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The False Promise of Electronic Medical Records (EMR)

March 12, 2013
inDisinformation and the healthcare system, EMR, Information Technology in Healthcare, Medicine: Healthcare System
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Stanley Feld M.D. FACP,MACE

The
promise of the Electronic Medical Record (EMR) is fading for physicians and
patients. The EMR was supposed to reduce the cost of medical care, improve
quality of care, improve physician communications, reduce duplicate testing and
improve efficiency of care.

In
2009 President Obama declared that EMRs,

  “would
save some $80 billion a year, safeguard against medical errors, reduce
malpractice lawsuits, and greatly facilitate both preventive care and ongoing
therapy of the chronically ill.” 

EMR’s have
done none of the above. EMRs have been a money-loser for most physicians.

I
had predicted that fully functioning EMRs were too expensive for most
practicing physicians. EMRs bought in the past were not fully functional.
Therefore physicians would have to purchase new fully functional EMRs.

Physicians
understand that all data collected, whether accurate or not, has been used
against them in the past. They are hesitant to provide more data at their own
expense that compromise the privacy of their patients and potentially harm their
own reputation.

They
would be happy to participate in the project if the EMR improved their ability
to serve their patients without a potential penalty.

Physicians
suspect there is another agenda underlying President Obama’s insistence on the
adoption of EMRs.

It
is clear the government and healthcare insurance industry want to control the
healthcare system. As the payers they do not want the physician/patient
relationship to control the healthcare system.  

A
recent survey from
forty-nine community practices in a large EHR pilot study by the Massachusetts
eHealth Collaborative studied the projected five-year financial returns on
investment to physicians’ practices. It was published in Health Affairs.

The
survey concluded,

We found that the average
physician would lose $43,743 over five years; just 27 percent of practices
would have achieved a positive return on investment; and only an additional
14 percent of practices would have come out ahead had they received the
$44,000 federal meaningful-use incentive.

Only a few practices would
have had EMR’s that qualified for the Obama administrations meaningful –use
incentives. The Obama administration’s criteria for meaningful-use are too
strict and complex for EMR software that physicians can afford.

More amazing is that the
only way for a practice to have a positive cash return on investment for their
EMR is to game the healthcare system using their EMR. The resulting cost of
medical care would rise.

 “The largest difference between practices with
a positive return on investment and those with a negative return was the extent
to which they used their EHRs to increase revenue, primarily by seeing more
patients per day or by improved billing that resulted in fewer rejected claims
and more accurate coding.”

This does not constitute an improvement in medical care. It also
contradicts the idealistic advantages of the electronic medical record.

The survey concludes that current meaningful-use incentives
alone may not ensure a positive return on investment from EMR adoption.

The authors suggest,

“Policies
that provide additional support, such as expanding the regional extension
center program, could help ensure that practices make the changes required to
realize a positive return on investment from EHRs.”

 The government and
healthcare insurance industry’s goal is to reduce physicians’ reimbursement for
those physicians that do not meet Obamacare’s imposed criteria for quality
medical care. These criteria will be set by IPAB.

Many physicians in practice object to converting medical care
into a commodity. Medical care is a very personal and complex interaction.

I have said previously that about 50% of the therapeutic index
(therapeutic effect) is determined by the patient physician relationship.

 "We need to move to EHR forward for a number of reasons,
but if I am a small practice I am going to really think about a few
things," she says. "One is how to decrease the cost of adoption and
the cost of the system itself.

“ To the
extent you can reduce the upfront cost that is going to help bring down the
amount you have to figure out how to make up elsewhere. Increasingly there are
new models taking this into account for small practices to decrease the big
upfront costs."

There are two basic problems, cost and the real purpose of EMRs.
Both can be remedied.

The costs of an EMR to a medical practice can be remedied
easily.  My ideal electronic medical
record could reside in the cloud. It would be available at no cost to physicians.
The patient data would be fully secured and only used by patients and their
physicians.

Physicians would pay for its use by the click. The EMRs would be
maintained and updated for free.

The EMRs could only be used for physician education purposes and
not for penalizing physicians.

If there is a terrible physician in the community a way needs to
be found to deal with that physician within his community. This is where
consumer driven evaluation would work.

Lost in this discussion is the real politics of EMRs.

 Jerome Groopman and Pamela Hartzmen
wrote,

 “The
electronic medical record (EMR) is touted as the key to containing costs,
reducing errors, improving quality, and simplifying administration: an “elegant
exercise in wishful thinking

Dr. Groopman and Pamela Hartzman debunk the 2005 RAND study that
led to this belief by President Obama. They show that there is little evidence
to support the president’s belief.

Dr. Groopman claims the RAND study is self serving to software
companies that sponsored the study.

 Allscripts
Healthcare Solutions ,  the Cerner Corporation  and Epic Systems of Verona, Wis. are the major EMR software companies.

“In February 2009, after years of behind-the-scenes lobbying by
Allscripts and others, legislation to promote the use of electronic records was
signed into law as part of President Obama’s economic stimulus bill.

“But today, as doctors and hospitals struggle to make new records
systems work, the clear winners are big companies like Allscripts that lobbied
for that legislation and pushed aside smaller competitors.”

At Allscripts healthcare solutions,
annual sales have more than doubled from $548 million in 2009 to an estimated
$1.44 billion last year, partly reflecting daring acquisitions made on the bet
that the legislation would be a boon for the industry.

At the Cerner Corporation of Kansas City, Mo., sales rose 60 percent during that
period. With money pouring in, top executives are enjoying Wall Street-style
paydays.

Current and former industry executives say that
big digital records companies like Cerner, Allscripts and Epic Systems of
Verona, Wis., have reaped enormous rewards because of the legislation they
pushed for

The weird thing is many of
these EMR systems bought by large hospital systems are not fully functional
(meaningful-use). The EMRs are requiring additional hospital system outlays of
cash to make them fully functional.

