Permalink:

Did Americans Get Any Healthier Over The Past Decade?

January 10, 2010

inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

• Leave a comment

Stanley Feld M.D.,FACP,MACE

President Obama finally admitted that we are at war with terrorists. He said there are problems in the massive intelligence bureaucracy.

It “failed to connect the dots of intelligence.” If the agencies were coordinated Umar Farouk Abdulmutallab, a known terrorist, who paid cash for his ticket, did not carry luggage and did not have a proper visa would not have been permitted to board the plane to Detroit on Christmas Day.

It was not a failure to connect the dots. There are systems defects in the bureaucracy. The intramural politics of bureaucracies prevents important information from moving up the food chain.

Robert Baer makes this point clear in his book “See No Evil 1988”. The CIA does not have agents in the field that understand local politics.

.

The author, working in the Counter-Terrorism Center when it was just starting out, has an extremely important story to tell and every American needs to pay attention. Why?

“Because his account of how we have no assets that are useful against terrorism. There are four other stories within this excellent book, all dealing with infirmed bureaucracies.”

The administration’s response to the potential terrorist attack demonstrates Robert Baer point.

“The National Counterterrorism Center’s NCTC and CIA—have a role to play in conducting (and a responsibility to carry out) all-source analysis to identify operatives and uncover specific plots like the attempted December 25 attack. . . .”

The agencies were not coordinated and missed the obvious terrorist.

How does this relate to the Healthcare Reform debate?

The Democrats in congress and President Obama’s administration are about to pass a terrible healthcare reform bill. The bill misses the obvious. An example of an ineffective bureaucratic agency is the Healthy People Project

The goal of healthcare reform should be to help Americans receive effective healthcare. I have contended that increasing bureaucracy and the cost of maintaining a bureaucracy does not deliver better healthcare or make Americans healthier. President Obama’s healthcare bill expands government bureaucracy.

“ Worse, all of this bureaucracy is packed into a monstrous package without any regard to each other. The only thing linking these changes — such as the 118 new boards, commissions and programs — is political expediency. Each must be able to garner just enough votes to pass. There is not even a pretense of a unifying vision or conceptual harmony”

Real repair of the healthcare system is missing:

Real healthcare education,

Real cultural changes in eating and self responsibility,

Real enforceable food production legislation,

Real tort reform,

Real healthcare insurance reform,

Real chronic disease management systems education for both physicians and patients.

These real changes will help decrease the cost of medical care.

Unfortunately none of these changes are in President Obama’s healthcare reform bill. Instead there are 118 new boards, commissions, and programs doing its thing to generate reports and pilot studies.

Atul Gawande in a recent New Yorker article pointed out that President Obama’s healthcare reform bill offers pilot studies.

“So what does the reform package do about it? Turn to page 621 of the Senate version, the section entitled “Transforming the Health Care Delivery System,” and start reading. Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality? It does not. Instead, what it offers is . . . pilot programs.

Where we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude.”

I have pointed out in the past that poorly designed pilot studies are a waste of money.

Dr. Gawande tries to illustrate the potential value of a pilot study and justifies President Obama’s healthcare reform bill.

The federal government published preliminary results of the Healthy People Project health goals for the nation from 2000 to 2010. Its healthcare goals have not been achieved.

“There are more obese Americans than a decade ago and not fewer. We eat more salt and fat, not less. More of us have high blood pressure and diabetes. More of our children have untreated tooth decay, obesity and diabetes.”

The lack of control of these diseases result in their complications.

"We need to strike a balance of setting targets that are achievable and also ask the country to reach," said Dr. Howard Koh, the federal health official who oversees the Healthy People project. "That’s a balance that’s sometimes a challenge to strike."

This is bureaucratic jargon. It is one thing to ask the country to achieve these goals. It is another thing to get people to change their habits. The Healthy People Project has been in existence since 1980.

After more than 30 years, the goals aren’t well known to the public and only a modest number have been met.

“About 41 percent of the 1990 measurable goals were achieved. For the 2000 goals, it was just 24 percent. Worse, the nation actually retreated from about 23 percent of the goals.”

I would say this expensive bureaucratic pilot study was a failure.

Healthy People 2010 called for the percentage of adults who are obese to drop to 15 percent. In 2000, 25% of all adults were obese. Now, about 34 percent of adults are obese. Twenty eight percent of Americans had hypertension in 2000. Today 29% of Adult Americans have hypertension. The Projects goal was to reduce hypertension to 16%.

“To many health officials, simply making progress is a victory. An analysis of 635 of the nearly 1,000 targets for the past decade shows only 117 goals have been met. But progress was made toward another 332. In other words, there was improvement in 70 percent of the measures.

"That’s evidence of a healthier nati
on," Koh said.”

You have got to be kidding!! Is this what we want from President Obama’s Healthcare Reform bill, 118 new bureaucratic agencies? There is something wrong here.

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

Permalink:

Did Americans Get Any Healthier Over The Past Decade?

January 10, 2010

inUncategorized

• Leave a comment

Stanley Feld M.D.,FACP,MACE

President Obama finally admitted that we are at war with terrorists. He said there are problems in the massive intelligence bureaucracy.

It “failed to connect the dots of intelligence.” If the agencies were coordinated Umar Farouk Abdulmutallab, a known terrorist, who paid cash for his ticket, did not carry luggage and did not have a proper visa would not have been permitted to board the plane to Detroit on Christmas Day.

It was not a failure to connect the dots. There are systems defects in the bureaucracy. The intramural politics of bureaucracies prevents important information from moving up the food chain.

Robert Baer makes this point clear in his book “See No Evil 1988”. The CIA does not have agents in the field that understand local politics.

.

The author, working in the Counter-Terrorism Center when it was just starting out, has an extremely important story to tell and every American needs to pay attention. Why?

“Because his account of how we have no assets that are useful against terrorism. There are four other stories within this excellent book, all dealing with infirmed bureaucracies.”

