Stanley Feld M.D.,FACP,MACE

Obama Asks Nation for Input On Reforming Health System

‘We Want Your Exact Ideas,’ Daschle Says

I believe Tom Daschle and your healthcare team have preformed ideas on how to repair the healthcare system. Some are good ideas but most are poor ideas. The bad ideas will not work and only make things worse. Their business plan is rooted in an old paradigm. Your administration should change the business plan so that it enables patients to be responsible for their own health and their healthcare dollars.

Here are my exact ideas:

Let’s use common sense to create an innovative system to repair the healthcare system.

In my last letter to you I promised to describe the basic problems causing the dysfunction of the healthcare system. I have previously stated that all the stakeholders are at fault in causing the dysfunction. The biggest villain is the healthcare insurance industry. Government healthcare programs are dependent on the healthcare insurance industry to be the administrative service provider. The healthcare insurance industry’s lack of real financial transparency is the cause of major increases in healthcare costs.

The social contract in the healthcare system is between patients and physicians. If we did not have patients and physicians we would not need a healthcare system. Patients should drive and control the healthcare system. They should not be the victim of a dysfunctional system.

Patients should be responsible for their well being (health) and medical care. Presently, patients’ do not have incentives to be responsible for their health. This attitude can be changed by providing financial rewards for health maintenance. If patients owned their healthcare dollars and had the ability to keep the unspent money in a tax free retirement trust account patients would become skilled purchasers of healthcare. If patients had a pre existing illness and spent the required amount of money to avoid complications of their chronic disease they should receive a reward of additional money. There will be consumers who abuse the system but these outliers should be easy to spot.

Tom Daschle’s plan should be focused on letting patients own and control their healthcare dollars. If he could shift his focus to this concept your administration would be on the way to a solution to fix the system rather than extension of policies that are destined to fail. Massachusetts’ universal care system is a perfect example of healthcare policy that is destined to fail.

How do you get consumers have incentive to be cautious about their health and their healthcare dollar? If s were responsible for the first $6000 of their healthcare insurance dollar you would see a marked reduction in the costs to the healthcare system.

Your administrations should teach consumers how to spend their healthcare dollar wisely. You should also be concentrating on decreasing society’s hazards to our health in a serious way. This approach would be much better than creating a Federal Health Board that dictates access to care.

Repair of the healthcare system could be achieved by instituting my ideal medical saving account. The federal government would end up spending less money and improving care. Patients will be motivated to take better care of themselves. They would be motivated to shop for the best care rather than having care dictated by a panel of experts.

Your administration must create a system where patients are the deterrent to abuse in the healthcare system and not the government. Patients can do it more efficiently. Your administration can set the appropriate rules and regulations.

A recent article in the Journal of Clinical Endocrinology and Metabolism showed that 20% of hospital admissions have undiagnosed diabetes mellitus. These complications could have been prevented if the patients knew they had diabetes and knew how to control their blood sugars before the complications. This awareness could be achieved with the government promoting public service announcement and developing a system of cultural change. I referred to Mayor Blumberg’s subway campaign in my War on Obesity.

Physicians need to be put in a position where they compete for patients. This would result in better service and better care. Punitive damages imposed by your healthcare team will not encourage physicians to excel. It generates more anger and mistrust among your workforce (physicians).

How about some malpractice relief to decrease the national burden of defensive medicine?

How about some recognition for pursuit of excellence by ordinary practicing physicians? The practicing physician is your major workforce and not you academic experts who will be the judges in your Federal Health Board. Recognition is a non punitive way that will encourage physicians to excel.

How about medical informatics crafted as an extension of the physician’s care? Many physicians are opposed to internet information because there is so much junk on the internet. If the information came from the physician’s personal site it would be easier for physicians to put the patient’s disease into clinical perspective.

How about the government providing a universal Electronic Medical Record? The administrator can charge physicians by the click rather than physicians making a capital expenditure they cannot afford. E-prescribing capability should be provided in the same way. The federal government provided us with Electronic billing in the 1980’s and its implementation has worked well.

Money will be saved by creating a better system and not creating a more bureaucratic system.

I hope you will seriously consider implementing some of my suggestions and decrease the fixation on building a consensus without the practicing physicians’ input using the wrong ideas to create healthcare policy. These policies are destined to fail.