These costs are passed on to
the consumer.

The president
and his health-care team have yet to address these difficult and pressing
issues. Our culture adores technology, so it is not surprising that the
electronic medical record has been touted as the first important step in curing
the ills of our health-care system. But it is an overly simplistic and
unsubstantiated part of the solution.

It is important to note Drs. Groopman and Hartzman total and
refreshing frankness.

We both voted for President Obama, in part because of his
pragmatic approach to problems, belief in empirical data, and openness to
changing his mind when those data contradict his initial approach to a problem.
We need the president to apply scientific rigor to fix our
health-care system rather than rely on elegant exercises in wishful thinking.

Please note that Drs. Groopman and Hartzman said it not
me.

I have said this many times in the past. The same statement
applies to the Obamacare in its entirety.

”We
need the president to apply scientific
rigor to fix our health-care system rather than rely on elegant exercises in
wishful thinking.”

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



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Facts and Misuse Of Facts

March 9, 2013
inDefective scientific studies, Healthcare Insurance Industry, Medicine: Healthcare System
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Stanley Feld M.D.,FACP,MACE

All of us try to understand
the facts and make logical decisions by synthesizing the facts.

There is a lot of
misinformation and disinformation being printed. This misinformation and
disinformation leads to the wrong conclusions because the facts are inaccurate.

 A master purveyor of this misinformation and
disinformation is Paul Krugman.

I believe his misuse of
facts is icreasing as he is subconsciously realizing his ideology is incorrect.

Here are a few examples of
disinformation or misinformation in Paul Krugman’s most recent article “Mooching
off of Medicaid” 

“For there
is a lot of price-gouging in health care — a fact long known to health care
economists but documented especially graphically in a recent article
in Time magazine. “

This is true. The margins on hospital systems
retail prices are outrageous. The margins on some discounted hospital system prices
are equally outrageous.

 There is a continuous price war between hospital
systems and payers (government and healthcare insurance companies).

 The uninsured and under insured primary stakeholders
(consumers) are stuck with these outrageous prices.

"As Steven
Brill, the article’s author, points out, individuals seeking health care can
face incredible costs, and even large private insurance companies have limited
ability to control profiteering by providers."

 This statement is not quite true. Most people
have healthcare insurance. The healthcare insurance industry and government
have negotiated discounted prices that are as low as 10% of the retail prices
published in Steven Brill’s article.

In the struggle to retain providers, private
insurance companies offer slightly higher prices than the government.

The healthcare insurance industry knows the
government’s exact reimbursement prices. The private insurance companies
provide the administrative services for the government’s healthcare plans.

Individuals not under the umbrella of these discounted
prices are liable for these high prices. As insurance premiums increase,
employers are reducing insurance coverage for employees.

The deductibles and co-pays are increasing to unaffordable
levels for everyone as an increasing numbers of employees are becoming under insured.
 

 “For there
is a lot of price-gouging in health care —"

 Price gouging is the result of a lack of
transparency and special deals the government and the healthcare insurance
industry makes with certain hospital systems   

“Medicare
does much better at preventing price gouging , and although Mr. Brill doesn’t point this out, Medicaid — which has
greater ability to say no — seems to do better still”.

 This is false. There are fewer physicians
seeing Medicaid patients because reimbursement is very low. In fact, in most
cases physician reimbursement is lower than physician overhead. The result is
access to care for a Medicaid patient is restricted. The access to care for
private insured patients is not.

Hospitals receive a bonus for
seeing Medicaid patients. This fact is not transparent and known by few.

 “And
despite some feeble claims to the contrary, privatizing Medicaid will end up
requiring more, not less, government spending”,

Paul Krugman makes declarative statements as if
they are unequivocal evidence. 

 “because
there’s overwhelming evidence that Medicaid is much cheaper than private insurance.”

The evidence in Paul Krugman’s quoted study is
not that overwhelming.

I reviewed this 2008 study. The demographic
difference of the Medicaid group compared to the privately insured group is
different. The difference can reveal alternate conclusions.

 


Jpeg demographics krugman
 

Note the demographic differences of the Medicaid
vs. Private insurance patients.

 

Heath status good 
    53.5% vs 41.2%

Mental health             17.4 % vs 
6.4%

Hispanic                     23.4% vs 16.9%

African American        27.5%
vs 16.4%

White                          49% vs 66%

Employed                   48% vs 74.6%

No hi school degree   36.7% vs 17.2%

Married                        33.6% vs 51.7%

Income less than poverty 62.3% vs 22.2%

 

An alternate conclusion could be that it is too
difficult for Medicaid patients to find a physician. Medicaid patients are more
poorly educated. The do not seek physicians’ help compared to the privately
insured group. Medicaid patients cannot afford the minimal out of pocket
expenses.


Jpeg 2 costs

 

To my amazement the unadjusted annual per person
Medicaid spending was higher in this article for the Medicaid insured group
than the privately insured group by $1000.  

Paul Krugman states Medicare
and Medicaid have lower administrative costs.

“Partly
this reflects lower administrative costs, because Medicaid neither advertises
nor spends money trying to avoid covering people”.

 He goes on to say.

 “But a lot
of it reflects the government’s bargaining power, its ability to prevent price
gouging by hospitals, drug companies and other parts of the medical-industrial
complex.”

The government does have
bargaining power. However reimbursement to physicians is so low that it is
difficult for Medicaid patients to find a physician.

This could be a reason
Medicaid costs are lower than privately insured patients with a high school
education and a job.

Acute care hospitals have a
10% Medicaid threshold. They can also be eligible for incentive pay.