The administration’s response to the potential terrorist attack demonstrates Robert Baer point.

“The National Counterterrorism Center’s NCTC and CIA—have a role to play in conducting (and a responsibility to carry out) all-source analysis to identify operatives and uncover specific plots like the attempted December 25 attack. . . .”

The agencies were not coordinated and missed the obvious terrorist.

How does this relate to the Healthcare Reform debate?

The Democrats in congress and President Obama’s administration are about to pass a terrible healthcare reform bill. The bill misses the obvious. An example of an ineffective bureaucratic agency is the Healthy People Project

The goal of healthcare reform should be to help Americans receive effective healthcare. I have contended that increasing bureaucracy and the cost of maintaining a bureaucracy does not deliver better healthcare or make Americans healthier. President Obama’s healthcare bill expands government bureaucracy.

“ Worse, all of this bureaucracy is packed into a monstrous package without any regard to each other. The only thing linking these changes — such as the 118 new boards, commissions and programs — is political expediency. Each must be able to garner just enough votes to pass. There is not even a pretense of a unifying vision or conceptual harmony”

Real repair of the healthcare system is missing:

Real healthcare education,

Real cultural changes in eating and self responsibility,

Real enforceable food production legislation,

Real tort reform,

Real healthcare insurance reform,

Real chronic disease management systems education for both physicians and patients.

These real changes will help decrease the cost of medical care.

Unfortunately none of these changes are in President Obama’s healthcare reform bill. Instead there are 118 new boards, commissions, and programs doing its thing to generate reports and pilot studies.

Atul Gawande in a recent New Yorker article pointed out that President Obama’s healthcare reform bill offers pilot studies.

“So what does the reform package do about it? Turn to page 621 of the Senate version, the section entitled “Transforming the Health Care Delivery System,” and start reading. Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality? It does not. Instead, what it offers is . . . pilot programs.

Where we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude.”

I have pointed out in the past that poorly designed pilot studies are a waste of money.

Dr. Gawande tries to illustrate the potential value of a pilot study and justifies President Obama’s healthcare reform bill.

The federal government published preliminary results of the Healthy People Project health goals for the nation from 2000 to 2010. Its healthcare goals have not been achieved.

“There are more obese Americans than a decade ago and not fewer. We eat more salt and fat, not less. More of us have high blood pressure and diabetes. More of our children have untreated tooth decay, obesity and diabetes.”

The lack of control of these diseases result in their complications.

"We need to strike a balance of setting targets that are achievable and also ask the country to reach," said Dr. Howard Koh, the federal health official who oversees the Healthy People project. "That’s a balance that’s sometimes a challenge to strike."

This is bureaucratic jargon. It is one thing to ask the country to achieve these goals. It is another thing to get people to change their habits. The Healthy People Project has been in existence since 1980.

After more than 30 years, the goals aren’t well known to the public and only a modest number have been met.

“About 41 percent of the 1990 measurable goals were achieved. For the 2000 goals, it was just 24 percent. Worse, the nation actually retreated from about 23 percent of the goals.”

I would say this expensive bureaucratic pilot study was a failure.

Healthy People 2010 called for the percentage of adults who are obese to drop to 15 percent. In 2000, 25% of all adults were obese. Now, about 34 percent of adults are obese. Twenty eight percent of Americans had hypertension in 2000. Today 29% of Adult Americans have hypertension. The Projects goal was to reduce hypertension to 16%.

“To many health officials, simply making progress is a victory. An analysis of 635 of the nearly 1,000 targets for the past decade shows only 117 goals have been met. But progress was made toward another 332. In other words, there was improvement in 70 percent of the measures.

"That’s evidence of a healthier nation," Koh said.”

You have got to be kidding!! Is this what we want from President Obama’s Healthcare Reform bill, 118 new bureaucratic agencies? There is something wrong here.

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

Permalink:

Did Americans Get Any Healthier Over The Past Decade?

January 10, 2010

inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

• Leave a comment

Stanley Feld M.D.,FACP,MACE

President Obama finally admitted that we are at war with terrorists. He said there are problems in the massive intelligence bureaucracy.

It “failed to connect the dots of intelligence.” If the agencies were coordinated Umar Farouk Abdulmutallab, a known terrorist, who paid cash for his ticket, did not carry luggage and did not have a proper visa would not have been permitted to board the plane to Detroit on Christmas Day.

It was not a failure to connect the dots. There are systems defects in the bureaucracy. The intramural politics of bureaucracies prevents important information from moving up the food chain.

Robert Baer makes this point clear in his book “See No Evil 1988”. The CIA does not have agents in the field that understand local politics.

.

The author, working in the Counter-Terrorism Center when it was just starting out, has an extremely important story to tell and every American needs to pay attention. Why?

“Because his account of how we have no assets that are useful against terrorism. There are four other stories within this excellent book, all dealing with infirmed bureaucracies.”

The administration’s response to the potential terrorist attack demonstrates Robert Baer point.

“The National Counterterrorism Center’s NCTC and CIA—have a role to play in conducting (and a responsibility to carry out) all-source analysis to identify operatives and uncover specific plots like the attempted December 25 attack. . . .”

The agencies were not coordinated and missed the obvious terrorist.

How does this relate to the Healthcare Reform debate?

The Democrats in congress and President Obama’s administration are about to pass a terrible healthcare reform bill. The bill misses the obvious. An example of an ineffective bureaucratic agency is the Healthy People Project

The goal of healthcare reform should be to help Americans receive effective healthcare. I have contended that increasing bureaucracy and the cost of maintaining a bureaucracy does not deliver better healthcare or make Americans healthier. President Obama’s healthcare bill expands government bureaucracy.