Stanley Feld M.D.,FACP,MACE

Many feel the healthcare system is so complex and dysfunctional that it is going to be impossible to repair. I have faith in the American system and the American people. I believe people are going to stand up soon and say enough is enough. We are going to force the government to help us help ourselves.

Winston Churchill said “You can always count on Americans to do the right thing – after they’ve tried everything else.”

I also believe American public is getting close to the point of demanding our elected officials make the correct rules to let us help ourselves.

Freedom of speech and freedom of the press has helped us solve many problems we have encountered in the history of America. The freedom to be creative and innovative drives us forward despite the complexity of any issue.

In healthcare we have all the technology and infrastructure necessary to do it right. I believe the internet and social networking will create the infrastructure for creating a competitive environment among the various secondary stakeholders.

Stakeholder vested interests naturally try to protect their products and services often to the determent of the general good. I am not criticizing the pursuit of a stakeholders’ vested interest. .

However, I am criticizing our elected officials’ resistance to make rules that will align everyone’s vested interest.

If a product or service is out of touch with the needs of the people it must not be permitted to survive. Obsolete companies have remade themselves with new products in order to survive. Companies not adjusting to the changing consumer demand simply must be permitted to disappear.

The healthcare system has many challenges. Eighteen percent of our gross national product (GNP) is spent in healthcare. Each year this percentage increases. Despite the increase in healthcare expenditures, access to physicians’ services is decreasing. Physician reimbursement is also decreasing.

Where is all of the money going if not to the physicians? Why do patients feel they are not receiving timely and appropriate care? Why is there an ever increasing shortage of primary care physicians while medical schools are producing more physicians yearly?

I have covered the answers to these questions previously. However, the politicians and the stakeholders in the healthcare system have not made any progress toward an answer to these questions or a solution to the problems. The problems of increasing cost, decreased access, affordable care, and avoidance of the complications of chronic disease have not been addressed in any logical way by any of our presidential candidates or candidates running for other offices.

Why? The solution to the Repair of the Healthcare System for each stakeholder varies with the differences in each stakeholder’s vested interest.

The primary stakeholders (patients and physicians) should be in control of the healthcare system. Patients should be responsible for their own care and their own healthcare dollar. Consumers should be subsided if they qualify for subsidy. The criteria for qualifying for subsidy must be clear and realistic.

Consumers with “adequate” healthcare insurance are not motivated to change behavior. Obesity, alcohol intake, and lack of exercise are increasing daily. Obesity is a major risk factor in precipitating chronic disease. The complications of chronic diseases are responsible for the expenditures of 90% of the healthcare dollars spent. This culture must be changed to make progress.

America food industries in pursuit of their vested interest do little to help fight the obesity epidemic. (See War on Obesity Part 1-7) The Fast food industry has not done anything to decrease the incidence of obesity. They have offered not so low calorie “salads” as a loss leader in order to look good in the eyes of the consumer. Cheap fast food containing an abundance of salt and fat contribute to the obesity epidemic and the high incidence of hypertension and diabetes mellitus.

Restaurants at all level serve large high calorie portions in order to raise prices while giving customers their money worth. When a company (TGI Fridays) tries to reduce the size of the portion while decreasing the price their volume of sales decreases.

The media has no interest in a public service campaign to discourage obesity. In having a successful public serviced campaign the media would lose a large share of their advertising revenue. The “open 24 hours” campaigns and the 99 cent meals are large revenue generators for the media. Two for the price of one fast food offers by all companies is endless.

The Supermarket industry is not interested in my War on Obesity because the “taste” of fatty food loaded with salt and sugar “taste” better than the non fat non salt non sugar food. Next time in the Supermarket notice the shelf space for cookies, soda pop, prepared foods and other fattening items.

The prepared foods in Supermarkets are not as healthy as advertised. They are convenient by loaded with fat and calories.

As a society, we have fallen for the organic food hype. The food costs a little more but it is healthy for you. Who said? Much organic food is loaded with calories and salt and promotes obesity.

National physicians’ organizations ( AMA,AAFP,ACP ect) have not helped its physician members’ help their patients stay healthy. Organized medicine has a terrific opportunity to step up and promote good health, fitness, and healthy habits community to community in a serious way. I’ll bet organized medicine could get physician volunteers from every community with a well organized and integrated public relations program. It would have to be sustained and awareness would have to be created at the political level, the social level, the educational level, and the corporate level to create the cultural change needed in society.