 “In addition, to be eligible to receive a
Medicaid EHR incentive payment, acute care hospitals must also meet a 10
percent Medicaid patient volume threshold.”

Paul
Krugman and others conclude,

“Our nation cannot control runaway medical spending without
fundamentally changing how physicians are paid.”

Physicians receive only 9% of healthcare
dollars spent. The real facts are physicians write orders for the inflated services
of the hospital systems without receiving financial benefit. In fact, the
government restricts physician participation. Physicians’ reimbursement
decreases yearly.

It is very easy to draw the
wrong conclusions when relying on inaccurate facts from so called experts.

The real challenge is to
dig down and get the correct facts.

This is not done because
ideology, non-transparency and bias stand in the way. This contributes to the
healthcare system becoming more dysfunctional and costly each year.

 Healthcare policy errors are made because
policy is made using incorrect facts.

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



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A Point Of View

March 4, 2013
inMedicine: Healthcare System
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Stanley Feld M.D.,FACP,MACE

Steven Brill’s 24,000 word
article “Bitter Pill” is an excellent review of some hospital charges. He
presents examples of outrageous hospital charges.

 Many consumers have experienced these charges
but have ignored them. Few have understood them. Their healthcare insurance
coverage negotiated the reduced payment.

His examples of charges
from real patient bills such as $199.50 for a troponin test. Medicare pays
hospitals $13.94 for the test. The hospital accepts the charge. The actual cost
of the test is less than $4.00.

A
hospital charge for a simple complete blood test was $157.61. Medicare would
pay $11.02.  The actual cost to the
hospital might be fifty cents.

A
simple finger stick blood sugar hospital charge was $18.00.  Accu-chek gives the machine away to sell the sticks. A box
of 50 test strips costs $27.00 or $.55 a strip. It cost less that one penny to
produce a strip.

Now
that more people are unemployed and fewer people are insured or have adequate
insurance, consumers are starting to pay attention to these fees.

 It is about time that a major news media
outlet published something about these outrageous hospital system charges to
consumers.

After all, the media is the message!

Maybe the message will
generate the necessary community outrage for effective reform.

I have often heard “when
you are sick enough to need a hospital you do not have the time to shop
around,” for the best price.

It is true. However, no one
has questioned hospitals for charging those rates.

The poor, uninsured and
underinsured are the consumers this price system hurts the most. Society needs
to protect these Americans from this outrage.  

Consumers with adequate
healthcare coverage do not even look at the explanation of benefits for their
healthcare bills.. Their healthcare insurance company pays the bill after
negotiating the price with the hospital system.

As premiums and deductibles
rise these fee are getting more attention.

There is so much data in
Steven Brill’s multi-page document that I am sure comprehension is low. It does
not mater. 

Steven Brill’s message is
crystal clear. The situation is intolerable. The American public is being
ripped off. Healthcare pricing is destroying our nation’s economic growth.

Brill does not explain the
reasons how these high prices evolved. He does not explain whom if anyone
should be doing something about them.

He does not come out and
say the solution is government takeover of the healthcare system. However, he
implies it throughout his article.

Any fair minded individual
would be sympathetic to this implied notion. However. Steven Brill disregards
the fact that the government got us into this mess.

I have explained this over
and over again.

The Berkeley economist James C. Robinson pointed out that improving
the healthcare system is different than making technological improvements in an
outmoded corporation.

The success of all other transformations has been consumer driven.

The healthcare system has evolved to the point that consumers must
shut up, do as they're told, and be prepared to write a blank check.

 Healthcare policy wonks
have concluded that healthcare must be commoditized and depersonalized.

This thinking has resulting in the present healthcare system’s pricing.
No one understands it or is attempting to modify it.  

  • “The corporate system of health
    care has produced stronger organizations and more intense performance
    competition than the traditional system dominated by professionals.
  • This transformation of the health
    care system has swept away the framework of professional dominance in
    medicine.”

The excuse has been that consumers do not know how to drive the
healthcare system. It is too complicated.

This excuse has been used to "justify every inefficiency,
idiosyncrasy, in the healthcare system driven by professionalism, by
interest-serving institutions and corporations in the health care industry to
control and raise the price of healthcare."

Hospital systems have realized that in order to control the system
medical care must be commoditized. There is also government agreement.

 “Hospitals, insurers and other institutions
involved in health care battle over available dollars.

These institutions also know that
hiding the true cost of healthcare from the consumer is the way to inflate
value and increase cost.”

Hospital systems also know in order to control the healthcare system
completely they need to own physicians’ skills and intellectual property.

Patients and physicians drive the healthcare systems not
corporations and hospital systems.

Physicians like the public are blind to hospital charges and costs.
There is no price transparency. The hospital systems are positioning themselves
as parasites to take advantage of patients and physicians.

The government is trying to encourage hospital employment of
physicians so it has fewer entities to deal with. This is a mistake.

Steven Brill indirectly implies government driving healthcare for
all is the cheapest and best way. He is wrong.  

A government single party payer system will only increase the
price of healthcare and create unhappier patients with restricted access to
medical care.

Physicians are not interested in having their skills and
intellectual property treated as a commodity.

Physicians will become more cynical. They will unionize and restrict
their hours worked in a week.

These developments will cause the ultimate demise of the
healthcare system.

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



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Hospital Systems’ Abuses Of The Healthcare System

February 28, 2013
inConsumer Driven Health Care, Disinformation and the healthcare system, Medicine: Healthcare System
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Stanley
Feld M.D.,FACP, MACE

In my very first blogs in
2006 I made the point that all the stakeholders are to blame for the dysfunctional
healthcare system.

Most of the incentives that
created a technology driven healthcare system have been perverse. All the major
stakeholders’ incentives are misaligned.

The major stakeholders are
consumers, physicians, government, healthcare insurance companies,
pharmaceutical companies and employers.