“ Worse, all of this bureaucracy is packed into a monstrous package without any regard to each other. The only thing linking these changes — such as the 118 new boards, commissions and programs — is political expediency. Each must be able to garner just enough votes to pass. There is not even a pretense of a unifying vision or conceptual harmony”

Real repair of the healthcare system is missing:

Real healthcare education,

Real cultural changes in eating and self responsibility,

Real enforceable food production legislation,

Real tort reform,

Real healthcare insurance reform,

Real chronic disease management systems education for both physicians and patients.

These real changes will help decrease the cost of medical care.

Unfortunately none of these changes are in President Obama’s healthcare reform bill. Instead there are 118 new boards, commissions, and programs doing its thing to generate reports and pilot studies.

Atul Gawande in a recent New Yorker article pointed out that President Obama’s healthcare reform bill offers pilot studies.

“So what does the reform package do about it? Turn to page 621 of the Senate version, the section entitled “Transforming the Health Care Delivery System,” and start reading. Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality? It does not. Instead, what it offers is . . . pilot programs.

Where we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude.”

I have pointed out in the past that poorly designed pilot studies are a waste of money.

Dr. Gawande tries to illustrate the potential value of a pilot study and justifies President Obama’s healthcare reform bill.

The federal government published preliminary results of the Healthy People Project health goals for the nation from 2000 to 2010. Its healthcare goals have not been achieved.

“There are more obese Americans than a decade ago and not fewer. We eat more salt and fat, not less. More of us have high blood pressure and diabetes. More of our children have untreated tooth decay, obesity and diabetes.”

The lack of control of these diseases result in their complications.

"We need to strike a balance of setting targets that are achievable and also ask the country to reach," said Dr. Howard Koh, the federal health official who oversees the Healthy People project. "That’s a balance that’s sometimes a challenge to strike."

This is bureaucratic jargon. It is one thing to ask the country to achieve these goals. It is another thing to get people to change their habits. The Healthy People Project has been in existence since 1980.

After more than 30 years, the goals aren’t well known to the public and only a modest number have been met.

“About 41 percent of the 1990 measurable goals were achieved. For the 2000 goals, it was just 24 percent. Worse, the nation actually retreated from about 23 percent of the goals.”

I would say this expensive bureaucratic pilot study was a failure.

Healthy People 2010 called for the percentage of adults who are obese to drop to 15 percent. In 2000, 25% of all adults were obese. Now, about 34 percent of adults are obese. Twenty eight percent of Americans had hypertension in 2000. Today 29%
of Adult Americans have hypertension. The Projects goal was to reduce hypertension to 16%.

“To many health officials, simply making progress is a victory. An analysis of 635 of the nearly 1,000 targets for the past decade shows only 117 goals have been met. But progress was made toward another 332. In other words, there was improvement in 70 percent of the measures.

"That’s evidence of a healthier nation," Koh said.”

You have got to be kidding!! Is this what we want from President Obama’s Healthcare Reform bill, 118 new bureaucratic agencies? There is something wrong here.

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

Permalink:

The House And Senate Bills Are Terrible Bills For Medical Care And The Economy. Part 5

November 21, 2009

inMedicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

• Leave a comment

Stanley Feld M.D.,FACP,MACE

I have asked readers to write to the President and their representatives. I have had several requests asking for an outline of the note. Below is a letter outlining the points to make if you oppose the bills in congress. The note should be sent to the President and your Senators and Representatives. The political party they belong too does not matter. If Congress receives 100,000 letters it might understand the sentiment of the people it is suppose to represent.

All you have to do is copy the text and paste it into an email to the President and your representatives. The email address can be found at;

http://www.whitehouse.gov/CONTACT/

https://writerep.house.gov/writerep/welcome.shtml

http://www.senate.gov/general/contact_information/senators_cfm.cfm

Dear Representative, Senator, or President Obama

I am asking Congress and the administration to use common sense to repair the healthcare system. Enough is enough. The Democratic dominated Senate and House have constructed bills that will increase spending, increase the deficit, increase bureaucracy, increase government power over our lives and decrease our freedom of choice.

The Democratic controlled Congress continues to use creative bookkeeping to present bills it claims are budget neutral. The claim is fooling no one. Despite all the protests, Congress is ignoring the will of the people.

The universal healthcare strategy in Massachusetts has failed. President Obama’s healthcare strategy (with similar defects as the Massachusetts plan) with fail and cost the nation dearly.

The healthcare policies in both bills will not achieve the goals of universal care, affordable care and increasing the quality of care. It will commoditized medical care and destroyed the patient physician relationship. I am afraid the President and congress are about to compound past errors in healthcare policy at a very high cost to taxpayers and our economy.

Our present problems in the healthcare system are the result faulty regulations piled upon faulty regulations in an attempt to correct the previous defects. Stakeholders have been driven to adjust to these faulty regulations to protect their vested interests. These actions have lead to ever increasing costs and more defects in healthcare policy.

Willie Sutton (bank robber) told us to go where the money is. In healthcare the biggest waste of money is in:

Healthcare insurance industry administrative services waste and healthcare insurance industry abuse; The wastes amounts to $200 billion dollars per year. Appropriate rules and regulations could eliminate the problem of administrative services waste. The public option will not eliminate the administrative services waste. It will add to it. http://www.lijit.com/search/stanleyfeld?type=blog&q=administrative+cost+and+the+healthcare+insurance+industry&x=0&y=0

Ineffective chronic disease management: 80% of the healthcare dollars spent ($1.6 trillion dollars per year) is spent on treating the complications of chronic disease. These diseases include hypertension, diabetes mellitus, asthma, osteoporosis, and obesity. CMS estimated that the cost is even higher at 90% of the healthcare dollar spent for chronic disease complications. The obesity epidemic across all age groups. It is going to bankrupt us all. There is in the bills to combat the obesity epidemic. http://www.lijit.com/search?uri=http%3A%2F%2Fwww.lijit.com%2Fusers%2Fstanleyfeld&start_time=&p=g&view_id=tT5oCgpkPEUAABEzQ0UAAAAh&q=chronic+disease+management&x=0&y=0
Defensive medicine: As a result of the malpractice systems in many states the cost of defensive medicine is somewhere between $460 billion and $750 billion dollars a year. Putting a cap on malpractice awards and appropriate education of physicians and consumers could eliminate the $750 billion dollars of unnecessary expense. The is nothing in the bills that addresses the malpractice reform issue. http://www.lijit.com/search?uri=http%3A%2F%2Fwww.lijit.com%2Fusers%2Fstanleyfeld&type=blog&q=defensive+medicine+and+malpractice+reform&x=0&y=0

A universal electronic medical record is essential to reducing healthcare costs. Lack of a universal EMR costs the healthcare system at least 100 billion dollars a year in medical errors and duplication of testing.