The environmental organizations are doing it and are becoming successful. Much of Corporate America wants to be known as a “Green Company” today in order to win the favor of the consumer.

Why hasn’t organized medicine stepped up to the plate? I know it could cite initiatives but how many have been transformational? Physicians want to keep their patients healthy. Organized medicine should help physicians with public service campaigns incorporating the grass roots physicians in order to change the culture of America’s health habits and health.

It would be a wonderful service for patients and physicians. It would also go a long way to reducing the costs of the healthcare system by reducing the incidence of chronic diseases and its complications.

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

Stanley Feld M.D.,FACP,MACE

It is easy for the presidential candidates to promise healthcare for all during a presidential election year. However this promise is made without testing reality. The reality is America can not afford to deliver healthcare to all. The country is having difficulty keeping its public hospitals open. These public hospitals are centers for last resort care.

“The prospects that Grady Memorial could close, and that Atlanta’s health infrastructure could crumble, have forced a civic re-examination of the region’s commitment to its least fortunate, a reckoning that has revived old antagonisms over race, power and class.”

“Some have suggested that Grady must compete for paying customers in Atlanta’s fierce medical marketplace, while others say that taxpayers should contribute more to continue its mission. Will Grady outsource, or simply downsize? And if it must downsize, which patients should be turned away?”

None of the presidential candidates have suggested viable solutions to the healthcare system’s problems. I think the Democratic Party wants its declared initiatives to fail. After the initiatives fail they will claim there is no other choice but universal healthcare system with the government as the single party payer. The failure of the proposed insurance paradigm is a back door entry to a single party payer system.

A recent Fortune magazine article said: “Medicare is poised to wreak havoc on the economy. And our presidential candidates are avoiding the issue.”

Alan Greenspan has been quoted as saying “the biggest threat to the American economy is Medicare. You’d think that the greatest threat to America’s economy would be Topic A for the presidential candidates. But it’s actually a topic they hate to touch.”

Instead, the great debate between Hillary Clinton and Barach Obama is to mandate universal coverage or not. If you require people to buy healthcare insurance using a defective healthcare insurance model all you will be doing is providing more customers for the healthcare insurance industry.

“An analysis of their speeches shows that last year Senators Hillary Clinton, John McCain, and Barack Obama would occasionally mention the Medicare mess. But recently, with the economy slowing and voters feeling insecure, all three candidates have turned more populist: Their economic talking points are about feel-good reassurances, not about facing hard realities.”

Americans should be suspicious of Sen. Clinton’s promises. I mention her because she has been the most vocal in diverting us from the reality of the government run healthcare systems mess.

“Unfortunately the day of reckoning is imminent. Sometime in the next President’s first term, Medicare Part A (hospital insurance) will go cash-flow-negative, and it’s all downhill from there.”

“Medicare services more than 40 million old and disabled Americans. As the country ages, Medicare and Medicaid will devour growing chunks of U.S. economic output.”

This is especially true if our obesity epidemic continues. Obese people are more prone to chronic diseases such as diabetes mellitus, hypertension and coronary artery disease.

If we institute universal coverage and single party payer the estimate of healthcare costs consuming 18% of our GNP will jump to 40% of our GNP by 2020.

“In 2070, when today’s kids are retiring, Medicare, Medicaid, and Social Security will consume the entire federal budget, with Medicare taking by far the largest share. No Army, no Navy, no Education Department – just those three programs.”

“Those estimates, reported in the latest Financial Report of the U.S. Government, assume that Medicare payments to doctors will be slashed drastically, by some 41% over the next nine years, as required by current law. It won’t happen. Every year for the past five years, Congress has overridden the mandatory cuts.”

It is obvious something has to change. The estimate of healthcare costs is base on a defect financial reporting by the US Government. The financial report admits these defects.

“As for future cuts, the Financial Report says drily, “Reductions of this magnitude are not feasible and are very unlikely to occur fully in practice.” So in reality, Medicare will go into the hole even faster than official projections reflect. And they show that if Medicare had to be accounted for like a company pension fund, it would be underfunded by $34 trillion.”

The Congress has been correct in its override of proposed Medicare cuts yearly. However, they have done it for the wrong reasons. I have been against the Medicare cuts to cognitive physicians. Medicare cuts do not solve the basic structural healthcare problems.