The primary stakeholders
are consumers and physicians. The government, healthcare insurance companies,
pharmaceutical companies and employers are secondary stakeholders. Some
secondary stakeholders provide administrative services and some reimbursement.
None provide medical care.

None of the actions of any
of the stakeholders are transparent. All the stakeholders are trying to take
advantage of the payers (consumers, employers and the government).

The government should be
the neutralizing force. It should level the paying field for all the stakeholders.
Government should not permit one stakeholder take advantage another
stakeholder.

Everyone except the
primary stakeholders “patients and physicians” figured out the money game in
the healthcare system early on.

Government and employers
were next to last in figuring out the game of money gouging.  This happened in the early 1980’s when both
said they cannot pay any higher price for healthcare services.

At that point the hospital
systems and the healthcare insurance industry figured out another way to continue
the money gouging. The result was HMOs and managed care. They did not work.

The opacity of pricing
continued, cost shifting flourished, and the price of medical care continued to
rise.

Physicians are not
blameless. However, they are the easiest to blame. Physicians are the least
organized and least aggressive stakeholders in the healthcare system.

In the past, I have
pointed out the real problems that have resulted in the dysfunctions of the
healthcare system. Health policy wonks seem to ignore the real problems.

Consumers and physicians
are mere pawns in this money game.

Without consumers or
physicians there would be no healthcare system. They generate the engine that
provides the need for medical care and administrative services.

I have covered much of the
abuse of the healthcare system by most of the stakeholders.

I have been relatively
easy on hospital systems and pharmaceutical companies until now.

However, the basic problems
in the healthcare system must be to be recognized and then fixed. All of the
problems have to be recognized at the same time and fixed simultaneously.

A patch on one problem
simply intensifies the overall problems.

Obamacare does not solve
any of the real problems. It is an attempt at patching a problem. It will only
make the problems worse and will not reduce the cost of care.

On February 20,2013 TIME
Magazine published an article by Steven Brill. The article is an excellent article
pointing out the abuses of the hospital systems.

“Bitter Pill Why Medical Bills are Killing Us” presents
examples of the abuses of large and small hospital systems.

The basic philosophy that
hospital systems should operate by should be “Patients First.”  It is not. It is how much money can I make
from each patient.

Steven Brill asked the
major question. “ Why are hospital bills so high?”

He presented the answer:


 

http://www.time.com/time/video/player/0,32068,2178453595001_2136781,00.html

The answer is obvious to
all physicians.

One fellow physician
wrote.

Stan

Although
we know much of this, this is an excellent overview of healthcare costs.

 Steve

All Americans ought to
understand the distortions hospital system pricing creates. The government
ought to make hospital pricing transparent to everyone..

The government should include
the hospital system’s retail price, wholesale price and actual cost for an item
or service.

Then, consumers can choose
the hospital system to go to.

Policy makers continually criticize
this ideal saying that illnesses are sudden and patients are not in a position
to choose a hospital system or negotiate price.

If the hospital system is
compelled to compete on price the price will be the same as the competitive
price when the patient gets sick. If one hospital is much higher than the next
hospital the patient will know this before hand.

Hospital system charges
are actually higher than they appear. Most hospital systems are non-profit
organizations. The hospital systems do not pay taxes.

Hospital charges are
opaque to everyone, including physicians. Physicians generate the services
hospitals charge for.

As seen in Steven Brill’s
article oncology charges are extremely high.

One oncologist wrote to me
and said he could administer the same therapy in his office for one-tenth the hospital
cost.

However, neither the government nor the healthcare insurance industry
would reimburse him for the office procedure. It is the same procedure he performs
in the hospital.

Doesn’t that seem strange? What is going on?

Steven Brill discovered
that it is almost impossible to find out what hospital systems are charging.

The same opacity is true
for pharmaceutical charges.  The
pharmaceutical charges are further inflated by multiple middlemen involved in
drug distribution.

This has been less true
for drugs since Internet Drug stores publish drug prices.

However, since the patients’
physicians prescribed the drug patients are hesitate to use substitute drugs.
The patients’ attitude is that the healthcare insurance company will pay for
the drug less the copay.

Therefore the patients are not interested in looking
up the difference in price or the options for substitution.

This is the reason consumers need skin in the game.

The result of consumer apathy is an increase
in healthcare insurance premiums.

Steven Brill covers the
grotesqueness of retail hospital system charges. He also points out the amount
Medicare reimburses for the grossly inflated charge.

The consumers without
insurance are the consumers that get stuck with the retail charges. Insurer consumers recieve a large discount.  The uninsured
consumers are least likely to be able to afford these charges.

In some cases Medicare
reimbursement is less than 20% of the hospital retail charge. Steven Brill
points out that at this time Medicare reimbursement to hospitals is still 10
times its actual costs.

The article “Bitter Pill” is
excellent. It covers many categories of hospital system abuse by the use of
case studies.

The facts are
overwhelming.  I am going to try to
categorize these facts in my next blogs. The abuses will be easier to remember.

Consumers must be educated.
The hope is consumers can be activated by education. Only a consumer driven
healthcare system can drive the abuse out of the healthcare system. 

Then,
Americans will have an affordable healthcare system.

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



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Why Not Avoid The Financial Problems?

February 24, 2013
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

It is
very clear to me that neither the Obama administration nor the senate wants to
solve the root causes of the federal deficit problem.

The
sequestration debates are not getting to the root causes of the deficit. Eighty
five billion dollars will not make a dent in America’s 16 trillion dollar
budget deficit.

President
Obama is running around the country scaring everyone with the notion that vital
services must be cut or else the country will be paralyzed.

Recently
the congress and the President appropriated $60.2 billion dollars for aid to
Sandy victims. This is almost as much as the sequestration is going to
eliminate.