The $30 billion dollar subsidy in the economic subsidy package will not solve the problem. The average physician’s cost for a universal record is $60,000 dollars. A $20,000 dollar subsidy does not help many primary care physicians afford an EMR.

A universal electronic medical record could be distributed by the government free of charge. Physicians would be charged by the click for its use. EMR software and maintenance service fees would be included. Presently less than 10% of physicians and hospital systems have fully functional EMR’s. http://www.lijit.com/search?uri=http%3A%2F%2Fwww.lijit.com%2Fusers%2Fstanleyfeld&type=blog&q=ideal+electronic+medical+records&x=21&y=8

The administration should be going to where the money is rather than developing a more complex bureaucracy with increased potential for waste and abuse. Repair of the healthcare system should be consumer directed with the help of the government and not government directed.

Instead the President and Democrats controlled congress will increase taxes and out of pocket expenses for everyone. The taxes will be imposed four years before the benefits are instituted in order to decrease the real deficit spending. During a recession penalties imposed on employers will decrease employment. The only job growth in this recession so far has been government related or government created jobs. The tax increases will lengthen the recession and inhibit job creation and innovation.

The bill will decrease freedom of choice, result in an increase in rationing of care and intensify the doctor shortage.

Please listen to the people who elected you.

Please do everything in your power to fix what is broken and not destroy our innovative spirit and inhibit our freedoms.

Sincerely

Please write to the President, your Representatives, and Senators before it is too late. The Democratic controlled government has decided to ram this bill through without bipartisan participation. You can stop them one vote at a time.

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

.

Permalink:

President Obama Says “Healthcare Will Not Be Rationed”

August 4, 2009

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

• Leave a comment

Stanley Feld M.D.,FACP,MACE

Rationing of healthcare services is not new. Medicare presently rations healthcare services. Private healthcare insurance also rations healthcare services. Physicians and patients need medical preapproval for tests, surgery and specialty consultations. If a physician wants a patient to have a simple CBC (complete blood count) and the reason for the test is not documented by an appropriate code the government and the healthcare insurance industry does not allow the charge.

Physicians’ offices spend hours trying to get preapprovals for their patients from people who are trained to look up indications for procedures on a computer.

This week President Obama has denied that his healthcare reform bill will ration healthcare services. The facts of HR 3200 and his own speeches contradict his statement. In his speech to the American Medical Association, President Obama said

“The only way to control health care costs is to get doctors to provide less care — fewer tests, fewer procedures, fewer everything. Of course, the Administration wants to eliminate only that care that is "unnecessary."

Who will determine what is unnecessary? The government will with President Obama’s healthcare reform bills!!

Ezekiel Emanuel M.D. .a medical ethicist, (Rahm Emanuel’s brother and President Obama’s medical advisor) has defined unnecessary in his book and papers. President Obama’s Office of Management and Budget Director Peter Orszag has agreed.

Peter Singer, a medical ethicist, had a long article in the New York Times magazine section defending the fact that healthcare must be rationed.

The Administration has determined that neither you nor your physician should be the judge of the treatment you need. The government will tell physicians how it wants them to practice medicine.

The government, in an attempt to avoid blame for healthcare rationing, plans to set up an independent group of “experts” to set reimbursement fees or not allow payment for services it deems unnecessary. If a physician disagrees with the “experts” because the “experts” might not have all the facts the physician can appeal.

The process will be inefficient. It will generate waste and is doubtful it will improve care.

“ The Administration is asking for independent authority to set reimbursement fees for all providers under Medicare. To assist in this effort, the Administration is proposing a new federal health board to decide whether health care services are "effective" or "appropriate."

The Obama administration has concluded that the best way to discourage "unnecessary care" is not to pay for it. Who is liable for not delivering “unnecessary “ care that might be necessary and life saving? The government is not liable according to HR3200. Malpractice reform for physicians and patients is not to be found in President Obama’s healthcare reform bill. Yet $750 billion dollars are wasted on defensive medicine.

The administration’s new proposal represents an increase in regulations and in turn an increase in healthcare services rationing.

If healthcare is to be rationed how should it be rationed?

The administration’s answer is defined by Dr. Emanuel’s philosophy.

He advocates a system he calls a complete lives system. The complete lives system discriminates against the elderly.

“Emanuel advocated allocating health resources in order to maximize collective life years. He justifies denying care to elderly patients in the following way. Suppose a 25-year-old and a 65-year-old have a life threatening disease. Since the 25-year-old has many more potential years of life ahead of him, he should receive preferential treatment, says Emanuel.”

Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years. Dr. Emanuel has said health services should not be guaranteed to "individuals who are irreversibly prevented from being or becoming participating citizens."

Think about Ted Kennedy. Think about the treatment he is receiving to save his life. Who is paying for it? Is the government paying for his treatment with Medicare Part C? Should he be denied treatment by a panel of “experts” when his prognosis is so terrible and he has already lived a full and productive life? If Ted Kennedy believes in his own bill shouldn’t he stop treatment that might to save his life? Should he have freedom to choose to live or die? Will Ted Kennedy be a productive citizen in the future?

My view is the individual should decide on his treatment along with his trusted physician. The government position should be to provide patients with appropriate education so they can choose the best treatment options. The government should provide funds for physician education to teach the best treatment options. The government should not decide for us.

