideas presented. We all
agreed that charity was a lousy word. The common denominator should be that
giving be self-satisfying.

I was the
cleanup hitter. I started off by saying a mentor somewhere along the line gave
my brother and me the thirst for lifelong learning. I have learned from this meeting
that we have somehow transmitted this thirst to all four boys.

I also said
we all have to be involved in our community whether national or local.

This
statement pressed my Repairing the Healthcare System button. My brother is a
fan of my concept.

The boys
understand that the healthcare system is self-destructing. There is nothing
anyone can do because of the political irrationality of the day.

My point
was we should never stop trying.

This led to
the last question. Which character did each of us identify most with in “Atlas
Shrugged” and why?

I will leave
the answers for another time.

It was a
fascinating weekend. When I spoke to Cecelia during the weekend all I could say
was it was a phenomenal weekend as I was savoring the concepts discussed.

Wow. Same
time next year.

My Brother
and I discussing the progress of the Chautaugua at breakfast.

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

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Great Questions!

April 1, 2012

inMedicine: Healthcare System, Summary Blogs

• Leave a comment

Stanley Feld M.D.,FACP,MACE

A reader wrote,

“Stan

If the Supreme Court watchers are correct, it appears the court will strike down parts or possibly all of Obamacare later this spring.

If that happens, it is a good thing?

And if so, where do we go from here?”

The court should overturn Obamacare. In my view Obamacare is unconstitutional. President Obama deceived the congress, the public and the Congressional Budget Office about the true costs and intent of the law.

I hope the Supreme Court overturns Obamacare. Obamacare will be a disaster. Obamacare will destroy healthcare in this country. The public, media, and congress cannot yet understand it.

Many congressmen said they did not read the entire bill. Nancy Pelosi said “Don’t worry, we will understand what is in the bill once it has passed.”

Democratic spin-doctors and the traditional media accused the Internet page-by-page summaries of the bill as being anti-Obama propaganda.

President Obama disguised the costs and intent of Obamacare in a deceptive and clever way. It is a bill that puts America on Hayek’s Road to Serfdom.

Obamacare promotes dependence on the central government as it expands a failed entitlement.

It eliminates initiatives and incentives.

It decreases freedom of choice.

It expands an entitlement that America cannot afford.

America cannot afford to keep paying for the entitlement (Medicare) at the present enrollment. The states cannot afford the Medicaid entitlement much less its expansion.

President Obama ignores this enormous cost burden whose real cost estimates increase monthly by the CBO as the impact of Obamacare’s rules and regulations increase. Non-elected officials without a congressional oversight mechanism make rules and regulations.

How would you like to be told which doctor or which hospital you can go?

How would you like your physician to treat you in a certain way dictated by the federal government?

Medical science is changing rapidly. Best practices change quickly. The bureaucratic machinery implements change very slowly. Decisions for best practices and payment will be made by committee and not individualized by your physician using his best clinical judgment.

How would you like to put your health and healthcare needs and decisions in the arbitrary hands of some government institution that is being forced to save money?

How would you like to be forced to purchase a government insurance policy that has the right to restrict access to care and ration care?

How would you like the government to make all your healthcare decisions for you?

How would you like to not have freedom of choice and the right to participate in decisions about your health and healthcare decisions?

How would you like to be paying taxes for a very inefficient bureaucracy that does all these things to you?

Obamacare has already demonstrated that it is inefficient, wasteful, plays favoritism at the government's whim with no recourse by the individual.

An overriding goal of President Obama is central control of one sixth of the economy. He is pasting his healthcare reform act on top of a doomed 2011 business model.

Obamacare is accelerating the collapse of this doomed business model. Obamacare must be repealed or eliminated.

This has been healthcare journey so far.

Figure 1 shows the path of the healthcare business models since 1945

Figure 2 describes the hairball of interference by the government and the healthcare insurance industry in the physician patient relationship. It also describes the fragment view of the patient as a result of this hairball.

If the reader is interested in the reasons this all came about click on the underlined heading to read the source material in figure 3.

Figure 3: This is an easier figure to click on the source material and reference. The chasm between the patients and physicians must be eliminated in order to have an effective healthcare system.

Figure 4: America is at the critical turn now. All of the mistakes President Obama is making to Repair the Healthcare System are listed. He is going to accelerate the collapse of the healthcare system. The mistakes are referenced in the underlined headings. The references can be read by double clicking on the underlined headings.

Figure 5: My proposed future direction can be seen in this figure. The detail below these headings can be read by double clicking on each heading. Some of the headings are included in Obamacare. President Obama’s problem is he is going about implementing them in the wrong way.