“The Senate voted
Monday to provide $50.5 billion in aid for victims of Superstorm Sandy. The
vote means Congress has approved a total of $60.2 billion in aid for Sandy
victims”.

America’s
big deficit problem is created by out of control entitlement programs. Obamacare
is adding to entitlement spending. It will only increase the deficit.  

Our
politicians’ should be working hard to figure out a solution to increasing entitlement
spending. Yet the Obama administration has refused to consider entitlement
reform.

America’s
two largest entitlements are Medicare and Social Security. Food stamps, and unemployment
insurance, among others has some impact on the deficit.

Simple
reforms and a decrease in waste could solve the problem.

The
following two articles summarize the illusion of the existence of Social
Security and Medicare Trust Funds.

In
reality the money goes into these trust funds from payroll withholdings. The
government then borrows the money to pay general expenses. It provides an IOU
to the trust funds. In essence the trust funds are broke and the IOUs are an
unfunded liability of the federal government..

“And since the
federal government borrows the surplus from both funds (Social Security and
Medicare) to pay other expenses, the only thing in those trust funds own
special, non-negotiable, interest-bearing IOUs.”

 http://articles.washingtonpost.com/2012-10-18/opinions/35502037_1_trust-fund-medicare-trustees-health-care

http://www.forbes.com/sites/merrillmatthews/2012/08/21/think-social-securitys-trust-fund-is-a-scam-medicare-has-one-too/

In order
to pay Social Security and Medicare obligations the government shifts revenue
of current accounts into the trust fund accounts.

Citizens
paying into Social Security and Medicare all those years thought they were
paying for a retirement annuity. The assumption was the money would grow with
wise government investments and those funds would be able to pay their promised
liability to seniors.

Those
payments were really a disguised tax. As baby boomers become eligible for
Medicare and Social Security the obligation is increasing.

America
is reaching the point where more people are receiving these entitlement
benefits than the younger people who are funding them.

The logical result is the premium price for
Medicare coverage is scheduled to double in 2014. The deductibles for services are
scheduled to increase. The age requirement for eligibility is about to rise.  Access to care is decreasing as physicians
refuse to take Medicare. Rationing of care is increasing as hospitals are being
forced to assume risk. No one wants to assume the risk of taking care of sick
people. Especially when they are not very good at evaluating the risk.

Everyone
knows all of this. Nevertheless they turn away as the government either borrows
more or prints more money.

Americans
have been told by multiple administrations that citizens could not handle their
own Social Security or Medicare annuity very well. Therefore the government
must do it for them.

The
government has done an awful job managing our retirement annuities.

Social
Security and Medicare Trust Funds must become real trust funds that grow in
value in the future or the government should hand control over to the people.

The Obama
administration refuses to believe the significance of defensive medicine.
Defensive medicine’s cost to the healthcare system is somewhere between 300 to
700 billion dollars a year.


The Obama
administration’s estimate is it costs 3 billion dollars a year. They are wrong. Ask any physician.

Why
should physicians or hospital systems assume the risk of missing a diagnosis by
not doing a test?

The
emotional and financial consequences of a frivolous lawsuit can be devastating.

Simple
and fair tort reform will save the healthcare system around 500 billion dollars
a year.  The 500 billion dollars is more
than 5 times the cost of the 85 billion dollar sequestration. The administration
is wasting 500 million dollars to protect the business of malpractice trial
lawyers.

The
administration claims its overhead for Medicare is only 2 ½ %. This represents
the cost to pick an insurance company to adjudicate insurance claims. The true
cost is not clear. However, it is somewhere between 40-60% of every Medicare
dollar spent.

The
insurance company is permitted by the government to pack many expenses into the
direct patient care column and avoid going over the 15% medical loss ratio
allowed.

The ten
hidden taxes written into Obamacare are now starting to be felt. The Obamacare taxes
are going to increase the cost of medical care not decrease the cost as the
affordable care act promises. 

Patients
are directly responsible for many of their own medical outcomes.  If patients had skin in the game and
financial incentives they would pay attention to their self -care and their
physicians’ recommendations. 

There are
no incentives in Obamacare for patients to manage their care effectively.
Financial gain would get their attention.

These are
just a few of the solutions to the real problems in healthcare. There is much
more waste in federal spending than $85 billion dollars a year.

All you
have to do is look at the list of extraordinary waste that Senator Tom Coburn
has compiled.

Rand Paul
did a clever thing. He sent $600,000 of his senate office budget back to the
U.S. Treasury after carefully trying to save money. The 49 other senators and
over 400 congressperson ought to do the same. It would set an example for all
of the bureaucracy to do the same. In fact President Obama ought to demand it.

“The
Kentucky Republican returned $600,000 in funds he saved from his Senate office
budget in the last year, the Louisville Courier-Journal reported.

“It’s
the only budget I control,” Paul said at a news conference in Louisville. “It’s
not enough, but it’s a start.”

If every
congressperson saved 600,000 a year as Rand Paul did the deficit would be
reduced by $321 million dollars more a year. If all the cabinet positions and
their agencies tried to save money and were rewarded for saving money we would
start to make some progress in decreasing the deficit.

The Simpson
Bowles Report commissioned by President Obama would be helpful in eliminating
unnecessary agencies and duplication. Their report has been ignored by the
Obama administration.

Why has
President Obama refused to listen to people who have exposed the many areas of
government waste? It is incomprehensible.  

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



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Permalink:

My First Date With Cecelia

February 20, 2013
inLife's Experiences
• Leave a comment

Stanley
Feld M.D.,FACP,MACE

 

Cecelia and I are
approaching our 50th wedding anniversary. We were married on June
16,1963.

Our first date was on March
31,1959. March 31st has been a magical day for me.