Peter Clinch of Silver Springs, MD says it all in the comment section of Peter Singer’s article

“Health care, like all finite resources in the universe, is rationed today and will be rationed in the future. The question is who should be doing the rationing. In a society that respects life and values freedom, that task is best left to a marketplace of individuals making decisions for themselves, which is why health care reform should focus on decentralizing health insurance, not socializing it. Americans should be able to make decisions for themselves as to how much of their resources today they want to set aside for insurance that they may need in the future. To surrender our freedom and dignity to power-hungry central planners in exchange for lofty Utopian promises is an act that will mark us for generations to come as well-meaning but misguided fools”

President Obama, why don’t you attack the healthcare system’s real problems?

You should be concentrating on real malpractice reform and eliminate the need for defensive medicine, administrative waste, the large administrative service fees paid by outsourcing healthcare administration to the healthcare insurance industry, real price transparency, effective electronic medical records and e-prescriptions legislation, real chronic disease management, and public service advocacy to reduce obesity.

This is where government intervention can be effective in reducing costs to the healthcare system. Don’t continue to impinge on Americans’ freedoms. Americans will not tolerate it and you will have lost your opportunity to Repair the Healthcare System.

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

Permalink:

Medicare is Not Cheap For Either Seniors Or The Government: Part 3: The Real Issues Needed To Be Solved To Reform The Healthcare System Reform

July 5, 2009

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

• Leave a comment

Stanley Feld M.D.,FACP,MACE

President Obama is pushing a healthcare reform plan that will fail. However something has to happen and he is creating a populous uprising.

The reason it will fail if his healthcare reform plan is passed is the government cannot afford to pay for Medicare coverage for all. . Expanding coverage to the entire population will create bigger unsustainable defects in addition to the present unsustainable defects for seniors.

Private corporations and small businesses cannot afford to pay for private healthcare insurance coverage either. It is looking for a way to unload their private insurance obligation. The public option will be a way to do it.

This is the dilemma. The present public debate is not discussing the real issues. Healthcare coverage should be universally available at an affordable cost and be high quality. There is no argument with President Obama’s goals. The route he is taking will increase bureaucracy, decrease efficiency of medical care, restrict access to care, decrease quality of care and increase the cost of care. It will also increase government control over healthcare delivery and decrease patient choice.

What are President Obama’s options for reducing the cost of healthcare coverage if he gets his proposal passed?

a. Reduce the medical care coverage to patients

b. Ration care

c. Increase the patient deductible costs

d. Increase patients premiums

e. Decrease payment to physicians and hospitals

f. Decrease administrative waste

g. Decrease profits of healthcare insurance companies who will be the government’s administrative service provider. .

h. Decrease unnecessary medical treatments. Who decides what is unnecessary?

Other options not on the table

i. Develop a plan for end of life ethical decisions. Politicians are not interested in discussing this issue.

I wonder what Ted Kennedy’s bill will be and who will be paying it?

j. Decrease defensive medicine practices by instituting effective tort reform. President Obama said he is not considering this and received boo’s at the AMA meeting. He believes the lawyer claim that the cost is insignificant.

k. Decrease physicians’ overhead by decreasing rent, paperwork, committee meetings and needed full time employees for the excessive administrative work.

The government should develop an ideal electronic record and charge users by the click. Upgrades and maintenance would be free. It would create a completely functional EMR. President Obama 50 billion dollar plan will make vendors rich and have little impact on electronic medical record development.

l. Decrease Healthcare insurance industry’s administrative waste. It will not occur in a non price transparent and cost transparent environment.

m. Decrease patient abuse or the healthcare system.

n. Fund effective chronic disease management program.

There is no plan for re-teaching physicians how to run chronic disease management programs. A few poorly designed studies outsourced chronic disease management to proprietary disease management companies. The failed to report improvement in outcomes because they were not extensions of the primary physicians care.

o. Define responsibilities in the therapeutic unit (physician and patient). Patient physician contracts for chronic disease.

Who is responsible for the defects in the healthcare system leading to increased costs?

I believe these are the key questions to ask. Once answered, systems can be set up to correct the defects. The easiest group to blame is physicians. They are the least organized, the least effective lobbying group and the least generous to politicians.

1. Who is responsible for obesity?

Patients become obese by overeating and under exercising. Food industry by producing cheap high caloric value processed food. Government through subsides encourages food industry and farm industry to produce these food. There is little public service campaign to discourage obesity.

2. Who is responsible for AID’s infection?

Patients by sexual habits and behavior. Government has conducted public service education campaign that has encouraged effective prevention but has not been intense enough.

3. Who is responsible for drug and alcohol addiction?

Patients are responsible for their behavior. There are no public service campaigns that discourage this behavior. Many of our entertainment icons encourage the masses misbehavior.

4. Who is responsible for smoking?

Patients are responsible for this behavior. Government has been effective in promoting a non smoking policy. The tobacco companies have gotten around government efforts. Agricultural policy has not discouraged tobacco growth.

5. Who is responsible for air pollution leading to chronic lung disease, asthma and lung cancer?

The government is with its lack of a coherent environmental policy. The bill passed by the House of Representatives does not decrease pollution. It increases the cost to pollute. It is defective in have many negative exceptions.

6. Who is responsible for the epidemic of Diabetes Mellitus, lung disease, end stage renal disease, and osteoporosis?

All the stakeholders with the government most responsible for not having a positive health policy

6. Who is responsible for the high cost of insurance?

The healthcare insurance industry with the nature of its price structure, the practice of defensive medicine by physicians, the patients with first dollar coverage, the government by not enforcing regulations.

The Obama administration is focused on the wrong reforms. It is talking about expanding a broken non functioning system. All the actions by the various stakeholders are driven by perverse incentives. All of these perverse incentives are driven by economics. The economic morass has evolved since the introduction of Medicare in 1965. Most political decisions are driven by vested interests protecting their economic interests.