Figure 6: The spokes of the business model that must be implemented in the correct way are outlined in this figure. Details of the future state business model have been described in previous blogs.

I hope I have answered the reader's questions

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

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Chronic Disease Management And Education As An Extension of Physicians’ Care.

March 11, 2012

inChronic Disese Management, Consumer Driven Health Care

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Stanley Feld M.D.,FACP,MACE

All the Spokes in my Future State healthcare business model should be attended to simultaneously to be effective.

My vision ignores the barriers of the journey to implementing the changes in this discussion. There will be many barriers. Legacy vested interests find it difficult to see a better way when those interests are struggling to survive in the present system.

The healthcare system must be consumer driven. Consumers must be put in control of their healthcare dollars. The other stakeholders will then be forced to cater to the consumer.

When this happens all the stakeholders’ vested interests will become aligned. It will result in a decrease in healthcare costs and an increase in stakeholders’ satisfaction.

Patients will accept responsibility for the management of their health. Physicians will become more efficient in their delivery of care..

The music industry fought Apple after ITunes dis-intermediated its legacy business model only to find its profit increased.

Consumers must have a way to obtain adequate chronic disease management education. They must have transparent healthcare costs and understand treatment choices. Physicians must be actively involved in their patients’ education.

Chronic disease management education must be an extension of the physicians’ care. It is part of patients’ medical care. Physicians must be motivated to provide this care.

Effective chronic disease management is dependent on patients managing their chronic disease. Patients will take control only after appropriate incentives and educational methods are in place.

The goal is to decrease the onset of complications of a chronic disease. Patients can control their disease and decrease the occurrence of chronic complications. Eighty percent of the cost of medical care is spent on treating these complications.

Physicians must teach patients to become the professor of their chronic disease. The educational vehicle must be available 24/7 for patients to be able to review concepts they did not understand completely.

Physicians must have knowledge of current evidence based medical care to teach patients properly.

Much of the infrastructure is in place. It tends to be provided by secondary stakeholder and undermines the patient physician relationship. The infrastructure is not utilized properly.

Patients need to be responsible for controlling their disease. Chronic disease management is not an entitlement. It is a patient responsibility.

Patients are dependent of the government or the healthcare insurance industry to pay their bills. They have first dollar healthcare coverage

My ideal medical saving account would solve this issue. It would probably cost the government and the healthcare insurance industry less if they provided patients with $7,500 in a trust fund, provided the incentives for keeping money not spent and provided first dollar coverage after the patient spends $7,500 dollars.

Patients will then be converted to Prosumers (Productive consumers) and become intelligent consumers of healthcare.

Consumers would then encourage or force their physicians to provide appropriate chronic disease management education.

The formation of social networking on multiple levels could enable physicians to provide this education inexpensively and effectively.

For example, all of a physician’s diabetics patients can be members of his social network for diabetics. The information to learn about diabetes can be provided by his social network. Testing of patients’ understanding of core principles of diabetes can be done with direct feedback to the physician. This would provide the physician with insight to emphasize topics the patient did not understand.

The core information could also default to a more detailed explanation of the topics misunderstood.

It could be done for many chronic diseases such as asthma, COPD, heart disease, GI diseases, and joint diseases.

This education would promote the physician patient relationship. It would demonstrate than their physicians care about their care.

If there is a contradiction in the education between the physician’s thinking and the core information, a separate social network connected to the core information for physicians only can serve as a platform for debate between physicians. Continuing medical education could even be provided to give physician incentive to participate.

There are many innovative mechanisms to use to promote the patient-physician relationship, educate patients to be professors of their disease, and to be responsible for their own disease management.

The utilization of information technology through social networking will repair the healthcare system. It will enable access to education and affordable care.

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

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Ideal Medical Savings Accounts For Everyone: Encourage Patient Responsibility!

February 12, 2012

inConsumer Driven Health Care, Information Technology in Healthcare, Medicine: Healthcare System

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Stanley Feld M.D.,FACP,MACE

The third spoke in the future states wheel is Patient Responsibilty for their health and Healthcare dollars.

The Ideal Medical Saving Account would decrease the cost of the Healthcare System because it would dis-intermediate the Healthcare System’s complex and convoluted business model.

The Ideal Medical Savings Account should be an option for all consumers who have all types of insurance coverage. The Ideal Medical Savings Accounts would create competition for patients among physicians. It would create competition among healthcare insurers.

Medicare, Medicaid, corporate self-insurance plans, association healthcare plans, individual healthcare plans and ordinary healthcare insurance plans provided by employers could all offer the Ideal Medical Savings Account.