I had my Bar Mitzvah on March
31st even though my birthday is March 17th.   

Cecelia
and I became engaged on March 31st. 

I all began with my Aunt
Anna. My aunt Anna was a friend of Cecelia’s mother. Aunt Anna met Cecelia. She
liked her. She told Cecelia’s mother she had the perfect boy for Cecelia.

Cecelia did not need to be
introduced to any boys. At 161/2 years old she was already a
beautiful woman.

Aunt Anna was a persistent
woman. She bothered my brother Charlie at least 3 times a week for months to
call Cecelia and take her out.

My brother was a senior in
high school. He played on the high school’s basketball and baseball team. He
was a big man on campus. In addition to all of that he had a steady girlfriend.

He had no time or interest
in taking Cecelia out.

My family lived in a small
three story attached two bedroom house. My brother and I shared a bedroom. One
night he asked me to help him get Aunt Anna off his back.

He asked me to take Cecelia
out.

I said sure. I made a date
to take her out for pizza on a Wednesday night. I took her to the Pizza Parlor
on Boston Post Road and Gun Hill Road in the Bronx. The Pizza Parlor is gone
now.

Years later I found out that
she was not impressed with the pizza. She was impressed with my father’s baby
blue 1959 Pontiac Bonnieville convertible and its gigantic fins.

 
$(KGrHqEOKooE5kD5,1V-BO,lJIE!uQ~~60_3

 

http://www.ebay.com/itm/1959-PONTIAC-BONNEVILLE-CONVERTIBLE-BLUE-1-18-DIECAST-CAR-MODEL-BY-SUNSTAR-/140604420397

 

I fell in love with Cecelia
at first sight.

She was beautiful in her
blue button down shirt and jeans. She was very intelligent. She had many
interests. She was a great conversationalist.

I dated many girls in high
school and college. I was never as impressed as I was by the brightness of this
woman. As my father would say, “I was smitten”.

Cecelia was going to High
School of Music and Art. We had many of the same interests.

At Columbia College I was a
pre-med with a concentrates in chemistry and fine art.

Columbia College was my first
exposure to fine art and its history. At that point Cecelia knew as much or
more about the arts than I did.

Her élan blew me away.

When I got home that night I
told my brother I thought I would be marrying Cecelia.

He looked at me as though I
was nuts. We then turned the light off and went to sleep.

The rest is history. Cecelia
and I have had a wonderful trip through life together. We have always had mutual
respect for each other. We have grown in life together by cultivating mutual
interests. We have supported each other’s dreams.

Cecelia has always been my
heroine. I know I have always been her hero.

We raised two sons, Daniel
and Brad. When I think about it, they are a combination of both of us in
different proportions.

Daniel and Brad are fine men
and dedicated husbands. Both are married to wonderful women.  Cecelia and I are very proud of them.

As Cecelia and I approach
our 50th wedding anniversary with a great family, I can only think
of the corny phrase my mother used
over and over again when she was alive and the family was together,

“My cup runneth over”.

It was a very lucky first date.

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



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Permalink:

Why Obamacare Will Fail

February 17, 2013
inDisinformation and the healthcare system, Medicine: Healthcare System, Stakeholder Mistrust
• Leave a comment

Stanley Feld M.D.,FACP,MACE

Obamacare will fail because none of the stakeholders’ vested
interest are aligned.

The storm is brewing in the healthcare system.

Even Democrats are concerned.

Recently, I have been criticized for blaming the impending failure
on President Obama. President Obama would rather blame the impending failure on
congress.

 A reader wrote;

“President Obama is a nice
guy. He is trying very hard. Give him a chance.”

It is true. He seems like a nice guy. My criticism is not personal.
The fact is his philosophy and tactics are responsible for the mess. As time
goes on it seems more likely that Obamacare will not work out.

There are multiple reasons for the impending failure. A major
reason is Obamacare is developing new perverse incentives for stakeholders
rather than aligning all the stakeholders’ vested interests.

Obamacare is extraordinarily complex. It is confusing to all the stakeholders,
 especially as new rules and regulations
are being written.

By forcing the development of programs such as health insurance
exchanges, accountable care organizations, pay for performance plans,
functional electronic medical records, and the consolidation of healthcare
hospital systems and physicians against their will, Obamacare is creating
tensions and uncertainties that will be difficult to overcome.

Patients’ medical care and their relationships with their
physicians are personal issues. Obamacare is commoditizing medical care. It is
destroying the patient physician relationships. These relationships account for
at least one half of the therapeutic effect of medical treatment.

The 2300 page law usurps the power of the legislative branch of
government and shifts it to the executive branch. This is dangerous. It has
created additional tension and uncertainty for the nation.

Many congressmen who voted for the law did not read the law’s 2300
pages. The implications of much of the law were not understood. It did not have
bipartisan support.

In 2012, the executive branch of the federal government issued another
70,000 pages of guidance for participants in Obamacare. The executive branch
has created at least 22,000 new regulations and 68,000 new ICM codes.

The more complex a law becomes the more likely it is to be unsuccessful.

There is no question the healthcare system nears repairing. Healthcare
costs are exploding. Waste and bureaucracy are expanding.  Dysfunctional interactions between
stakeholders are mounting.

All of this results in an inability to deliver effective medical
care.

At present 55% of Americans of all ages receive healthcare
insurance through an employer sponsored healthcare plan. An additional 32% receive
healthcare insurance through government programs.

Thirteen percent (13%) of the population are uninsured or under
insured. Obamacare’s goal is supposed to provide healthcare insurance for that
13%.

Present predictions are that Obamacare will not provide universal
care. It is predicted that it will not save $850 billion dollars. The CBO, on
the basis of numbers provided by the administration, predicted the law would
save $850 prior to the passage of the law.  The CBO’s current prediction is Obamacare will
cost the nation an additional  $1.2
trillion dollars over 10 years.