In order to create an affordable and functioning healthcare system for all, President Obama and his team should be discussing how to align all the stakeholders’ vested interests so all are satisfied with the economic outcomes. The consumers are the primary stakeholder. The systems should be built to empower the consumers. President Obama should be focused on decreasing these factors and issues that stimulating our excessively expensive and dysfunctional healthcare system.

With his stimulus program for electronic medical records and his proposed healthcare plan he is throwing good money after bad. The money will be wasted and the healthcare system will not be improved. More people will be covered by healthcare insurance. The healthcare insurance coverage will be restricted by the government as a third party and not by the patients. Less medical care will be available and that will be bad.

I discuss most of these issues and the solutions in my blog http://stan.feld.com. The summary blogs are at http://stanleyfeldmdmace.typepad.com/repairing_the_healthcare_/2009/06/summary-blogs-to-repair-the-healthcare-system.html

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

Permalink:

“Rope A Dope”

June 10, 2009

inIn Store Clinics, Medicine: Healthcare System, Politicians,Healthcare and Vested Interests, Stakeholder Abuse of the Healthcare System, Stakeholder Mistrust

• Leave a comment

Stanley Feld M.D.,FACP,MACE

There are many issues involved in healthcare reform. The major issues to decrease defensive medicine with malpractice reform, rapid affordable installation of electronic health records, control of the obesity epidemic, effective chronic disease management and a change in the healthcare insurance model are not on the radar screen of the President or Congress.

The issue with effective healthcare reform is about money. In order to save a significant amount of money the above problems must be solved. As President Obama plan progresses in the congress the battle is all about political tactics and positioning for the midterm elections in 201

“On the one hand, President Obama and his party say they’re hoping to strike a good-faith compromise on health care. On the other, they’re threatening this "budget reconciliation" maneuver to coerce Republicans into rubber-stamping liberal policy.”

The Democrats want to get a handful of GOP Senators to support the bill before in gets to the floor. The goal is to short circuit a bloody debate before it begins. The Democrats are to join their fold. Chuck Grassley, Orrin Hatch, Susan Collins and Olympia Snowe voted for expanding the state children’s insurance program (Schip).

SCHIP was a compassionate bill and logical. However it is a bill that does not create patient incentives. It is difficult to imagine Republicans defecting to the poorly constructed bill that will created greater costs and more dysfunction to the healthcare system.

“This new entitlement — like Medicare but open to all ages and all incomes — would quickly crowd out private insurance as people gravitated to heavily subsidized policies, eventually leading to a single-payer system. So Democrats are trying to seduce diffident Republicans with a Potemkin compromise.”

All the the Democrat’s rhetoric in nonsense. Without a change healthcare insurance healthcare costs will continue to rise . We need only to look at the Massachusetts experience.

The administration is prepared to make promises to Republican such as the government healthcare plan would only be sold to the uninsured and small businesses that can not afford to provide employees with healthcare insurance because of the costs. Once the Republicans on on board and the bill is past the administration could modify this proposal and make it all inclusive.

“ The White House strategy is to dilute the healthcare plans proposal just enough to win over credulous Republicans. That is what has always happened with government health programs:”

President Obama is playing a game of got uh. Some one wrote to me and called it Rope A Dope.

“When Medicare was created in 1965, benefits were relatively limited and retirees paid a substantial percentage of the costs of their own care. But the clout of retirees has always led to expanding benefits for seniors while raising taxes on younger workers”.

Medicare’s cost to seniors has also risen with a base month cost of $99 per month per person or $2400 per year per couple. The catch is the deductible are $999 for hospital admission and and 80/20 deductible. The monthly payment per person is means tested and can go to $275 per month per person with after tax dollars. The a senior has to by Medicare Part F for deductible coverage. Its cost is 170 per month per person. Medicare Part D at it least expensive is $47 per month per person with high deductible.

In order to get full coverage the cost can be as high as $15,000 per year in after tax dollars.

Congressional actuaries expected Medicare to cost $3.1 billion by 1970. Medicare today costs $455 billion and rising.

Medicaid was intended as a last resort for the poor. It now covers one-third of all long-term care expenses in the U.S.. Its annual bill is $227 billion, and so far this fiscal year is rising by 17%.

Over time end stage renal disease and disabled person have been added to the Medicaid roles Other person also have been included.

“SCHIP was pitched a decade ago as a safety net for poor kids, and some Republicans helped sell it as a free-market reform. But Schip is now open to families that earn up to 300% of the poverty level, or $63,081 for a family of four. In New York, you can qualify at 400% of poverty.”

A common denominator to all of this unsustainable increases is the way the healthcare insurance industry controls the healthcare dollars. This leads to abuse by other stakeholders. Incentives must be aligned with the consumer controlling their healthcare dollars.

The Lewin group estimates that 119 million more persons with private insurance could be added to the 90 million already on Medicare and Medicaid. Health habits must be changed to combat obesity. The only way it will be changed is a change in farm policy and the consumers owning their healthcare dollars. Otherwise we are doomed to every increasing premiums and overuse of the healthcare system.

Any new federal health plan will inevitably follow the same trajectory, no matter how much Republican Senators might claim they’ve guaranteed otherwise.

President Obama is going to mount a public opinion campaign for his plan. The Republicans are going to cave in. They are trapped

Republicans would spend the rest of their days deciding whether to vote for tax increases to finance this, or stand accused of denying health care to the middle class.

President Obama will have successfully “Roped A Dope” Who is the Dope? All of us unless we get wise quickly.

The only way to Repair the Healthcare System is to enable consumers to own their healthcare dollars and to provide incentives to consumers to be responsible for their health. The government should make the rules to level the playing field and empower consumers to drive the healthcare system to their benefit.

These actions allow healthcare affordable to all including the government.