If MSAs were structured as my Ideal Medical Savings Account is structured the result would be a decrease in the cost of healthcare, a decrease in premium costs and an increase in healthcare quality.

The Ideal MSA must be paid for by pretax dollars as all other healthcare plans are.

If the government, individual or employer puts the first $6,000 of insurance in individual trusts for the consumer the entire healthcare and medical care supply chain would be disrupted by consumers.

An immediate argument is Medicaid patients are not smart enough to determine their own healthcare needs if they were responsible for the first $6000 of healthcare insurance coverage.

This is rubbish. It is condescending to patients on Medicaid. If the government is so worried they should provide education to help these Medicaid consumers make wise healthcare choices using available social media.

The entire goal of the Ideal Medical Savings Account is to provide incentives for consumers to become responsible for their health and healthcare needs rather than be entitled to medical care.

The mechanism for this reversal from a dysfunctional system’s business model to a functional system’s business model is patients’ owning their healthcare dollars and having financial as well as medical incentive to be responsible for their health, maintaining their health, and choosing the most efficient and effective medical care.

Consumers would become Prosumers (Productive consumers) of health care rather than passive consumers of healthcare.

This mechanism has worked in many industries using the Internet as a facilitator.

The Internet can become an extension of the physicians care.

At present there are many web sites offering advice to patients. The defect is they are not an extension of the physician’s care of the patient.

Physicians would be motivated through competition for the patients’ owned healthcare dollars to choose the sites for his patients that would be an extension of their care.

Physicians associations could create web sites for their members. Social networking between physicians and their patients could direct their patients to that site. This would be the meaning of an extension of the physician’s care.

Patient responsibility is the third spoke in my formulation of the future state business model of a functional healthcare system.

It must be remembered that the present state’s business model is dysfunctional. It must be repaired.

The future state must not be encumbered by any of the baggage of the dysfunctional present state business model.

If the future state model is made clear to patients, potential future patients and recovered patients (consumers) they will demand for this future state model.

Using social media consumers can drive the healthcare system to the future state business model.

It turns out everyone is better off and the system is more efficient and costs less for consumers.

The consumers would own the first $6,000. They would be responsible for the management of there healthcare dollars. They would also be responsible for choosing their physician.

I have found that when physicians and patients sign a patient physician contract the treatment results improve. Both physicians and patients have their responsibilities clearly defined.

The patient physician contract motivates patients to be responsible for their own care. Patients responsible for their care is critical to successful clinical outcomes.

If there were a financial incentive attached to this physician patient contract along with a potential bonus the results would be even better.

This was especially true in the treatment of Diabetes Mellitus.

In treating chronic diseases such as Diabetes, physicians must be the teachers, prescribers and coach. Patients must become the professor of their disease. Patients live and care for their disease 24/7.

Financial incentives would motivate patients to take an active role in their medical care.

Obesity is a major problem in America today. Patients and patient education is the only solution to the “The Obesity Epidemic.”

The only way to decrease obesity is by burning more calories than is eaten. Society must encourage exercise, and reducing intake. It turns out society encourages the opposite.

Mayor Bloomberg is doing the right thing in New York City. He uses simple transit Subway advertisements to increase awareness caloric intake. He has required each restaurant to publish calorie counts.

It is a simple educational message that everyone can understand. It is amazing how intelligent people misjudge their caloric intake.

Constant repetition of calorie counts of various foods along with estimates of calories burned can result is a cultural change for the need to burn more than we eat.

Companies such as FitBit are building simple products to help us achieve this goal.

Obesity contributes to the onset of many chronic diseases. The treatment of the complications of chronic disease result in eighty percent of the healthcare dollars spent for direct patient care.

If a consumer abuses his health and ends up spending the initial $6,000 he has no money left to put into his retirement account.

If a patient has a chronic disease and has excellent control of his disease he can avoid the complications of his disease. If the patients take the appropriate medical care avoids hospitalization and the emergency room for the year, the provider of his Ideal Medical Saving Accounts can afford to give that person a bonus for his retirement account.

This would add an additional financial incentive for consumers.

As a society we are smart enough to solve the problem of a dysfunctional healthcare system. The present course is unsustainable.

The future state’s business model with consumers responsible for their healthcare dollars and the patient physician relationship restored can achieve the goal of a sustainable healthcare system.

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

Please send the blog to a friend

“DCMS News: Special Message from the Dallas County Medical Society President

“DCMS News: Special
Message from the Dallas County Medical Society President