Healthcare insurance rates are rising by double digits each year.
Employers are passing the costs of the increasing insurance rates to their
employees through higher deductibles and copays along with lower healthcare
coverage plans.

 Obamacare will require
employers, who offer skimpy healthcare benefits such as Mini-med insurance, to
provide more robust ones.

To date the Obama administration has waived more than 2000
employers from providing more robust healthcare insurance coverage. At the time
these waivers expire companies with waivers, such as McDonald’s, will scream
bloody murder.

They will opt out of providing any healthcare insurance at all and
avoid government penalties. They will accomplish this by decreasing the number
of hours an employee will work to less than 30 hours a week. This is not good
for minimum wage workers. The uninsured rolls will increase.

The penalty of $3,000 per employee is less than the $15,000 healthcare
insurance cost per employee for employees working more than 30 hours a week.

Surveys have been published concluding that more than 50% of
employers are planning to drop healthcare insurance coverage.

The federal government is trying to discourage this by invoking
the IRS anti-abuse rules;

“The IRS has indicated that anti-abuse rules
will be implemented to curtail the use of Obamacare loopholes to
dodge the play or pay requirement.

  Yet as
some have already questioned, can the IRS legitimately utilize rule-making to modify
core components of a federal act? Or will this rule-based clean-up effort
simply spawn more lengthy litigation?” 

Obamacare’s health insurance exchange program is in big trouble.
Less than half the states have signed up to participate.

 States have opted out
because of the potential cost overruns. States are struggling to balance their
budgets. The federal government is only going to pay for health insurance
exchanges’ development and execution for the first two years.  The cost burden will then fall on the states.

The federal government keeps extending the deadline for states to
sign up. The federal government does not have infrastructure or manpower to set
them up.

The health insurance exchanges are supposed to be up and ready to sign
up consumer up in October 2013 and operating in January 2014.

Physicians do not know what to do about Obamacare. Physicians feel
helpless. They know Obamacare cannot work. Physicians do not have a leadership
organization that can direct physicians to have an effective voice.

Accountable Care Organizations (ACO’s) will fail because physicians
are trained to use medical judgment. They have not been trained to obey the
rules of hospital administrators.

They bristle when their value is determined by hospital systems or
federal agencies such as IPAB. They prefer to have their value determined by
their patients.

Physician leadership needs a new mentality to enable physicians to
act and articulate  the steps needed to
be taken to repair the healthcare system.

Physicians want the healthcare system to function equitably for
all the stakeholders and effectively for their patients.

Medical organizations have been consistently losing membership
because it has not represented or articulated the needs of practicing
physicians.

If Obamacare works as President Obama hopes, he will have secured
his legacy and solved the long-festering problem of the uninsured.

Obamacare will not solve the problems of increasing healthcare
costs nor provide universal care in its present form. This has been a pipe
dream all along.

Another reason Obamacare will fail is because it does not consider
the cost of defensive medicine significant. President Obama is not interested
in tort reform.

Obamacare doesn’t align any of the stakeholders’ vested interests.

When Obamacare fails it will provoke a citizen backlash that will
be very difficult to overcome.

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



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Permalink:

Patients’ Responsibility And Hospital Readmissions

February 13, 2013
inMedicine: Healthcare System, Quality medical care measures
• Leave a comment

Stanley Feld M.D.,FACE,MACE

Obamacare
has rules to penalize hospital systems if a patient was readmitted to the
hospital before 30 days of initial admission.

Prior to October 1,2012 Medicare revised hospitals' readmissions penalties
rules. On October 1 Medicare started fining hospitals
that have too many patients readmitted within 30 days of discharge due to
complications of their disease.

The formula for determining these penalties is
extremely complicated. The formula is almost impossible to understand.   

Hospitals whose admission rates are above the
national average will be penalized. The data analytics are supposed to risk
weight patients to see if the hospital should be penalized.

Patients with multiple co-morbidities have a higher
chance of readmission.

“The penalties are part of a broader
push under President Barack Obama's health care law to improve quality while
also trying to save taxpayers money.”

The gigantic perverse incentive is for hospitals to
avoid the initial admission of sick patients with multiple morbidities. Those are
the patients that have a better chance of being readmitted within 30 days.

It is also impossible to evaluate quality of medical
care using claims data. False  conclusions will not be a true reflection on who
is at fault and should be blamed and penalized for the readmission.

 It could be
that patients did not adhere to the discharge instructions.  

“About
two-thirds of the hospitals serving Medicare patients, or some 2,200
facilities, will be hit with penalties averaging around $125,000 per facility
this coming year, according to government estimates.”

The formula for penalty
assessment  is extremely complicated. The
Centers for Medicare & Medicaid Services has discovered errors in its
initial calculations in August 2012.  

“Nearly
one in five Medicare patients return to the hospital within a month of
discharge, costing the government an extra $17.5 billion in 2010.”

A total of 2,217 hospitals are being
punished in the first year of the program, which began Oct. 1. Of those, 307
will be docked the maximum amount: 1 percent of their regular Medicare
reimbursements.

Only acute myocardial infarction,
congestive heart failure and pneumonia will be evaluated the first year.

 

“Overall, Medicare has estimated it will recoup about $280 million
from hospitals where it determined too many heart attack, heart failure or
pneumonia patients returned within 30 days.”

The
Dartmouth Atlas of Health Care and the Robert Wood Johnson Foundation latest
report "The Revolving Door Syndrome on
hospital readmissions points out highly variable rates.

Ninety two (92) academic
medical centers and 37 hospitals saw readmission rates for their patients
actually increase. 