There are many other constructive solutions. These solutions include a War on Obesity, effective malpractice reform, encouragement of effective disease management and incentives for both patients and physicians to practice effective disease prevention and disease management to decrease the onset of complications of chronic diseases. The solution can only be accomplished with real price transparency by all the stakeholders, an ideal medical saving account, an ideal electronic medical record, and the creation of a system of competition so that the patients own their healthcare dollars and all the other stakeholders compete for their healthcare dollar. These elements of the solution can not be done piece meal. They have to be introduced and enacted as a complete package in order to be effective.

The solution proposed will probably never be enacted. The people (“People Power”) have to make the demand for effective change. There are too many powerful stakeholders who will lose and will not let effective change occur.

Physicians do an excellent job of fixing things that are broken. The government, corporate policies, patients, the healthcare insurance industry and physicians do little to prevent our bodies from becoming broken.
If Mr. Greenspan is correct and the healthcare crisis is “ the greatest threat to the U.S. economy and the candidates haven’t told us what they’d do about it, they haven’t told us a thing.”
The candidates should develop an understanding of the problems and viable solutions to the problems. However, they are avoiding them.

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

Stanley Feld M.D.,FACP, MACE

The following are additional solutions necessary for the Repair of the Healthcare System

• Develop Centers of Excellence and Focused Factories in both hospital based clinics and physician outpatient clinics to treat chronic diseases by a team of multi disciplinary experts using systems of care based on evidenced based medicine. Disease management systems can be developed in primary care physicians’ offices because there are not enough specialists to take care of all the patients with chronic disease. Treating chronic diseases this way should lower the complication rate for chronic diseases. The result should be a reduction in the cost of healthcare by at least 45%.

• Emphasis should be place on teaching the patient how to be the “professor of his disease”. Payment should be available to the Center of Excellence for this education.

• Promotion of and payment for early evaluation and recognition of chronic disease. It is essential to detect and prevent these chronic diseases early to prevent costly complications of these diseases.

• A sophisticated information system connecting medical care with financial outcomes. An ideal EHR should be made available to physicians on a per use basis so that the investment cost is not a burden to the physician. The information technology should be used as a learning tool for the physician to continually improve the quality of care and not as a weapon to penalize the physician. .

• Quality of care should be defined as whom to evaluate, how to evaluate, whom to treat, how to treat, how long to treat, how often the patient should be seen, how often the patient should be retested, and the measurement of adherence to medication. Measurement of quality should be all of the above. However, the key measurement of quality is the medical outcome as it relates to the financial outcome. If you prevent a $50,000 complication utilizing $1,000 of treatment you have a leveraged financial outcome as well as an excellent medical outcome. The main question is, “was the complication of the chronic disease avoided?” We are misguided when we start believing that measuring the percentage of our patients we measure cholesterol on, or the percentage of patients on whom we do colonoscopies or bone densities is a measure of quality of care. It is simply one element of quality medical care and it should not be rewarded as the Pay 4 Performance advocates are suggesting. This thinking makes us vulnerable to another false hope of reducing complications of chronic diseases.

• Increasing obesity in our population is a huge health risk. The government should declare war on obesity. It should strive to eliminate the many stimuli we are exposed to. It should institute a gigantic public media campaign to explain the health risks and the stimuli to overeat.

The most important need is to put the patient in charge of his disease management. The patient must be responsible for his care and in control of his health care dollar. We do not need more schemes destined to fail such as the California and Massachusetts mandates. We do not need the Pay 4 Performance scheme that will distort the healthcare system even further. We need some common sense infused into the development of a system that is driven by the patients and not the facilitator stakeholder for the purpose of the facilitator stakeholders’ bottom line.

If patients do not want to take care of themselves they will suffer medically and financially.
These are some of the solutions I have proposed. We need the political will and leadership to institute and execute these solutions. Responsibility for follow up care and compliance must be the patient. The physicians are the teachers educating patients to be experts in their disease self- management. In the present system the penalty to the patient is bad health. The new system should have a clear message of good health and financial reward. It is much cheaper for all the stakeholders in the long run.

The patient has to;
• Be responsible for the purchase of care.
• Have ready access to care.
• Be responsible for the appropriate adherence to care and medication regime given by the physicians.
• Be rewarded for excellent lifestyle changes and avoidance of complications of disease.

If this is accomplished, and it can be with appropriate leadership and the demand by the consumer, we can repair the healthcare system.