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

Permalink:

You Can’t Change The Practice Of Medicine With Demand-Side Reforms. Let Us Put An End To Pay For Performance (P4P) Initiatives: Part 1

January 25, 2009

inChronic Disese Management, Consumer Driven Health Care, Medicare, Medicine: Healthcare System, Pay for Performance (P4P), Quality medical care measures, Stakeholder Mistrust

• Leave a comment

Stanley Feld M.D.,FACP,MACE

I
have pointed out the folly of P4P initiatives as a methodology for improving the
quality of medical care. Quality
medical care has not been adequately defined. One definition could be to
maintain health at the lowest cost. Physicians have classically been trained to
fix things that are broken. The paradigm shift has been to prevent things from
becoming broken.

Prevention
is a two way street. It is the patient who needs to prevent disease from
occurring. It is the physician who must teach the patient how to prevent disease
and its complications.

Punitive
measures will not encourage behavior change. The economist, John Goodman,
stated: “You
can't change the practice of medicine with demand-side reforms.” I have
said repeatedly it can only be changed with innovative and incentive driven
education for both patients and physicians. This will lead to behavior change
and a true increase in quality of care.

Quality medical care should not be judged on what tests are done for a
particular chronic disease in a given year. It should be judged on the basis of
maintenance of health of a patient with chronic disease. It should be evaluated
as a dual responsibility of both the patient and physician. If there is going to
be an increase reimbursement for performance, performance has to be judged
correctly and both physician and patient should be rewarded.

Quality medical care should be judged on the maintenance of health and
avoidance of the complications of chronic disease. The treatment of the
complications of chronic disease utilizes 80% of the healthcare dollar. If
complications of chronic disease are avoided the costs to the healthcare system
costs would be decreased to manageable levels and Americans would be healthier.

Several readers have challenged me on the use of the term “socialized
medicine”. One reader said “our healthcare system is socialized already. The
government through Medicare and Medicaid controls 40% of the expenditures for
healthcare.” This is true.

The term “ socialized
medicine” has been demonized. I believe most physicians’ and patients’
objection to “socialized medicine” is rooted in experiences they have had. It
has restricted access to care and freedom of choice, and it has dictated
permissible care of physicians. It has also produced an added layer of
inefficient bureaucracy.

Medicare
premiums for patients are becoming expensive. The premium is determined by
means testing. It can be as high as $14,000 per year. The government subsidizes
that amount with an additional $6,600. Medicare advantage costs the government
over $9,000 extra. Yet there is a decrease in access to care as the costs of
the system are spinning out of control.

The government has its heart in the right place in wanting to provide
universal care. Americans should have access to healthcare coverage. A few
changes in the tax rules can solve many problems. The self-employed should be
able to purchase healthcare insurance with the same pre tax dollars as
businesses. They should have the same negotiated price structure large companies
have. The self-employed should have the same guaranteed insurability as those
working in a large company without a premium penalty.

The healthcare system’s costs rise each year. The Medicare premiums rise each
year and patient’s out of pocket expenses rise each year. Medicare is going to
bankrupt the country. It will only be accelerated by putting everyone on
Medicare.

In order to reign in expenses someone came up with the idea of pay for
performance. It is a reasonable concept if a system could be devised that could
evaluate performance accurately and encourage improvement.

In order to test validity of any concept the government subsidizes
initiatives at a great expense. These initiatives are costly because of the
bureaucratic evaluation of the requests for proposals and the measurement
mechanism.

The list of government initiatives is long. The pilot studies are 3 to 5
years. There have been many cost overruns so that several outsourced study
vendors are dropping out of the management of the initiatives. Most initiatives
have been unsuccessful in proving cost savings.

The reason for lack of proof of cost saving to the healthcare system is
because of errors in design. The wrong questions are being asked and the imposed
bureaucracy is punitive to the healthcare entities. Below are initiatives that
are presently funded for pay for performance.

MEDICARE "PAY FOR PERFORMANCE (P4P)" INITIATIVES

“Medicare has various initiatives to encourage improved quality of care in
all health care settings where Medicare beneficiaries receive their health care
services, including physicians’ offices and ambulatory care facilities,
hospitals, nursing homes, home health care agencies and dialysis
facilities.”

HOSPITALS

1. Hospital Quality Initiative (MMA section 501(b))

2. Premier Hospital Quality Incentive Demonstration

PHYSICIANS OR INTEGRATED HEALTH SYSTEMS

1. Physician Group Practice Demonstration (BIPA 2000)

2. Medicare Care Management Performance Demonstration (MMA section
649)

3. Medicare Health Care Quality Demonstration (MMA section 646)

DISEASE MANAGEMENT/CHRONIC CARE IMPROVEMENT

Chronic Care Improvement Program (MMA section 721)

ESRD Disease Management Demonstration (MMA section 623)

Disease Management Demonstration for Severely Chronically Ill Medicare
Beneficiaries (BIPA 2000)

Disease Management Demonstration for Chronically Ill Dual Eligible
Beneficiaries

Care Management For High Cost Beneficiaries

So far the chronic disease management initiative have not been proven to save
money.

The pilot initiatives are not directed by physician in private practice.
Physicians are the stakeholders that will make these initiatives work. Nine
sites selected are either healthcare insurance companies or disease management
groups. Disease management groups can be successful facilitators of physician
care only if they are extensions of physicians care rather than physician
substitutes.

Help desks of the healthcare insurance companies do not work because they are
not an extension of the physicians care. Free standing chronic disease
management clinics do not work because they are not extensions of physicians
care. Many hospitals have tried to set up Diabetes Education Centers only to
have them close because physicians do not refer patients to the centers. The
center is not reimbursed adequately by the government or private insurers to be
profitable. The fees charged in hospitals are at least twice as much as the fees
the physicians charges. Once the physician knows the charges he is even more
hesitant to send the patients to the centers.

The following are the groups selected for the pilot phase: Humana in South
and Central Florida, XLHealth in Tennessee, Aetna in Illinois, LifeMasters in
Oklahoma, McKesson in Mississippi, CIGNA in Georgia, Health Dialog in
Pennsylvania, American Healthways in Washington, DC and Maryland, and Visiting
Nurse Service of NY and United Healthcare in Queens and Brooklyn, New York.