   
Map
                                               Double click to see legend

David Goodman, MD, co-principal investigator
for the Dartmouth Atlas Project said. "Despite
awareness of the problem, progress and improvement has been slow."

The
report divided readmissions into two types, those affecting patients whose
first admission was for a surgical procedure and those affecting patients whose
first admission was for a medical condition such as congestive heart failure,
pneumonia, or heart attack.

The surgical 30-day readmission
rate dropped from 12.7% in 2008 to 12.4% in 2010, while the medical 30-day
readmission rate went from 16.2% to 15.9%. 

The report shows wide
variations
among academic medical
centers.

“The highest readmission rates in 2010 were the
Cleveland Clinic, with 21.6%, and the Hospital of the University of
Pennsylvania, with 21.4% among AMI, congestive heart failure and pneumonia.

The hospital with the lowest rate was NYU Langone Medical Center, with
14.4%. “ 

The University of
Medicine and Dentistry in New Jersey (UMDNJ) had the highest surgical
readmission rate with 20.7%, and the Stony Brook University Medical Center on
Long Island, with 20.6%.

If this data is correct
academic institutions will not be in the mood to be penalized for taking care
of sick patients.

Other studies have shown
that there is only a 50-60% adherence rate by patients to prescribed treatment.
This lack of adherence can be a significant driver to readmission rates. There
is no data evaluating patients’ role and responsibilities in re-admission
rates.

What are patients’
responsibility for their care? If patients do not receive enough education to
avoid hospitalization they should demand the education.

If patients are not
interested in self-management of their disease they should tell their
physicians.

If the patient is too sick
to learn to self-manage a family member should be involved.

Patients have responsibility
for their self management to avoid readmission is high!

Yet the government is quick
to blame hospitals and physicians for high re-admission rates without examining
all the facts.

Another factor not
evaluated in determining readmission rates is the pressure on the hospitals to discharge
patients quickly.

"Some
doctors feel they are caught in a squeeze play," the report says.
"Hospital administrators carefully monitor length of stay—they are eager
to send people home because the longer a patient stays, the less money they
make. Thus providers said that the prevailing pressure is to discharge
patients as early as possible" even if it's too soon.”

This
is the slippery slope the healthcare system is on. The data management is
faulty. The government is not evaluating all the complex variables resulting in
hospital readmissions. This defect leads to faulty decisions. Those decisions
lead to more complicated unintended consequences.

Consumer
should be driving the healthcare system not the government. The government
should make the rules to level the playing field for all stakeholders.

The
government should defend the interests of patients.

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



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Permalink:

A Wonderful Thing Happened Last Week

February 10, 2013
inMedicine: Healthcare System
• Leave a comment

Stanley Feld M.D.,FACP,MACE

Dr. Benjamin Carson gave the keynote address at
the National Prayer Breakfast. Dr. Carson is the director of pediatric
neurosurgery at  John Hopkins University
in Baltimore.

He is the son of an single mother. He grew up
living in poverty. He hated poverty. Among the things his mother taught him
were that excuses were not acceptable. Once that declaration is accepted one
can start figuring out solutions.

The You Tube of his speech is entertaining, riveting
and inspirational. Only 18,000 people have watched the You Tube so far. I
believe this speech should be watch by every American for its inspirational
message.

If the media is the message people watching
this You Tube should play close attention to President Obama’s body language
during the delivery of Dr. Carson speech..

One commenter noted;

“ Worth watching this 26 minute
video. Interesting to watch the president grimace as he gives a complete
opposite solution to every problem the country faces. One smart pediatric brain
surgeon.”

Every topic Dr. Carson covered pointed out the
potential greatness of Americans. He makes a strong case for the solutions to
the many problems America faces.

Embedded in each solution to each problem is
individual responsibility and not government dependence.

 

He makes the case for self-respect and
self-reliance.  He makes a plea for the  respect for others’ opinions whatever their
political or religious leaning.

 

 Dr.
Carson’s solution to the healthcare system can be found at the 20-minute point
in the You Tube.

  

http://youtu.be/YZfaXNBO9PU

He
covers the solutions to the problems education, the tax code and several other
problems we face. Some will say he is simplistic. I implore those who say he is
simplistic  to think about the potential
liberating power of his solutions as opposed to the potential freedom
stifliling solutions of big government.

Government must be a facilitator not a dominator.

Dr. Carson reminds his audience that five (5)
physicians signed the Constitution and the Declaration of Independence. He says
America needs physicians to speak out now and not worry about being politically
correct (PC) in our PC world

Dr. Carson says,

“Here's my
solution to the healthcare systems problem: When a person is born, give him a birth certificate, an electronic
medical record, and a health savings account to which money can be contributed
– pretax — from the time you're born 'til the time you die. When you die, you pass
it on to your family members, so that when you're 85 years old and you got six
diseases, you're not trying to spend up everything. You're happy to pass it on
and there's nobody talking about death panels.

Number one.
And also, for the people who were indigent who don't have any money we can make
contributions to their HSA every month because we already have this huge pot of
money. Instead of sending it to some huge bureaucracy, let's put it in their
HSAs. Now they have some control over their own healthcare”.

Funny, isn’t it?

This is exactly what I have been saying the
past six years as our healthcare system has been becoming more complex, more
dysfunctional, more costly, more controlling and more bureaucratic.

This is the advice I gave President Obama in
six letters as President-elect and in the early weeks of his presidency.

Obamacare is a ineffective patch on a
dysfunctional healthcare system. It has generated thousands of new regulations
that will be costly and difficult to comply with. The new regulations will be
impossible to enforce even though there have been 18.000 new IRS agents hired
to enforce them.

Dr. Benjamin Carson has injected common sense
into the national discussion without trying to offend anyone.

The key is to get politicians to listen to him.
If you agree, please send this on to people you know.

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



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