I believe we should give up on trying to produce a pay for performance system
that will reduce medical costs. The health policy wonks should concentrate on
something that will work.

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

Permalink:

The Therapeutic Magic Of The Physician Patient Relationship: Part 2

December 30, 2008

inUncategorized

• Leave a comment

Stanley Feld M.D.,FACP,MACE

The role of patients with chronic diseases and their physicians must be clear to both patients and physicians. Physicians are coaches. Patients are players. They live with their disease 24 hours a day. Day to day fluctuations occur in the management of chronic disease. An excellent example is patients with hypertension. Blood pressure fluctuates all day long. A single blood pressure measurement during a visit to a physician once every six month is meaningless. Patients must continually monitor their blood pressure to evaluate the effect of their medication. Physicians have to help patients evaluate these data points to make logical medication adjustments.

Patients must to be inspired to manage their chronic disease. This requires patients having confidence in their coaches. It is hard work for patients to monitor their blood pressure daily and learn the meaning of the fluctuations in their blood pressure.

Only day to day blood pressure control is going to prevent the complications of a stroke or a heart attack. Physicians along with the patients’ input must make the necessary adjustments. An effective physician and patient team can make appropriate day to day adjustments.

This idea of mutual trust and confidence between coach and player is illustrated by something that happened between a teacher and me in high school. It illustrates the essence of an effective physician-patient relationship.

It was a rainy day in the spring of 1953 during my junior year in high school. I was on the high school baseball team. The team could not practice that afternoon because of the weather. The team was sent to the Study Hall for the 8^th period.

Ms. W. was one of the 8^th period Study Hall teachers. She was my geometry I and II teacher. I thought she was the greatest. I never missed a question in class or on a test. She came over to me that rainy spring day to say hello. She asked how I was doing in trigonometry.

I told her I was doing terrible. I could not learn a thing from Mr. B. Mr. B. was the chairman of the math department. He taught trig very descriptively. It had no meaning to me. He did not teach us to understand the logic of trigonometry and its uses. No matter how much I tried to derive meaning from the text book by myself the material covered did not stick. I felt Mr. B. suppressed my ability to learn and problem solve. His goal was to have us memorize the material.

Mrs. W. asked me which period I had trigonometry and lunch. I told her trig 5^th period and lunch 6^th period. She said great she taught trig 6^th period and could get me transferred to her class. I could have lunch 5^th period.

I was thrilled beyond belief. She also said she hoped I was aware there was a departmental quiz being given the next day. I would be required to take it. She said the chances are I would do poorly on the test but she encouraged me to study when I got home.

The most amazing thing happened that night when I started studying for the quiz. All of a sudden I grasped concepts I could not grasp previously. Now that I was in Mrs. W. class I solved problems I could not solve previously. A difficult textbook seemed easy.

The next day I went into her trigonometry class, took the test, and got 100%. I know this has happened to all of us at some time in our life. I know it was the result of my knowing that someone had trust and confidence in me and the conviction that I could do the job.

The magical therapeutic power of the patient physician relationship.

If a relationship is positive with mutual respect and commitment by physicians and patients, patients can learn about the pathophysiology of their chronic disease. In turn they can learn to manage their disease properly.

In practicing endocrinology I developed a patient physician contract to define this patient physician relationship. My son, Daniel, alluded to this contract in his letter to me.

Physicians must be dedicated to teaching patients to be the professor of their disease. Physicians must enable patients to want to be the professor of their chronic disease to avoid the complications of the disease. Eighty percent of the healthcare dollar is spent on the complications of chronic disease.

The lesson of Mrs. W. is a powerful lesson. Mrs. W. did enable me to be comfortable and confident in my learning situation because of her trust. She empowered me to learn by myself with her confidence in me.

Many times patients with a chronic disease are frightened by their disease. This fright makes it difficult to learn how to control their disease to avoid its complications. Physicians must deal with this through a positive physician patient relationship. A positive patient physician relationship can make it easier for patients to learn to control their disease.

Converting healthcare into a commodity is discouraging physician-patient relationships. The healthcare system cannot be repaired without effective chronic disease management. Chronic disease management will not be effective without effective patient-physicians relationships.

AACE Diabetes Guidelines, Endocr Pract. 2002;8(Suppl 1)
a. Sample Patient-Physician Contract
I understand that if I agree to participate in the System of Intensive Diabetes Self-Management, I will be expected to do
the following:
1. Dedicate myself to getting my blood glucose level as close to normal as possible by following the instructions of the
diabetes self-management team
2. Regularly visit the clinic for a physical examination, laboratory tests, and nutrition counseling; follow-up visits will
be scheduled every 3 months or more frequently if deemed necessary by my physician or other members of my
health-care team
3. Bring a detailed 1-day food record to each follow-up visit, provide necessary nutrition information for me and my
dietitian, and adjust my eating habits to meet the nutrition goals established by my dietitian
4. Use medications as prescribed by my health-care team
5. Monitor my blood glucose levels at home as instructed and bring the results to each follow-up visit
6. Follow my prescribed exercise plan
7. Obtain identification as a patient with diabetes, for prompt assistance in case of an emergency
8. Ask my physician and other members of my health-care team to explain any aspect of my care that I do not entirely
understand
I understand that if I do not monitor myself carefully, there is a risk of hypoglycemia.
I also understand that if I do not strive to normalize my blood glucose, I am at increased risk of developing the
complications of diabetes mellitus.
My signature indicates that I have read and understand the above agreement.
__________________________________________
Patient
________________
Date
I agree to provide the leadership for the diabetes self-management team. Team members will be available to answer
your questions and help you self-manage your diabetes. I will continue to encourage you to maintain the best possible
control of your diabetes.
__________________________________________
Physician
________________
Date